HomeMy WebLinkAboutMiscellaneous - 77 BEAR HILL ROAD 4/30/2018N)
IN
Date...
.... . .... ....
TOWN OF NORTH ANDOVER
RMIT FOR WIRING
....................................................................
has permission to perform ...��'.............................. titi�
1 ........................ .............
wiring in the building of........�,..-sl }��t. !!..~..................................
...;�..............
a--% T
at.......................................................................................................... North Andover, Mass.
Fee -1..D.... ............. Lic. Noz.....r�.r.
....................................................................................
ELECTRICAL INSPECTOR
Check # 9Z4 1
S
2 53 1,—/ �f li c U i_
Commonwealth of Massachusetts
OifciaGl�UseOnlfy
Permit No.
Department of Fire Services
Occupancy and Fee Checked
'QM BOARD OF FIRE PREVENTION REGULATIONS [Rev. U07] (leaveblank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: / - l
City or Town of: NORTH ANDOVER To the Insp— ecT Wires
By this application the undersigned gives notice of his or her inten 'on toerff rm the electrical work described below.
Location (Street & Number)_ __ %� ��, /l /✓ -C�
Owner or Tenant 4elephone No.
Owner's Address
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 ❑ Undgrd ❑ No. of Meters
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters _
Number of Feeders and Ampacity Y
Location and Nature of Proposed Electrical Work: i . i , ✓ P / .., is J1 /., , e ✓ .)i n-,
Completion of the following table maybe waived by the Inspector of Wires.
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. grnd.
o. of Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
I No. of Zones
No. of Switches 2-
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
Number
.......
To
'' ?'��
KW
.K ""'"".....
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:*
No. of Devices or Equivalent
No. of Water KW
Heaters
No, of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Attach additional detail ifdesired, or as required by the Inspector of Mres.
Estimated Value of Electrical k: (When required by municipal policy.)
Work to Start: / Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless w ived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability ' surance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such cove e is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
Icertify, under thepains andpenalties ofperjury, that the information on thisapp c tion is true and complete.
FIRM NAME: _ 4 LIC. NO.: _
Licensee: p Signature LIC. NO.: U—I I
(If applicab e, enter "exe " i the license nu r line.) Bus. Tel. No.
Address: 1/) 1, ZL V'Ve 4
o � Alt. Tel. No.- I
*Per M.G.L c. 1 , s. 57-61 security work requires Department of Public Safety " " License: Lie. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, i hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent.
Owner/Agent PERMIT FEE. $
Signature Telephone No.
❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the A
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an \
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3L.
Permits shall be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012.
❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑
❑ Permit Extension Act — Permit/Date Closed:
Trench Ins ion
Pass
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:nL-
SERVICE INSPECTION:
Pass EN
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass M
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass 0
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
FINAL INSPEC N:
Pass IN
Failed7❑
Re- Inspection Required ($.) ❑
Inspectors Comments: A10
owe`j w—,
&I — 211,
Inspectors Signature:
Date: 4Z /�
DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com
The Commonwealth of Massachusetts
Z Department of IndustrialAccidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Name (Business/Organizationgndividual):
Address: (✓
City/State/Zip: lac K �) &ZI-t Phone #:
Are you an employer? Check the appropriate box: B) el
1.m a employer with employees (full and/or part-time).*
2.4 am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3. I am a homeowner doing all work myself. [No workers' comp. insurance required.] t
4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance.$
6.FJ We are a corporation and its officers have exercised their right of 'exemption per MGL c.
152, § 1(4), and we have no employees. [No workers' comp. insurance required.]
Type of project (required):
7. ❑ New construction
8. 0 Remodeling
9. ❑ Demolition
10 Building addition
11.0 Electrical repairs or additions
12. Q Plumbing repairs or additions
13. F1 Roof repairs
14.0 Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
i Homeowners who submit this affidavit indicating they 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-cohiraciors 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.
Insurance Company
Policy # or Self -ins. Lie. #: Expiration Date: y� j ��%%
Job Site Address: 21 g,-" � �l City/State/Zip: /'- yz,4V
Attach a copy of the Workers' compensation policy declaration page (showing the policy number and expirati date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00
and/or one-year imprisonment, as well as ci '1 penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a
day against the violator. A copy of this st a ent may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify hnjgj jf 1pains g 'pAnrrlties ofperjury that the information provided above is true and correct.
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person
Phone #:
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-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should'enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
~
�i:NMIII-1
Date .�.` ..�..�.` ..................
I
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that .................Il(L...t ...;:.:.%' .'IMG`' !M.AI....1 PC' C
has permission to perform ...... .!'..�4........ � *..... j.
wiring in the building of...i .........................................................
at ......��. 6G'^ �--k �.�. `�. �.:...................> orth Andover, Mass.
........................................................
C -
Fee .... ...............
Lic. No. ....... b. .................. El.....� �? , .....
ELEC L INSPECTOR
Check # J U�
The Commonwealth of Massachusetts Office Use Only
Department of Fire Services Permit# `j)
BOARD OF FIRE PREVENTION REGULATIONS Occupancy & Fee Checked
Rev. 1/07 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with Massachusetts Electrical Code (MEC), 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: July 9, 2014
City or Town of North Andover, MA 01845-2113 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) 77 Bear Hill Road
Owner or Tenant
Owner's Address
David & Kathryn McGillivray
Same
Tel. No. 978-258-8226
Is this permit in conjunction with a building permit: Yes = No FX I (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service
Amps
Volts
Overhead
Undgrd
No. of Meters
New Service
Amps
Volts
Overhead
Undgrd
No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work
Outdoor Hut Tub
Completion of the following table may be waived by the Inspector of Wires.
No. of Lighting Outlets
No. of Hot Tubs 1
No. of Transformers
No. of Lighting Fixtures
Swimming Pool
Generators
No. of Receptacle Outlets
No. of Oil Burners
No. of Emergency Lighting Battery Units
No. of Switches
No. of Gas Burners
FIRE ALARMS # of Zones
No. of Ranges
No. of Air Cond. Tons
No. of Detection
No. of Alerting
No. of Self Contained
Local Municipal Other
No. of Disposals No. of Heat Pumps kw
No. of Dishwashers Space/ Area Heating kw
No. of Dryers Heating Devices kw
No. of Water Heaters
I No. of Signs
TV Outlet
Telephone Devices
No. of Hydro Massage Tubs No. of Motors
Other: 50 amp 120/230 volt gfci feeder
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: July 9, 2014 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 the exhibited proof of the same to the permit
issuing office.
CHECK ONE: INSURANCE u X BOND r OTHER 1 (specify:)
I certify, under the pains and penalties of perjury, that the information on this application is true & complete.
FIRM NAME Dumais Electric LIC. NO.
Licensee Mark A. Dumais Signature --f/j� �%_ ,� LIC. NO.
(If applicable, enter "exempt" in the license number line.)
12170A
26665E
Address 8 NewportStreet Bus. Tel. No. 978-683-9438
Methuen, MA 01844 Alt. Tel No. 978-685-4553
* 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 insurance covera a normally
required by law. By my signature below, I herby waive this requirement. I am the (check one) r—nmer owner's agent
Owner /Agent r -y
Signature Telephone No. PERMIT FEE:
V�
TCP-� Lv 4(�
�N�(
Gk O,,V/ fj /<
M
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Nk�w www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Dumais Electric Inc.
Address: 8 Newport Street
Methuen, MA 01844 Phone #: 978-683-9438
Are you an employer? Check the appropriate box:
1. [3 I am a employer with 9
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.
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.:
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'
coma. insurance reauired.l
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.Q Electrical repairs or additions
11. E] 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' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Travelers
Policy # or Self -ins. Lic. #: IEUB-7C83307-8-14 Expiration Date: 2/2/15
Job Site Address: 77 Bear Hill Rd 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
Q
Signature: • Date: 7/9/14
Phone #: 978-683-9438
Official use only. Do not write in this area, to be completed by city or town offrciaL
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 C
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-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the annronriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 4-24-07 Fax # 617-727-7749
www.mass.gov/dia
J
Please visit our web site at http://www.mass.gov/dpl/boards/EL
DUMAIS ELECTRIC INC
MARK A DUMAIS (EL)
8 NEWPORT ST
METHUEN MA 01844-3425
Fold, Then Detach Along All Perforations
I~OMMONWE:ALTH OF M�1,S�5ACHl�SETTS
r B0ARD OF
E�EC(RI C' ANS r
} I:SSUES THEFOLLOWING LL.CENSE ASA
RE:G1 S1"i'RE� MASTER ILECTR I C ANS
�E
DUMAIS ELECTRIC �I�NC� r
1fY
,'kM°ARK 'A DUMA tS
`'
8 NEWPORT S5T•. �'>, r L"
y
IW
METt OE'N MA o1844-3425
y
121701"3j/ab 27306
41W
^Please visit our web site at http://www^mass.gov/dpi/boardo/EL
MARK A OUM&|S
(EL)
8 NEWPORT ST
M[THUEN MA 01844-3425
Fold, Then Detach Along AM Perforations
Locatio
No. F1 , r Date
Check #l�Lq �
2 f 1 4 -
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $�
Foundation Permit Fee $
Other Permit Fee $
TOTAL $_�
Building Inspector
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: I' Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on this page
LOCATION: / / 1✓3eqR C7t�/ t�Gt
PROPERTY OWNER DCt Ue-.G't /�l
Print I100 Year•Old Structure yes no..
MAP'NO: _ PARCEL: ZONING' DISTRICT: Mistoric District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Exp. Date:.-
cl �711✓
Residential
Non- Residential
❑ New Building
❑ One family
Exp. Date:
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
K Other Cm , `Te f-
0
❑ Septic ❑ Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
❑ Water/Sewer.
DESCRIPTION OF
�Z e-moijPce ovi
OWNER: Name: l Glee 67:0
Address: 77 13co-2 144 /l
CONTRACTOR Name:?e.fe2,5rn Pte,
Address: 3(o �Gb� R
R
TO BE PERFORMED:
Type or Print Clearly)
none: w t—be
71Uvz'y, /11/¢
Phone: "--' 9'(- 7� 9-u
I oa7i /
Supervisor's Construction License:
d a (9
Exp. Date:.-
cl �711✓
Home Improvement License:
Exp. Date:
F� �
ARCH ITECT/ENGINEE
Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ /,�CrZ) FEE: $
Check No.: S SC7 k Receipt No.:
NOTE: Persons contracting th unre i r contractors do not have access to the guar my fund
., . . _g _ _ M_ _fure of.contr`actori�
Signature of A ent/Owner
Plans Submitted ❑ lans Waived ❑ �ertific:d Plot Plan ❑ Stamped Plans ❑
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the app. -al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be subm'Ated with the building application
Doc: Doc.Bui?ding permit Revised 2012
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
Tanning/Massage/Body Art ❑ ..
Swimming Pools ' El J
Well ❑
Tobacco Sales ❑
Food Packaging/Sales ❑
Private (septic tank, etc. ❑
Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED
PLANNING & DEVELOPMENT
COMMENTS
DATE APPROVED
11
CbNSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Siqnature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes .
Planning Board Decision:
Comm
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Tows Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT- - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Departiiei t-signature/date `
COMMENTS
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No,
MGL Chapter 166 Section 21A -F and G min.$100-$1000 fine
NOTES and DATA — (For department use
® Notified for pickup - Date
Doc.Building Permit Revised 2010
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. 6. O CERTIFICATE OF LIABILITY INSURANCE
`•--�
DATE (MM/DD/YYYY)
10/1/2013
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
Bonacorso Insurance Agency, Inc.
83 Cambridge Street
CONTNAME.' Michael Bonacorso
PHONE(781)273-3200 FAX (781)273-0600
AC No :
E-MAIL
ADDRESS: mike@bonacorsoins.com
P.O. BOX 1502
Burlington MA 01803
INSURERS AFFORDING COVERAGE NAIC #
INSURERA.Acadla Insurance Company
INSURED
INSURER B :C N A Insurance Co.
Peterson Party Center, Inc.
INSURERC;AIM Mutual Insurance CO.
36 Cabot Road
INSURER D:
INSURER E:
X COMMERCIAL GENERAL LIABILITY
Woburn MA 01801
INSURER F:
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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
TYPE OF INSURANCE
A DL
SUBR
POLICY NUMBER
POLICY EFF
(MM
POLICY EXP
MM/DD/YYYY
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY
DAMAGE TO RENTED
PREMISES Ea occurrence $ 100,000
MED EXP (Any one person) $ 10,000
A
CLAIMS -MADE � OCCUR
X
X
PA 5061026 10
10/9/2013
0/9/2014
PERSONAL &ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG $ 2,000,000
POLICY X PRO- LOC
$
AUTOMOBILE
LIABILITY
E1.1 EDt SINGLE LIMIT
EOa 1,000,000
BODILY INJURY (Per person) $
AIx
ANY AUTO
ALL OWNED X SCHEDULED
AUTOS AUTOS
X
X
5063173 10
10/9/2013
0/9/2014
BODILY INJURY Per accident $
( )
HIRED AUTOS X NON -OWNED
AUTOS
PROPERTY DAMAGE
$
Per accident
Uninsured motorist BI split limit $
X
UMBRELLA LIAR
X
OCCUR
X
EACH OCCURRENCE $ 10,000,000
B
EXCESS LIAB
CLAIMS -MADE
AGGREGATE $ 10,000,000
DED I X RETENTION$ 10,000
085496458
10/9/2013
0/9/2014
$
C
WORKERS COMPENSATION
WC STATU- OTH-
XI ER
AND EMPLOYERS' LIABILITY Y / N
E.L. EACHACCIDENT $ 1 000,000
ANY PROPRIETOR/PARTNEW—CUTIVE
OFFICER/MEMBER EXCLUDED?
N / A
(Mandatory in NH)
Z8006586
0/9/2013
10/9/2014
If yes, describe under
E.L. DISEASE - EA EMPLOYE $ 1,000,000
E.L. DISEASE - POLICY LIMIT $ 1 000 000
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS/ LOCATIONS [VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
— I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
—I AUTHORIZED REPRESENTATIVE
chael J. Bonacorso
-- - -- t_ •�.��r v "IyDO-zU�U ACUKU CORPORATION. All rights reserved.
INRr25 mmnnrt ni Tho ernan r,�...e �...a l.. nn pro .o,.;�*o,o.i m�r4a ^f ernvn
N The Commonwealth of Massachusetts
Departntent of In dustrial A cciden ts
y Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
ivivmnlass.govIdla
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): PETERSON PARTY CENTER
Address: 36 CABOT RD
City/State/Zip: WOBU RN, MA 01801
Phone #:781-729-4000
Are you an employer? heck the appropriate ox:
Type of project (required):
1. A I am a employer with 200
4. ❑ I am a general contractor and I
6. ❑New construction
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet.
7. ❑ Remodeling
ship and have no employees
These sub -contractors have
8. ❑ Demolition
working for me in any capacity.
employees and have workers'
9. ❑ Building addition
[No workers' comp. insurance
required.]
comp. insurance.+
5. ❑ We are a corporation and its
10.❑ Electrical repairs or additions
3. ElI am a homeowner doing all work
officers have exercised their
1IT] Plumbing repairs or additions
myself. [No workers' comp.
right of exemption per MGL
12.7 Roof repairs
insurance required.] t
c. 152, §1(4), and we have noTEMP.
13.� Other TENT
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 iindicatina 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
..
emolovees. iri enc sub -contractors have emnloyees, they must provide Their worker' coma. oolicv number.
I ant an employer that is providing workers' compensation insurance for my employees. Below is thepolicy and job site
information.
Insurance Company Name: AIM MUTUAL INS CO
Policy # or-Self=ins.-Lic: #:-WMZ8006586
Expiration Date: 10/9/14 ...........
Job Site Address: 77 ge4r2 fill k a( City/State/Zip: /y"l Ad apy't
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 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 certify under the pains and penalties of perjury that the information provided above is true and correct.
781-729-4000
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 #:
r.
t �;lassachusetts - Depa amen: of Public Safety
s
C:J fzs l,.c�m�rv_�uuecc�rf r�✓�lcrGia.Yti.[Lel�
Office of Consumer Affairs & Business Rcguiatioo
p,�OME IMPROVEMENT CONTRACTOR
_ 5Registration: 109022 Type:
�sExpiratlon . .811820:15: Individual
'
Board of Building Regulations and Standards
construction Sunni<<,r � Doi
L,cense: CS -060219
DL4RIi TRAL`i a = V
33 H.�\"FORD RR
Stoneham itiLA 02-%80
Expiration
NLSRK R TRIi-;NA -
MARK TR41,N
Cornmissicnar
04!27/2015
A
33 fi:=,NFORD RD. _
STONEHAM, MA 02180
Undersecretary.
170
Boston,l•L=102116
'ot valid without
signature
License or registration valid for individul use only
before the expiration date. if found return to:
Office of Consumer Affairs and Business Regulation
10 Park Plaza --.Suite 5
Date ... �. I L '.) I—r)
.................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that...-D.UW')..0-k--:!.I' E-�e AV -4 �-
............. ................ ...................................................................
has permission to perform....'..1............!...................................................................................
wiring in the building of ...... m......... ....... .......................................................
....... ........
at ... ... )P -j .......................... /-,�4orth Andover, Mass.
Fee. 5q ........... Lic. No. ma/ ............... ......
ELECTRICAL INSPECTOR
Check #
11558
The Commonwealth of Massachusetts Office Use Only
' Department of Fire Services Permit#
BOARD OF FIRE PREVENTION REGULATIONS Occupancy & Fee Checked
Rev. 1/07 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with Massachusetts Electrical Code (MEC), 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: May 6, 2013
City or Town of North Andover, MA 01845-2113 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) 77 Bear Hill Road
Owner or Tenant David & Kathryn McGillivray Tel. No. 978-258-8226
Owner's Address Same
Is this permit in conjunction with a building permit: Yes a] No = (Check Appropriate Box) 5-31 )�
Purpose of Building Utility Authorization No.
Existing Service Amps Volts Overhead Undgrd No. of Meters
New Service Amps Volts Overhead Undgrd No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work
Master Bed - Bath, Kitchen, 1/2 Bath, Laundry, Bsmt Room
Completion of the following table may be waived by the Insaector of Wires.
No. of Lighting Outlets
No. of Hot Tubs
No. of Transformers
No. of Lighting Fixtures
70
Swimming Pool
Generators
No. of Receptacle Outlets
48
No. of Oil Burners
No. of Emergency Lighting Battery Units
No. of Switches
38
No. of Gas Burners
1
FIRE ALARMS # of Zones
No. of Ranges
No. of Air Cond.
1 Tons 5
No. of Detection
No. of Alerting
No. of Self Contained 11
Local F—qunicipal rOther r
No. of Disposals 1 No. of Heat Pumps
kw
No. of Dishwashers 1 Space / Area Heating
kw
No. of Dryers 1 a@ Gas Heating Devices
kw
No. of Water Heaters
No. of Signs
TV Outlet 4
Telephone Devices 1
No. of Hydro Massage Tubs No. of Motors
Other: (z) toe Kick heaters
(1) sub panel
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: May 2, 2013 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 the exhibited proof of the same to the permit
issuing office.
CHECK ONE: INSURANCE FTI ; BOND OTHER r (Specify:)
I certify, under the pains and penalties of perjury, that the information on this application is true & complete.
FIRM NAME Dumais Electric LIC. NO. 12170A
Licensee Mark A. Dumais Signature LIC. NO. 26665E
(If applicable, enter "exempt" in the license number line.)
Address S NewportStreet Bus. Tel. No
Methuen, MA 01844 Alt. Tel No
978-683-9438
978-685-4553 \1
* 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 insurance coverage normally
required by law. By my signature below, I herby waive this requirement. I am the (check one) rimer Fvner's agent
Owner / Agent
Signature Telephone No. FPERMITFEE:
I
�� o Lc 1 Z- 3- l 3 l^"�'I
The Commonwealth of Massachusetts Print Form
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Dumais Electric Inc.
Address: 8 Newport Street
Citv/State/Zin: Methuen, MA 01844
Phone #:978-683-9438
Are you an employer? Check the appropriate box:
1.0 I am a employer with 9 4. ❑ I am a general contractor and I
employees (full and/or part-time).*
2. ❑ 1 am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
have hired the sub -contractors
listed on the attached sheet.
These sub -contractors have
employees and have workers'
comp. insurance.t
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. F1 Electrical repairs or additions
I 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.
f 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.
Insurance Company Name: Travelers Insurance Company
Policy # or Self -ins. Lic. #: UP -7C833078
Job Site Address: 77 Bear Hill Rd
Expiration Date: 2/2/14
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 certif
v under the pains and penalties ofperjury that the information provided above is true and correct.
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
Phone #:
Information and Instructions
46
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-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 7-2010 www.mass.gov/dia
COMMONWEALTH OF MASSACHUSETTS
.REGISTERED MASTER ELECTRICIAN
ISSUES THE ABOVE LICENSE TO:
:DUMAIS ELECTRIC INC
MARK A DUMAIS.
8 NEWPORT ST
METHUEN MA 01844-3425031
12170 A 07/31/13 831670
COMMONWEALTH OF MASSACHUSETTS.
AS A REG JOURNEYMAN ELECTRICIAN
ISSUES THE ABOVE LICENSE TO:
-MARK A DUMAIS fm
8 NEWPORT ST Vim,
METHUEN MA 01844-3425x;
26665 E 07/31/13 831671
Date JZ�
......
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ............. . `
has permission for gas Inst llation .Q .t ..� . U
�e � I � ver
m the buil mg f ... ..�.......................... .
at.. ....... North Andover Mass.
Fee......... Lic.No............ ..................... ...
GASINSPECTOR
Check # wMq
hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my
Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. `
PLUMBERIGASFITTER NAME: _At i e" r,� &/ fVtr,�/ C'l'G(<jLICENSE # 102X SIGNATURE `
COMPANY NAME: ADDRESS: %�0 a3 ""t� % !v
I/
CITY: !J ri' to STATE: Aj re ZIP: n < <� 1, FAX:
TEL: CELL: `/,,;) Ii 9— EMAIL: 7 a LL c, c A ,a
MASTER;' JOURNEYMAN ❑ LP INSTALLER ❑ CORPORATION ❑ # PARTNERSHIP ❑ # LLC ❑ #
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT.TO PERFORM GAS FITTING WORK
GOWNER
TYPE OR
PRLNT
CLEARLY
CITY: /1/_ MA. DATE: :1-2-5---/3 PERMIT # '
JOBSITE ADDRESS: _Zz����`�i fir% �� OWNER'S NAME: Uge
ADDRESS: TEL: FAX:
OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL 9
NEW: RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO ❑
APPLIANCES? FLOOR—Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER f
BOOSTER
CONVERSION BURNER
COOK STOVE J
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCK
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM 1 SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
INSURANCE COVERAGE
I have a current liabiii insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES;E�NO ❑
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 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 E3 AGENT E]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 under the permit issued for this application will be in compliance with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. `
PLUMBERIGASFITTER NAME: _At i e" r,� &/ fVtr,�/ C'l'G(<jLICENSE # 102X SIGNATURE `
COMPANY NAME: ADDRESS: %�0 a3 ""t� % !v
I/
CITY: !J ri' to STATE: Aj re ZIP: n < <� 1, FAX:
TEL: CELL: `/,,;) Ii 9— EMAIL: 7 a LL c, c A ,a
MASTER;' JOURNEYMAN ❑ LP INSTALLER ❑ CORPORATION ❑ # PARTNERSHIP ❑ # LLC ❑ #
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
,Y www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Name (Business/Organization/Individual): A-(,- 6- ef_e� ,hg!_.cc V,=
Address:_ nnig D j3e2 X 7
City/State/Zip: W dQ r CPhone #:
kre you an employer? Check the appropriate box:
tqllam a employer with _:
4. El am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
❑ I am a sole proprietor or partner-
listed on the attached sheet. t
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
❑ I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, §1(4), and we have no
insurance required.] i
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7emodeling
8. ❑ Demolition
9. ❑ Building addition
10. ❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
iy applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
omeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
ntractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
w iin employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
'ormation.
urance Company Name: A-( Lo y'- Lc -a
is h C
icy # or Self -ins. Lid. #: Gtn% A 9n� S l3 �- Expiration Date: d7 -02 C5'
Site Address: 7 7 +_ J ��o- � 1i)� City/State/Zip: �_ 1�c��cx ��-(Cb G f S 1+ j
:ach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
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
tp to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
estigations of the DIA for insurance coverage verification.
i Itereby cert under the p ns and ties of perjury that the information provided above is true and correct
� O %�
ine#: �;-?k'^F,-/5- V �
?fficial use only. Do not write in this area, to be completed by city or town official.
�ity or Town: Permit/License #
Issuing Authority (circle one):
. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
i. Other
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 nbt 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-contractor(s) name(s), address(es) and phone numbers) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP 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.
,he Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA. 021.11
Tel. # 617-727-4900 ext 406 or. 1.877-MASSAFE
This certifies that. �� . C Q..... v�. ' . AJ -0?: .
has permission to perform .. �' l ?��? .. .... "- - A....�2
plumbing in the buildings of. Iv ` A—..1 ................ .
at .. �... ��' ��!�.: �'............. North Andover, Mass.
Fee 5l.65`�'.. Lic. No. )D� 11... Hb ................... ...
PLUMBING INSPECTOR
Check #
0
r----- .� .,.r-r%nue rfl tiRmawn Wr1RK
MASSACHUSETTS UNIFORM APPLICATION FOR A PER I l v rcrrvi�re �.�s•L..... -
-_
<� --� P11AA DATE 3V S PERiv1lT,.
( CITY 4 u � ,, . >
JOBS! ADDRESS 7 `7 a��_ ay
OW!dER`S NAMa , < < 9 l��
P
TYPE OR
PRINT
CLEARLY
OWNER ADDRESS TEL
0CCUPAN CY TYPE: \ COMMERCIAL ❑
NEW ❑ RFNONIATION r REPLACEMENT: i1
FI)! URES -1 FLOOR -
BATHTUB
.TUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYS
DEDICATED GASiOtUSAND SYS
DEDICATEDGREASE SYS
DEDICAI D %:1 �111ATFR SYS
DEDICA T ED ipjA i ER RECYCLE SYS
DRINKING FOUNTAIN
DISHWASHER
FOOD DISPOSER
FLOOR I hREA DRAIN
INTERCEPTOR. fINTERIOP.j
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE 'MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATrcR ALL TYPES
WATER PIPING
OTHER
B -SMT 1 1 j 2 j 3; 4
FAX
EDUCATIONAL ❑ RESIDENTIAL -2j- -
PLANS SUBMI T TED: YES ❑ NO ❑
5 6 7 ( 8 1°-! 1u 11 12 13
INSURANCE COVERAGE:
I have a current liability insurance policy or its substas7tiat equivalent which, meets the requirements of N7C-L Cie. 142. Yes No
IF YOU CHECKED YES: PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY PR� OTHER TYPE OF INDEMNITY ❑ BOND ❑
OWNER`S INSURANCE WAIVER- I am away= that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Lairs, and that my signature on this permit application waives this requirement. ��r /
CHECK ONE BOX ONLY: OWNER ❑ AGENT ❑
Signature of Owner or Owners Agent
I hereby certify that all of the details and information i have submitted (or entered) regarding th appiication are true a piton w`Il b to din
best of my Knowledge and that all plumbing work and installations performed under the unit issued for this app
compliance with all Pertinentprovisionof the Massachusetts state Plumbing Code and Chapter 142 o?thGeneral Laws. \
PLUMBER NAME Nl i ! J ,t: �� � r -Q •� SIGNATURE
y % _ MP JP ❑ C ORPOPfJ ON Ir -19- °XR ; NERS'IP
❑ ± LC ❑' F
LIC .f��'l
COMPANY NAME
AA L_ p&__ -c ce
_ ADORE-S:'/''e
t' O K 7S X
CITY Ur
f/
�.- STA L
ZIP o t EMAIL
f LL
TEL __ CELL F2,9-&/-� - `fid' Y & FAX
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The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
600 Washington Street
Boston, MA. 02111
h z< www.massgov/riia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le;?ibly
Name (Business/Organization/Individual): AWL 6-- - 4ngee�
Address: nn/� ) t3e�l jt
City/State/Zip: W t1co r C�a _ Phone
kre you an employer? Check the appropriate box:
am a employer with 7
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
❑ I am a sole proprietor or partner-
listed on the attached sheet. #
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
❑ I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] i
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7,-emodeling
8. EJ Demolition
9. ❑ Building addition
10. El Electrical repairs or additions
11.❑ Plumbing repairs or additions
12. ❑ Roof repairs
13.❑ Other
iy applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information.
omeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
ntractors that check this box must attached an additi6nal sheet showing the name of the sub -contractors and their workers' comp. policy information.
Fn iin employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
brmation.
urance Company Name: ,t�L( Lo C- C
icy # or Self -ins. Lid. 2 Sr l3 Sr Expiration Date: o'( —02 6'
Site Address: —? J `� �'�� E ,- „ (' �1 City/State/Zip: a(/ _ 14��% �y -i�(� �. G t s �5
:ach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
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
ip to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
estigations of the DIA for insurance coverage verification.
hereby certlry tin der the pa ns and ties ofperjury that the information provided above is true and correct.
- C -7—/c"_
)fficial use only. Do not write in this area, to be completer) by city or town official.
�ity or Town:
Permit/License 4
Issuing Authority (circle one):
.. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector
i. Other
Location 7 Ate, 4;/
Note I -1
Check
26111
Date / 6) Y . /,
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $_
Other Permit Fee $
TOTAL
Building Inspector
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: ��l' -3 Date Received
Date Issued:
MPORTANT: Applicant must complete all items on this page
LOCATION_ _ - �3�i���tv�► d
PROPERTY OWNER O*yle-
Print 100 Year Old Structure yes no
MAP NO06, 4 PARCEL 07 ZONING'DISTRICT: Historic District yes no.
Machine __
, Shop Village yes- no)
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic ❑ Well
❑ Floodplain ❑ Wetlands
❑ Watershed, District
Il1Nater/Sewer
AA DESCRIPTION OF WORK TO BE PERFORMED:
,ftaf'C% X'/ L.l X ZY
e-
Vti ro3
OWNER: Name:
Address:
ijcrov aal -9ir
Aky)r b
Please Type or Print Clearly)
MC_CoI//iv1-M\'
—�s• 1A V L r0 0F- 14-4 D v*r_
%l,,-�er,►c ��.,,� T ria -fizz
Phone: 61> G PY - 41 Y
CONTRACTOR Name:Phone:. 99, Y w 2'
Address: AA
Supervisor's, Construction, Licenser 0 �' 5_03 73 Exp: Date:
Home; Improvement License_: f JAG U Z Exp. Date: '-S'� o) u
ARCHITECT/ENGINEER & Wdi4vx, IKc 6✓Ak J Phone: 4 7* 321 -/-?7J
Address: Reg. No.
FEE SCHEDULE: BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. ✓ '�
( v
FEE: $TotI Project Cost. $�� 415(.L t
Check No.: 7 g Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Plans Submitted Plans Waived 11 Certified Plot Plan ❑ Stamped Plans 11
Building Department
The foliowing is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc: Doc.Building Permit Revised 2012
Plans Submitted 9,
Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
Tanning/Massage/Body Art ❑
Swimming Pools ❑
Well ❑
Tobacco Sales ❑
Food Packaging/Sales ❑
Private (septic tank, etc. ❑
Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENT
DATE REJECTED
F
DATE APPROVED
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes _
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Driveway Permit
DPW Towk., Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT. TempDum §ter on site
Located at;124�Mair;Street 8. p yes
Fire Department sig atiare/date,=.4f,:. s-._� fn.
a{E ,4
COMMENTS
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTFS and DATA — (For department use)
�V uuh---
LJ Notified for pickup - Date
Doc.Building Permit Revised 2010
Enter construction cost for fee cal -
North Andover Fee Calculation
Construction Cost
3969580.00
m
$ -
$
4,758.96
Plumbing Fee
$
594.87
Gas Fee 100 comm.
$
100.00
Electrical Fee
$
594.87
Total fees collected
$
6,048.70
77 Bear Hill Road
531-13 on 1/23/2013
Add 11x14 Sunroom, 10x24 kitchen
addition, change all windows,
remodel bathroom
Project: t McGillvary Beams 77 Bear Hill Rd Andover MA
Location: Interior Beam 18 ft span
Uniformly Loaded Floor Beam
(2009 International Building Code(AISC 13th Ed ASD)]
A992-50 W10x49 x 18.0 FT
Section Adequate By: 7.0%
Controlling Factor: Deflection
DEFLECTIONS Center
Live Load 0.56 IN U385
Dead Load 0.14 in
Total Load 0.70 IN 0309
Live Load Deflection Criteria: L/360 Total Load Deflection Criteria: U240
REACTIONS A B
Live Load 16857 Ib 16857 Ib
Dead Load 4176 Ib 4176 Ib
Total Load 21033 Ib 21033 Ib
Bearing Length 1.06 in 1.06 in
BEAM DATA Center
Span Length 18 ft
Unbraced Length -Top 0 ft
STEEL PROPERTIES
W1 Ox49 - A992-50
Properties:
Read
Provided
Yield Stress:
Fy =
50 ksi
Modulus of Elasticity:
E =
29000 ksi
Depth:
d =
10 in
Web Thickness:
tw =
0.34 in
Flange Width:
bf =
10 in
Flange Thickness:
tf =
0.56 in
Distance to Web Toe of Fillet:
k =
1.06 in
Moment of Inertia About X -X Axis:
lx=
272 in4
Section Modulus About X -X Axis:
Sx =
54.6 in3
Plastic Section Modulus About X -X Axis:
Zx =
60.4 in3
Design Properties per AISC 13th Edition Steel Manual:
Flange Buckling Ratio:
FBR =
8.93
Allowable Flange Buckling Ratio:
AFBR =
9.15
Web Buckling Ratio:
WBR =
23.18
Allowable Web Buckling Ratio:
AWBR =
90.55
Controlling Unbraced Length:
Lb =
0 ft
Limiting Unbraced Length -
wT =
2337
for lateral -torsional buckling:
Lp =
8.97 It
Nominal Flexural Strength w/ safety factor:
Mn =
150699 ft -Ib
Controlling Equation:
F2-1
Web height to thickness ratio:
h/tw =
23.18
Limiting height to thickness ratio for eqn. G2-2: h/tw-limit =
53.95
Cv Factor:
Cv =
1
Controlling Equation:
G2-2
Nominal Shear Strength w/ safety factor:
Vn =
68000 Ib
Controlling Moment: 94649 ft -Ib
9.0 ft from left support
Created by combining all dead and live loads.
Controlling Shear: -21033 Ib
At support.
Created by combining all dead and live loads.
Comparisons with required sections:
Read
Provided
Moment of Inertia (deflection):
254.21 in4
272 in4
Moment:
94649 ft -Ib
150699 ft -Ib
Shear:
-21033 lb
68000 lb
\ page
Dan L Gelinas P.E. /
Gelinas Structural Engineering LLC
579A North End Flvd. r
0 Of
Salisburv;M �ai?�2i- !1.4
L_ _f
StruCalc Version 3:53:49 PM
LOADING DIAGRACf. rs
DA EL L.
O GELNAS
O STRUCTLAAL m
.� Nu. 33394 ) JN.
FLOOR LOADING
Side
1
Side 2
Floor Live Load
FLL =
1873
psf
0 psf
Floor Dead Load
FDL =
415
psf
0 psf
Floor Tributary Width
FTW =
1
ft
0 It
Wall Load
WALL =
0 plf
BEAM LOADING
Beam Total Live Load:
wL =
1873
plf
Beam Total Dead Load:
wD =
415
plf
Beam Self Weight:
BSW =
49
plf
Total Maximum Load:
wT =
2337
plf
13�t
NOTES Io 10644 10e
Project: t McGillvary Beams 77 Bear Hill Rd Andover MA
Location: Interior Beam
Uniformly Loaded Floor Beam
[2009 International Building Code(AISC 13th Ed ASD)]
A992-50 W10x60 x 20.0 FT A 90-T4Section Inadequate By: 2.3% D �_ eV P,
Controlling Factor: Deflection
DEFLECTIONS Center
Live Load 0.68 IN U352
Dead Load 0.17 in
Total Load 0.85 IN U281
Live Load Deflection Criteria: U360 Total Load Deflection Criteria: U240
REACTIONS A B
Live Load 18730 Ib 18730 Ib
Dead Load 4750 Ib 4750 Ib
Total Load 23480 Ib 23480 Ib
Bearing Length 1.18 in 1.18 in
BEAM DATA Center
Span Length 20 ft
Unbraced Length -Top 0 ft
STEEL PROPERTIES
W1 Ox6O - A992-50
Properties:
Yield Stress:
Fy =
50 ksi
Modulus of Elasticity:
E =
29000 ksi
Depth:
d =
10.2 in
Web Thickness:
tw =
0.42 in
Flange Width:
bf =
10.1 in
Flange Thickness:
tf =
0.68 in
Distance to Web Toe of Fillet:
k =
1.18 in
Moment of Inertia About X -X Axis:
lx=
341 in4
Section Modulus About X -X Axis:
Sx =
66.7 in3
Plastic Section Modulus About X -X Axis:
2x =
74.6 in3
Design Properties per AISC 13th Edition Steel Manual:
p
Flange Buckling Ratio:
FBR =
7.43
Allowable Flange Buckling Ratio:
AFBR =
9.15
Web Buckling Ratio:
WBR =
18.67
Allowable Web Buckling Ratio:
AWBR =
90.55
Controlling Unbraced Length:
Lb =
0 ft
Limiting Unbraced Length -
for lateral -torsional buckling:
Lp =
9.08 ft
Nominal Flexural Strength w/ safety factor:
Mn =
186128 ft -Ib
Controlling Equation:
F2-1
Web height to thickness ratio:
h/tw =
18.67
Limiting height to thickness ratio for eqn. G2-2: h/tw-limit =
53.95
Cv Factor:
Cv =
1
Controlling Equation:
G2-2
Nominal Shear Strength w/ safety factor:
Vn =
85680 Ib
40Dan L Gelinas P.E. /
� O
Gelinas Structural Engineering LLC
579A North End Blvd
SalisburvMA 019511PSIA .
StruCalc Version 8.0.111.0a "1' ; Z ' 13 3:54:46 PM
DAWEL L.
GELINAS
STRUCTURAL
t4a. 33934
20
FLOOR LOADING
Side 1
Side 2
Floor Live Load
FLL = 1873 psf
0 psf
Floor Dead Load
FDL = 415 psf
0 psf
Floor Tributary Width
FTW = 1 ft
0 it
Wall Load
WALL = 0 plf
BEAM LOADING
Beam Total Live Load:
wL = 1873 plf
Beam Total Dead Load: wD = 415 plf
Beam Self Weight:
BSW = 60 plf
Total Maximum Load:
wT = 2348 plf
p
t
Controlling Moment: 117400 ft -Ib
10.0 ft from left support
Created by combining all dead and live loads.
Controlling Shear: 23480 Ib
At support. /� I
Created by combining all dead and live loads.
Comparisons with required sections: Read Provided
Moment of Inertia (deflection): 348.71 in4 341 in4 n I y f
Moment: 117400 ft -Ib 186128 ft -Ib fl I
Shear: 23480 lb 85680 lb
NOTES
Project: t McGillvary Beams 77 Bear Hill Rd Andover MA
Location: GArage Beam
Uniformly Loaded Floor Beam
12009 International Building Code(AISC 13th Ed ASD)]
A992-50 W 12x26 x 24.0 FT
Section Adequate By: 32.1 %
Controlling Factor: Deflection
DEFLECTIONS Center
Live Load 0.61 IN U476
Dead Load 0.18 in
Total Load 0.79 IN U365
Live Load Deflection Criteria: U360 Total Load Deflection Criteria: U240
REACTIONS- A B
Live Load 5760 Ib 5760 Ib
Dead Load 1752 Ib 1752 Ib
Total Load 7512 Ib 7512 Ib
Bearing Length 0.68 in 0.68 in
BEAM DATA Center
Span Length 24 ft
Unbraced Length -Top 0 ft
STEEL PROPERTIES
W 12x26 - A992-50
Properties:
Yield Stress:
Fy =
Modulus of Elasticity:
E =
Depth:
d =
Web Thickness:
tw =
Flange Width:
bf =
Flange Thickness:
ft =
Distance to Web Toe of Fillet:
k =
Moment of Inertia About X-X.Axis:
Ix=
Section Modulus About X=X Axis:
Sx =
Plastic Section Modulus About X -X Axis:
ZX =
Design Properties per AISC 13th Edition Steel Manual:
Flange Buckling Ratio:
FBR =
Allowable Flange Buckling Ratio:
AFBR =
Web Buckling Ratio:
WBR =
Allowable Web Buckling Ratio:
AWBR =
Controlling Unbraced Length:
Lb =
Limiting Unbraced Length -
120 plf
for lateral -torsional buckling:
Lp =
Nominal Flexural Strength w/ safety factor:
Mn =
Controlling Equation:
F2-1
Web height to thickness ratio:
h/tw =
Limiting height to thickness ratio for eqn. G2-2:
h/tw-limit =
Cv Factor:
Cv =
Controlling Equation:
G2-2
Nominal Shear Strength w/ safety factor:
Vn =
Controlling Moment: 45072 ft -Ib
12.0 ft from left support
Created by combining all dead and live loads.
Controlling Shear: -7512 Ib
At support.
Created by combining all dead and live loads.
50 ksi
29000 ksi
12.2 in
0.23 in
6.49 in
0.38 in
0.68 in
204 in4
33.4 in3
37.2 in3
Dan L Gelinas P.E.
Gelinas Structural Engineering LLC
579A North End Blvd of
Salisbury MA 01952-1738
StruCalc
Version 8.0.111.0 1/16/2013 3:32:10 PM
FLOOR LOADING
9.15
47.13
Side 1
Side
Floor Live Load
FLL =
40 psf
0 psf
Floor Dead Load
FDL =
10 psf
0 psf
Floor Tributary Width
FTW =
12 ft
0 ft
Wall Load
WALL =
0 pif
AL
NO. 33994
BEAM LOADING
_
Beam Total Live Load:
wL =
480 pif
Beam Total Dead Load:
wD =
120 plf
Beam Self Weight:
BSW =
26 Of
Total Maximum Load:
wT =
626 pif
8.54
9.15
47.13
90.55
0 ft
�(
5.33 ft
OF
92814 ft -Ib
rr_,?-,DA
47.13
L.
53.91
S
AL
NO. 33994
56120 Ib
_
Comparisons with required sections: Read Provided
Moment of Inertia (deflection): 154.42 in4 204 in4
Moment: 45072 ft -Ib 92814 ft -lb
Shear: -7512 lb 56120 lb
Garage Beam
w12x26
6<e1eL-
(T/Boise Cascade Quadruple 1-314" x 16" VERSA -LAM® 2.0 3100 SP DesignslGarage
Dry I 1 span I No cantilevers 10/12 slope Wednesday, January 16, 2013
BC CALC® Design Report - US 12-00-00 OCS
Build 1926 File Name: BC CALC Project
Job Name: Description: Designs\Garage
Address: Specifier: D�16�1City, State, Zip: , Designer:
Customer: Company:
Code reports: ESR -1040 Misc:
Total Horizontal Product Length = 24-00-00
Reaction Summary (Down / Uplift) ( lbs )
Bearing Live Dead Snow Wind Roof Live
B0, 3-1/2" 5,760/0 1,818/0
B1, 3-1/2" 5,760/0 1,818/0
Live Dead Snow Wind Roof Live OCS
Load Summary
Tag Description Load Type Ref. Start End 100% 90% 115% 160% 125%
1 Standard Load Unf. Area (Ib/ft^2) L 00-00-00 24-00-00 40 10 12-00-00
Controls Summary
Value
%Allowable Duration Case
Location
Pos. Moment
43,750 ft -lbs
58.5%
100%
1
12-00-00
End Shear
6,552 lbs
30.8%
100%
1
01-07-08
Total Load Defl.
U309 (0.913")
77.6%
n/a
1
12-00-00
Live Load Defl.
L/407 (0.694")
88.5%
n/a
2
12-00-00
Max Defl.
0.913"
91.3%
n/a
1
12-00-00
Span / Depth
17.7
n/a
n/a
0
00-00-00
_% Allow
% Allow
Bearing Supports
Dim. (L x W)
Value
Support
Member
Material
BO Post
3-1/2" x 7"
7,579 lbs
n/a
41.2%
Unspecified
B1 Post
3-1/2" x 7"
7,579 lbs
n/a
41.2%
Unspecified
Notes
Design meets Code minimum (U240) Total load deflection criteria
Design meets Code minimum (0360) Live load deflection criteria.
Design meets arbitrary (1 ") Maximum total load deflection criteria.
Calculations assume member is fully laterally braced.
Design based on Dry Service Condition.
Fastener Manufacturer: Simpson Strong -Tie, Inc.
Page 1 of 2
Disclosure
Completeness and accuracy of input must
be verified by anyone who would rely on
output as evidence of suitability for
particular application. Output here based
on building code -accepted design
properties and analysis methods.
Installation of BOISE engineered wood
products must be in accordance with
current Installation Guide and applicable
building codes. To obtain Installation Guide
or ask questions, please call
(800)232-0788 before installation.
BC CALC@, BC FRAMERS, AJS-,
ALLJOIST@ , BC RIM BOARD-, BCI@ ,
BOISE GLULAMTm, SIMPLE FRAMING
SYSTEM@, VERSA -LAMS, VERSA -RIM
PLUS@ , VERSA -RIM@,
VERSA -STRAND@, VERSA -STUD@ are
trademarks of Boise Cascade Wood
Products L.L.C.
'0 OF
DANIEL L.
GELiMAS
STRUCTURAL
No. 33994
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This certifies that
has permission for as in tallation.. kA.�-. .....
in the buildings of ... . ...............
-
at ...... T
77 `,,\
...... North Andover, Mass.
Fee. .5o. -:-. . Lic. No. :3( L� - - - Mb ................... ...
GASINSPECTOR
Check# ,T7 1
8556
Pck *3e. 7 t-) -) I
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY NORTH ANDOVER MA DATE JANUARY 15 2013 PERMIT #
I
IK
Jp
V-�
JOBSITE ADDRESS 77 BEAR HILL RD. OWNER'S NAME DAVE MCGILLIVARY
GOWNER
ADDRESS I DAVE MCGILLIVARY TE978-258-8226 FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY
NEW: E] RENOVATION: ® REPLACEMENT: El PLANS SUBMITTED: YES® NO®
APPLIANCES 7 FLOORS—• 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
JBSMI
BOOSTER
CONVERSION BURNER
COOK STOVE J
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER _J
ROOF TOP UNIT
TEST_ --
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER I INSTALL AN UNDERGROUND 1 _
GAS LINE AND CONNECT TO A
PLUMBERS INSPECTED LINE
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LI TY INS E P CY OTHER TYPE INDEMNITYE] BOND Ej
OWNER'S INS N W E am a th a licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts G ra aw and my ' nature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ® AGENT
SIGNATURE OF OWNER OR AGENT
I her y c ify that all of the details and information I have submitted or entered regarding this application are true and a rat est of <nowledge
and t a I plumbing work and installations performed under the permit issued for this application will be in mplia ith a 'r ent sion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME I JOHN COOMBS LICENSE # 3064 SIGNATOR
MP ® MGF ® JP[D JGF ® LPGI CORPORATION E]# TNERSHIP®# LLC ®#
COMPANY NAME: EASTERN PROPANE GAS ADDRESS 1131 WATER ST.
CITY I DANVERS STATE MA ZIP 01923 TEL 1-800-322-6628
FAxF CELLI EMAIL
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=plo} tts d ull and/or par -rimy
ed the sub -ca Lors
have ='-d onu-
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listed On ell al:'2ivIleCi chest.
am a Sole pro-proo: pa -mer
Tues- suit -con -ton have
Ship and have noemp]O y e✓
employees and have worhtn'
worl.ing itor me in any capaciry.
_
FNo worl=ss' comp. TCsurance
comp. insurance.=
lit are a co-moraTIOD" nd 1%S
officers hour elOercised tne�
1 am all homeou�er ciolnz all wort
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myse1?. [NO workers' cnarp.
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Type of praj�ct (required}
6. 1'•! eV.' GaIlSLrI�cT] OL
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] U.❑ �lecaica rspas or addition:
1.❑ plumbing repars o= addraons
Root repair
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ny apnlirthza_i bo._ ant --Il m, -S: also MI out tis: section mlow shovg tam wormer' -=Ip rm mmi: m � _
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tom own.:, tivho svamz anis amdavi mdicalm� th ,oy
7IIL,:L."LJTn t=L C11 --CL - -','007_ IIIDT. arra^nr.0 a-i6itim;q Stl�* Shvwm��Y. nam o_ tn�. �¢L-OaIIuz.-2� aad Mal -
.
aid wb.eEn.T- oTna_tjlose �IIII�s aav�
ploy=s. Z the snit cent a for have �pit�ysa thc}' ==L grovine to warl --s' cow. poli -7, numbP_
an err�Zoyer tlzai is prm�i g warl.�rs' compensLzrior ir`surance for my Lalvw is to f poli 7, and jab ,sem
�a;•rrzQi?.an
�urzalce Company Nam.=: ! 1B�p i y I�ITU� 11»UR.kNC_= COIJtP:=.NY
licy t Or SeL-inc. Lic., : WC1-541 ^358DS-D52
p>1-aon Date: DB l 15 / 2013
C,o� City/5rate/Zip: n �� c.� w -e
tach acopy- of the vor);e s' compensation policy declaration page (showinn the Polis;' n>rmb�^and eypirarion date}_
ijure T scot rt coverage zs regui ed under Section 25A of I GL c. i 52 can lead io the imposinon or ni,nina] penalises a a
e up t0 11,300.00 and/o-.one-gear imprlson-mtm as well as civil ptnal�aes in int fD--z> of a STOP COPY OPDER. and a nrlt
UP to S'230-00 a day agai��st the iolatOr. Be an T150� faa't 2 -07 Oi this' StatEImtni may b= 10TWaTO AEf 10 The 0 ice o'1
esti=ati0 of the D1A for insurance cove -age verification.
O J °T�177 ce�zifl; v_nder Ih_F pair_c and penal` °fPer7ur}: ZIi� rte inj°rmazi°r_ provided above w n�f vzd corr�c�
P = 978-750-5500
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0ther
El
Location 1 �4' 2- /
No. —13
Date 2 - Za ' 4 --
Check
26051
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee
Other Permit Fee $
TOTAL $ t
Building Inspector
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO:'� Date Received 1Z -z_0 1 2
J :7�I
Date Issued: 2- .o - % z --
IMPORTANT:
IMPORTANT: A plicant must complete all items on this page
LOCATION'_ ;Z- 41+cl
Print
PROPER 9Y OWNER . 19 -uc- 4"IKA7 r_ . _%Y►�- 61 hy rzay
--- _ _.
Print 100:Year. Old Structure yes no: .
MAP NO: PARCEL•: ZONING DISTRICT: Historic District yes no.
Machine Shop- Village yes. no,
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
P? One family
XAddition
❑ Two or more family
,❑ Industrial
❑ Alteration
No. of units: �'`
'- ❑ Commercial .
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic ❑ Well:
❑ .Floodplain El Wetlands
❑ Watershed,Distdct,
Water/Sewer.
41DESCRIPTION WORK TO PE PERFORMED:
11'
ove
0� a% �4 J
Identific ion Please Type or Print Clearl
OWNER: Name: D,o u e a k>k4e- ^ c 6)ll,vY-A-,i Phone( /?) _� ��'
Address: K d Al,
CONTRACTOR Name: p �- 14r,d 4- ,fka Phone:121. 6 � 65/ x
Address-, ve:/'hc�'��e�.. %►�)9
Supervisor's Construction License.:. C� �' ,5-1 � 3_ _ Exp. Date:_ _ _
Home Improvement`License: J C Exp. Dater'��/�
srg3
ARCHITECT/ENGINEER /11&g4,A4 h"zCO)hyS Phone: �97�') �?cl- sm?
Address: At 4rj Reg. No.
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ 3 FEE: $ /0,y
Check No.: Receipt No.: a(26 -S7
NOTE: Persons contract g with unregistered contractors do not have access to the guaranty fund
Signature of Aent/Owner/� Ga;.LG.Si nature of contractor
Plans Submitted 4� Plans Waived El Certified Plot Plan ❑ Stamped Plans ❑
9
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
u Building Permit Application
u Workers Comp Affidavit
o Photo Copy Of H.I.C. And/Or C.S.L. Licenses
o Copy of Contract
u Floor Plan Or Proposed Interior Work
o Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
o Building Permit Application
a Certified Surveyed Plot Plan
o Workers Comp Affidavit
o Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
Li Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
u Mass check Energy Compliance Report (If Applicable)
o Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
o Building Permit Application
o Certified Proposed Plot Plan
o Photo of H.I.C. And C.S.L. Licenses
a Workers Comp Affidavit
o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
u Copy of Contract
o Mass check Energy Compliance Report
o Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc: Doc.Building Permit Revised 2012
Plans Submitted X Plans Waived ❑ Certified Plot Plan 0 Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ®
Tanning/Massage/Body Art ❑
Swimming Pools ❑
Well ❑
Tobacco Sales ❑
Food Packaging/Sales ❑
Private (septic tank, etc. ❑
Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ /
COMMENTS�%f
CONSERVATION Reviewed on — Si nature
% A4e7l'41�-.
COMMENTS
_ 11L�— jjA0-9 az/**� L'q
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
s Planning Board Decision:
I
Conservation Decision:
Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Tow Engineer: Signature:
Located 384 Osgood Street
FIRE'DEPARTMENT _ Temp Dumpster on siteyes no
Located at 124 Main Street
Fire Departi-hent,sidnature/date
COMMENTS
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA — (For department use
® Notified for pickup - Date
Doc.Building Permit Revised 2010
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12/20/2012 2:30 PM FROM: MTM Insurance Microsoft TO: 19786889542 PAGE: 002 OF 002
ACORD CERTIFICATE OF LIABILITY INSURANCE
DATE 0/2[)I
1YYYY)
2/20/2012
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER
CONTACT Victoria Lowes, CISR
MTM Insurance Associates
1320 Osgood Street
PHONE (978) 681-5700 FAX (978)681-5777
AIC No Ex AIC No:
E-MAIL.ADDRESS.vickiel@mtminsure.com
INSURER(S) AFFORDING COVERAGE NAIC S
North Andover MA 01845
INSURERA -Maiden Specialty Insurance
INSURED
INSURER B:Safety indemnity Insurance 33618
Cote & Foster Contracting, Inc
INSURERC:Ccnnerce & Industry Insurance
20 Aegean Drive
INSURERD:Travelers Insurance Group
INSURER E :
NAX1000490
Methuen MA 01844
INSURER F
I WvmmAI =J W aster In cr vc1/1c[r Kl nrneaoro.
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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
TYPE OF INSURANCE
ADDL
SUBR
POLICY NUMBER
POLICY EFF
MMIDDIYYYY
POLICY EXP
MMIDDIYYYY
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000
A
X COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE a OCCUR
NAX1000490
2/31/2011
2/31/2012
CA MAGE TO RENTED
PREMISES Ea occurrence $ 100,000
MED EXP (Any oneperson) $ Excluded
PERSONAL & ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OPAGG $ 2,000,000
X POLICY PRO-
RO LOC
JECT
$
AUTOMOBILE LIABILITY
Ea COMBI
EDI SINGLE LIMIT 1,000,000
BODILY INJURY (Per person) $
B
ANY AUTO
ALL OWNED X SCHEDULED
TOS
6216231
2/31/2011
2/31/2012US
BODILY INJURY (Per accident) $
X HIRED AUTOS X NON -OWNED
AUTOS
PROPERTY DAMAGE $
Per accident
Underinsured motorist BI s lit $
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE $
EXCESS LIAB
CLAIMS -MADE
AGGREGATE $
DED RETENTION $
$
C
WORKERS COMPENSATIONVIC
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
es, describe under
DySCRIPTION OF OPERATIONS below
DE
N/A
004962937
r I
6/20/2012
I
6/20/2013
STATU- OTH-
X ORY IMITS ER
E.L. EACH ACCIDENT $ 500,000
E.L. DISEASE - EA EMPLOYEE $ 500,000
E.L. DISEASE - POLICY LIMIT $ 500,000
D
Property Coverage
I6608A981820TIA11
2/31/2011
2/31/2012
BusienssPersonal Property $37,853
Scheduled Equipment
Contrctors Equipment $166,928
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required)
Certificate holder as listed below
Town of North Andover
384 Osgood Street
North Andover, MA 01845
%.AVACLLIA 1IVIV
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
MacDonald CPCU, CIC
.,......ra.. 44 k,LV I V,VvJ t9 IUBB-2010 ACORD CORPORATION. All rights reserved.
INS025 (201005).01 The ACORD name and logo are registered marks of ACORD
1,"
CONSERVATION DEPARTMENT
Community Development Division
December 13, 2012
David J. McGillivray
77 Bear Hill Road
North Andover, MA 01845
77 Bear Hill Road, North Andover
Construction of a 12' x 24' Deck on Sono -tube Footings
Conservation Conditions of Approval, NACC #104
Pursuant to section 4.4.2 (A) of the North Andover Wetlands Protection Regulations, William
Foster (builder), filed for a small project for work proposed at 77 Bear Hill Road, North Andover.
The proposed work includes of a new 12' x 24' deck on hand -dug sono -tube supports. The deck is
approximately 60 feet from the edge of an intermittent stream and associated Bordering Vegetated
Wetland (BVW) as shown on the herein referenced plan. The BVW area also serves as a stormwater
detention basin. The detention basin was built in the late 1970's within a resource area and has been
determined to be jurisdictional by the North Andover Conservation Commission (NACC).
During the December 12, 2012 public meeting, the NACC voted unanimously to approve this
project. All work shall conform to the following:
RECORD DOCUMENTS: Small Project Filing Including:
Application Checklist and narrative;
Interior layout plans prepared by William Foster;
Site Plan and aerial photograph both with hand edits;
Filing received: December 5, 2012 .
The following conditions are hereby mandated:
CONDITIONS:
Prior to the start of construction the applicant shall ensure that the site contractor has reviewed
the small project permit and is aware of the wetland resource area and the limits of the proposed
work. _
2. Prior to the start of construction, the applicant shallinstall erosion controls (trenched silt fence,
hay bales, silt sock, etc.) between the proposed work and the resource area. Please contact the
Conservation Department to inspect the erosion control before work begins.
1600 Osgood Street, Building 20, Suite 2-36, North Andover, Massachusetts 01845
Phone 978.688.9530 Fax 978.688.9542 Web www. http://www.townofnorthandover.com/conservel.htm
Excess construction material shall be properly disposed of offsite and accepted, engineering
and construction standards and procedures shall be followed in the completion of the
project.
4. Upon completion of the approved project and site stabilization, please contact the Conservation
Department for a final inspection.
5. This permit shall expire nine months from the date of issuance
Should you have any question or comments regarding the contents of this letter, please do not
hesitate to contact the undersigned at 978.688.9530 at your earliest convenience. Thanking you in
advance for your anticipated cooperation with this matter.
Respectfully,
NORTH AN OVE CO SERV TION DEPARTMENT
kJA /' .
Je nifer A. Hughes
nservation Administrator
1600 Osgood Street, Building 20, Suite 2-36, North Andover, Massachusetts 01845
Phone 978.688.9530 Fax 978.688.9542 Web www. http://www.tovmofnorthandover.com/conservel.htm
COTE nnow FOSTER�
CUSTOM BUILDING + REMODELING
December 10, 2012
Proposal submitted to Dave & Katie McGillivray for construction of a sunroom and
kitchen addition with finish basement below. Remodel & relocate existing half bath and
laundry to new first floor addition, relocate dining room walls, remove kitchen into living
room walls, keep existing chimney and living room walls, roof raise above family room
for new master bathroom and walk-in closet, re -frame garage roof to receive new master
bath and use above garage for attic storage, remove existing common bath and change all
windows and exterior doors. Work to be performed at the address of 77 Bear Hill Rd.,
North Andover, MA.
Details of project are outlined as follows:
1. Permit — All required permits required to complete project with the exception of
special permits such as conservation, zoning or planning will be supplied by
Contractor.
2. Design — All design work required to acquire permit and complete project to be
included. Design to be generated through discussions between Cote & Foster
Contracting and homeowner.
3. Sight Engineering - Not included. (We would need a plot plan for permitting).
4. Structural Engineer — Structural engineering as required to satisfy building dept.
for steel beam in kitchen and garage.
5. Portable Toilet Facilities - To be supplied by Contractor on site.
6. Debris Removal — Any debris generated by construction to be removed by
Contractor for all renovations by way of dumpsters.
7. Chimney Removal -Chimney to remain. Frame opening into office and master
bathroom.
8. Excavation —
• after the deck has been removed by Cote and Foster, remove the deck
footings (bury them onsite with the backfill)
• remove a small wood retaining wall at the rear corner of the house and set
aside for placement into the onsite dumpster at a later date (we assume the
retaining wall at the rear of the garage will remain in place)
20 Aegean Drive • Unit 15 • Methuen, MA 01 844
Tel: 978-682-6518 • Fax: 978-682-1221
www.coteandfoster.com
• remove small bushes that are in conflict with the proposed work and
dispose of offsite
• after the brick walkway has been removed by Cote and Foster, strip
topsoil, stockpile onsite
• planning on a frost wall, excavate for footings
• after the footings are stripped, install a 4" SCH -40 PVC solid roof drain
collection system with 5 risers and run it out to daylight a maximum of 40
feet
• backfill the footings, place crushed stone inside, grade and prepare the
floor for concrete
• after the building work is complete, return to the site, spread the existing
topsoil and grade the area to drain (landscape, rake & seed is not included)
• at the front of the house, remove the bushes and dispose of them offsite, to
prepare for farmers porch
Exclusions:
• ledge, unsuitable materials, contaminated materials, snow, frost, boulders
greater than 2 cubic yards or any other unknown materials excavation or
materials replacement
• tree cutting, tree liming, tree or limb chipping or log removal
• retaining walls, fences or guard rails
• pool work
• irrigation systems repair or modifications
• removal and/or replacement of the existing walkways
• landscaping, topsoil, planting or raking and seeding
• removal of the temporary roadway (this should be done with the
landscaping)
9. Foundation — 10"x 20" footing with two #5 rods continues throughout. 10"
concrete wall. Note: All concrete to be minimum 3000 PSI at 28 -day cure.
10. Concrete Floor — 3" to 4" of 3000 PSI concrete with 6"x 6" wire mesh
reinforcement. Concrete to have a smooth troweled finish.
11. Concrete Cut — Access through existing foundation wall. Cut and remove
existing concrete. Use concrete piece under slab fore base material.
12. Foundation Sealer - To be sprayed on waterproof system "rubberized"
13. Demolition — Demolish all areas as indicated to make way for new work and to
accommodate new layout. Access and fixtures per design, including all bathrooms
and ceilings in family room, kitchen and dining room.
14. Frame — 2"x 6" P.T. sill with 2"x 6" double. Floor joist to be 2" x 10" at 16"
O.C. Floor sheathing to be 3/4" Advantech glued and nailed. Wall frame to be 2" x
6" at 16" O.C. Wall sheathing to be 1/2" CDX Fir Plywood. Second floor frame to
be 2" x 10" at 16" O.C. Floor sheath to be 3/4" Advantech glued and nailed.
28. Insulation —
• CEILING 12 KRAFT FACED R-38 16
• CEILING - COLD ABOVE 12 KRAFT FACED R-38 16
• GARAGE CEILING 9 1/2 KRAFT FACED R-30 16
• SLOPED CEILING 10.5 H/D KRAFT FACED R-38 15
• EXTERIOR WALLS - 1 ST FLOOR 5.5 FRICTION FIT WITH POLY R-
2115
• EXTERIOR WALLS - 2ND FLOOR 5.5 FRICTION FIT WITH POLY
R-2115
• BATH PARTITIONS 3 1/2 FRICTION FIT R-11 15
• OVERHANG 12 KRAFT FACED R-38 16
• BLOCKERS AND RUNNERS 5.5 FRICTION FIT R-2115
• VENTS NA "16"" POLY VENTS" NA 16
• FIRESTOPPING N/A
29. Plaster —'/2" Blue Bd. at all walls and ceiling +1/16" of skim coat plaster at all
surfaces. All walls to have smooth finish. All ceilings to be smooth. All closet
interior finish to be textured.
30. Floor coverings:
(a) Hardwood - Red or white oak flooring to include purchase, installation,
sanding and three coats of clear urethane finish. Other wood species may
increase cost. Total allowance $5,130.00.
(b) Tile — Prep to be den shield bedded in thin set and nailed. Tile
installation, materials and labor. Tile material allowance of $4./sq. ft.
Note: Any patterns or diagonal tile may result in additional costs for
materials and labor. Total allowance $10,656.00.
(c) Carpet - Allowance of $30./yd. to include purchase of carpet pad and
installation. Total allowance $2,000.00 plus $1,590.00 for basement,
Totaling $3,590.00.
• Kitchen -Tile
• Half Bathroom -Tile
• Laundry -Tile
• Full Bathroom -Tile
• Master Bathroom -Tile
• Office & Family Room -Carpet
• New Family Room -Oak
• Sunroom-Oak
• Bedroom #1 -existing oak
• Bedroom #2 -existing oak
• Bedroom #3 -existing oak
• Existing Master Bedroom -blend oak into old bath area, sand & re -finish
existing bedroom
• Foyer -Tile
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1
CONSERVATION DEPARTMENT
Community Development Division
December 13, 2012
David J. McGillivray
77 Bear Hill Road
North Andover, MA 01845
77 Bear Hill Road, North Andover
Construction of a 12' x 24' Deck on Sono -tube Footings
Conservation Conditions of Approval, NACC #104
Pursuant to section 4.4.2 (A) of the North Andover Wetlands Protection Regulations, William
Foster (builder), filed for a small project for work proposed at 77 Bear Hill Road, North Andover.
The proposed work includes of a new 12' x 24' deck on hand -dug sono -tube supports. The deck is
approximately 60 feet from the edge of an intermittent stream and associated Bordering Vegetated
Wetland (BVW) as shown on the herein referenced plan. The BVW area also serves as a stormwater
detention basin. The detention basin was built in the late 1970's within a resource area and has been
determined to be jurisdictional by the North Andover Conservation Commission (NACC).
During the December 12, 2012 public meeting, the NACC voted unanimously to approve this
project. All work shall conform to the following:
RECORD DOCUMENTS: Small Project Filing Including:
Application Checklist and narrative;
Interior layout plans prepared by William Foster;
Site Plan and aerial photograph both with hand edits;
Filing received: December 5, 2012
The following conditions are hereby mandated:
CONDITIONS:
Prior to the start of construction the applicant shall ensure that the site contractor has reviewed
the small project permit and is aware of the wetland resource area and the limits of the proposed
work.
2. Prior to the start of construction, the applicant shall install erosion controls (trenched silt fence,
hay bales, silt sock, etc.) between the proposed work and the resource area. Please contact the
Conservation Department to inspect the erosion control before work begins.
1600 Osgood Street, Building 20, Suite 2-36, North Andover, Massachusetts 01845
Phone 978.688.9530 Fax 978.688.9542 Web www. http://www.townofnordiandover.com/conservel.htrn
3. Excess construction material shall be properly disposed of offsite and accepted engineering
and construction standards and procedures shall be followed in the completion of the
project.
4. Upon completion of the approved project and site stabilization, please contact the Conservation
Department for a final inspection.
5. This permit shall expire nine months from the date of issuance
Should you have any question or comments regarding the contents of this letter, please do not
hesitate to contact the undersigned at 978.688.9530 at your earliest convenience. Thanking you in
advance for your anticipated cooperation with this matter.
Respectfully,
NORTH AN O4VE SERV TION DEPARTMENT
PA
� 2.
r--
Je rifer A. Hughes
nservation Administrator
1600 Osgood Street, Building 20, Suite 2-36, North Andover, Massachusetts 01845
Phone 978.688.9530 Fax 978.688.9542 Web www. http://www.townofnorthandover.com/conservel.htm
Location
No.
/
Date �a { f• I I t i
TOWN OF NORTH ANDOVER
Certificate of Occupancy
Buil$,0'r6S Permit Fee
JD-Indation Permit Fee
�Othe{ I,@ it Fee I I—
Sewer CqngFee
Cnection Fee
AO-
1411,11—$
O -TOTAL $ ��
Building Inspector
Div. Public Works
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FORM U
TOWN OF NORTH ANDOVER
LOT RELEASE FORM
SUBDIVISION 15E --)}(Z }FILL RO14D
ASSESSORS MAP 00004p4
SUBDIVISION LOT(S) L6+- (D
PERMANENT ADDRESS ASSIGNED BY D.P.W.
STREET '77 16E*h2 HILL Izb. , NO. HOJDoOEp-, hip
APPLICANT Alec. 4- BA"44A CaFLUso PHONE 691—glg3
DATE OF APPLICATION-jjg,r, -J q�11
TOWN USE BELOW THIS LINE
PLANNING BOARD
DATE APPROVED
TOWN PLANNER DATE REJECTED
CONSERVATION C6MMISSI N
i llA'TL•' APPROVED
CONSE ATION ADMIN.-Pr.ar- , uc r % . DATE REJECTED
BOARD OF HEALTH
DATE APPROVED
HEALTH SANITARIAN DATE REJECTED
DEPARTMENT OF PUBLIC WORKS
DRIVEWAY PERMIT
SEWER/WATER CONNECTIONS
FIRE DEPT.
RECEIVED BY BUILDING INSPECTION
DATE
a
form shall be signed by the agents of the Planning and Health Boards,
nservation Commission prior to the issuance of any building permits
subject lot. This form shall not releive the applicant from the
,,ee of any applicable Town requirement or Bylaw.
z
Town of North Andover
!.' BUILDING DEPARTMENT
A Homeowner License Exemption
(Please print)
DATE r;/ 17 149/
JOB LOCATION '17
Number Street Address
Section of town
HOMEOWNER" "If �- RgRbC$�USO
' Name 883 �/�-289- 3535
Home Phone Work Phone
PRESENT MAILING ADDRESS -7? g6_A,Q Hl -
RD,
L• IVD0UEp- till
City Town 'p/gats
State Zip code
The current exemption for "homeowners" 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 ided
, ..DEFINITION OF HOMEOWNER: 109.1.1)
...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
d�
ing, attached or detached structures accessory to such use and/or farnwell-
-''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, on a form acceptable to the Bulding Official
that he/she shall be responsible for all such work performed under the
building permit. '
�,. (Section 109.1.1)
jI. The undersigned "homeowner" assumes responsibility for compliance
. State Building Code and other applicable codes, by-laws, rlesandwlth the
regulations.
The undersigned "homeowner" certifies that he/she understands
North Andover Building Department minimum inspection Proceduureshar�d
Town of
requirements and that he/she will comply with said procedures and
requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Note: Three family dwellings 35,000 cubic feet, or larger, will be
required to comply with State Building Code Section 127:0, Construction
Control.
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N511,LOILIP
This convenient "Options Directory" will help you to
plan a custom pool package.
PHONE: (306) 66&6307
STEP HANDRAIL MOUNT ......
(For Metal Stairs Only)
POOL STEPS w/HANDRAIL
HYDRO -THERAPY FITTINGS .. ... .
8" SNAP -STRIP COPING
OPTIONAL LINER PATTERNS
SLIDES ..........t.lJ.i/.%!f .t-.'....
O7 STAINLESS STEEL LADDERS re
O POOL HEATERS ...C%I�.� .:....
O9 POLYETHYLENE and PVC PIPE
e
X10 DIVING BOARDS .. (?. ��? �f 1
11 UNDERWATER LIGHTS. Flhh K.0016,%
12 MAIN DRAINS .... •! •f4........... .
13 REBARS .......... f4 .............
14 LADDER MOUNT.. . . ........ .
15 POOL BASE/ tftfTE 4 Ot ?.
16 WALL FOAM .......
11 DECK SUPPORT BRACES .14 -
18 AUTOMATIC POOL CLEANER
19 SOLAR POOL COVER (Not 11lustrated)
20 WINTER POOL COVER (Not Illustrated) �� C
' See Pool Price List
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NGRTpj
TOWN OF NORTH ANDOVER
,
Certificate of Occupancy $
* #
Building/Frame Permit Fee $ A SC
sZZ, �
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Other Permit Fee $
Sewer Connection Fee $
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TOWN of NORTH ANDOVER
owner of the above propert
Date Owner dame
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TOWN of NORTH ANDOVER
owner of the above propert
Date Owner dame
Location li / —, IZ 1/,e/1 // A
No. -S-5-3 Date
Check # /6 S
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ 06) --
Check
y
633 4
Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
_ � :.�-�8 ?F♦pT � ;�,
BUILDING PERMIT NUMBER: ��- 3 DATE ISSUED:
SIGNATURE:
Building Commissioner/Inspeqdir of Buildings Date
SECTION i- SITE INFORMATION
1.1 Property Address:
11.(2 Assessors Map and Parcel Number:
lel I
Map Number Parcel Number
n
o'-712
� 12 i3��- 7 �C
/ ��//%
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
I Lot Areas Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Required Provide R redProvided
Rapired Provided
1.7 Water SupplyM.GL.C.40. 54) 1.5. Flood Zone Information:
Public 0 Private 0 Zone Outside Flood Zone ❑
1.8 Sewerage Disposal System:
Municipal ❑ On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1Owner f Record
ame (hii r Address for Service
g as -�
Signature Telepho
Nne-
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor:
Address c
'i
Signature Telephone
Not Applicable ❑
License Number
Expiration Date
3.2 Registered Home Improvement Contractor
Not Applicable ❑
Company Name
Registration Number
Address
Expiration Date
Signature Tele hone
Ma
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SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
-Signed affidavit Attached Yes .......❑ No ....... ❑
SECTION 5 Description of Proposed Work check au applicable)
New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑
Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify
Brief Description of Proposed Work:
ZY O )Co fl
I SECTION 6 - F.STTMATF.n CONSTRUCTION COSTO I
Item
Estimated Cost (Dollar) to be
Completed b rmit applicant
OFFWIAI;VSE:ONLY
1.
Building
(a) Building Permit Fee
Multiplier
2
Electrical
(b) Estimated Total Cost of
Construction
3
Plumbing
Building Permit fee (8) x (b)
0-5
30-
4 Mechanical HVAC
-5 Fire Protection
6
Total 1+2+3+4+5
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGE OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner/Authorized Agent of subject property
He ieby 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
1, as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
Print Name
c
Signature of Owner/A ent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR T ABERS 1ST 2 ND 3
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIWNSIONS OF GIRDERS
DIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHD1 INEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
01/02/1994 09:30 6038636725 PROMANA PAGE 05
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Carta, ftcate of Flame Resistance
FABRIC
RriED ISSUED BY
FABRIC JOHNSON OUTDOORS INC. Date of Manufacture
i
Num JOHNSON
NEIN YORK 13802 AUGUST 1999
F-140.01 fAsn'Awtwerr ori Hnsn
Tent PnorJu,q Deaplfbeo irenet�
j This M to 98ft ht 3rd products hensin havo bean manufucW red from MAtarfai inherently flame retardant as
here aelsr specified by the fnaterial supplier.
MMIiE: PRO MANIA EVENTS
1 Crnr NEWPORT STATE: NH
cerulloMen!lahswbyfsaNt7nt:
The &IMie ft r I F, an (his aslWioat. have been monufaotand wth an t XW#d flame -Mnrdent chanfcal in comabence with
Calbn t b1ste File Momhal Code, NFPA-7010, Unoem n I$ Laboratory Of Csneda, and how* been tested n accoedence wth the
II FedwM T" Method Speail Aims and meet or exceed 10e Milft" Flom Specifications of Ma, -.C -43006G.
I , odorand w oN of matenal 1402.__ vinyl VVHITE SLOCKOUT
n..we.Mw�k r►erwwrsd _----71' itA rt VAD in, ELITE; , e
SCGTIG+T L
Ffarne Retardant Process Used 1111 Not Be Removed By Washing And
Is Effective For The Life Of The Fabric
OW/dsr Mariufucturing, Inc.042
iAaM1Ylrtaeear of fllatne Ratsul rt V" L&*W" TFE 4CPAWrmEkT. JOHNSON ouTo00RS INC-
L - - Ta fge Scale
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