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Miscellaneous - 78 UNION STREET 4/30/2018
This certifies that .... . 1 m !Y � !0`-�ft.l. has permission to perform .P�Q:"�l. plumbing in the buildings of .... �) L�..................... at .... .. )D 1-�- tv— , ; .......... ' North Andover, Mass. Lic. No.f� , .... PLUMBING INSPECTOR Check # eY P TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY I North Andover MA DATE 05-03-13 PERMIT # - I�oC 22 JOBSITE ADDRESS 78-80 Union St OWNER'S NAMEJ Paul Dubois OWNER ADDRESS 175,Meadow Lane TEL —FAX OCCUPANCY TYPE COMMERCIAL E] EDUCATIONAL NEW: ® RENOVATION: El REPLACEMENT: FIXTURES Z FLOOR- BSM BATHTUB _ CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER _ FLOOR /AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE 1 MOP SINK TOILET ............ I RINAL ............. 'WASHING MACHINE CONNECTION ,WATER HEATER ALL TYPES DATER PIPING OTHER f 2 1 3 1 4 1 5 1 6 1 7 RESIDENTIAL PLANS SUBMITTED: YES ® NOQ INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES [a NO Q IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [D OTHER TYPE OF INDEMNITY E] 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. j CHECK 0 ONLY: OWNE AG T SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this a plication are true d c to h'e b t of noM and that all plumbing work and installations performed under the permit issued for this applicatio will be in compli c i II P in provisio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME JLICENSE# 10301 SIG ATURE MP0 JPE] CORPORATION ®# PARTNERSHIP®# LLC E3# COMPANY NAME I Timothy A. Giard Plumbing & Heating Inc ADDRESS I P.0 Box. 782 CITY North Andover STATE Ma ZIP 01845 TEL 978 689 8336 FAX 978 689 8300 CELL 978 490 7108 EMAIL plL@Lahoo.com In— MP 0 n— 10 -1- K W E■ O z 0 U W d � z � w 0 0o Z z O o � � w O W aLU sa z w P w O Q a a W a W 3 N a 0 0 a w a J a a a co CLi FE w I-- w W F Z z 0 U W a z z m a a, m 0 a The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ° +�,./ �` G i �— �� Plumb t 2�,_4 Address: F'.O. So -.,z � �z City/State/Zip: N6, Ane6-y- Kc—, Uk vy J Phone #: 9q Z~ Cog - F3 3C> Are Vu an employer? Check the appropriate box: Type of project (required): 1 I am a employer with 1-1 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. El Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition 8 . -11 working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL 11. ❑ Plumbing repairs or additions myself. [No workers' comp, c. 152, § 1(4), and we have no 12. ❑ Roof repairs required.] insurance . re uired employees. [No workers' 1311 other comp. insurance required.] 'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they ace doing all work and then hire outside contractors must submit a new affidavit indicating such tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. M Insurance Company Name:. MTh. `� Policy # or Self -ins. Lic. Expiration Date: Job Site Address: � � � �� unl o, S'4 City/State/Zip: 06 � 4 ndQ t.r i N(— (31 $4� Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1, 500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the vio tor. Be advised that a copy of this statement may be forwarded to the Office of Investigations of thor insurylp coverage verification. I do � — cI that the information provided Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License 3 true and correct. 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 #: Inforxmation and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or. written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or' -permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The CoxrmoRw0alth of Massachv..sPtts Depaftent of Industrial .Accidents Office of Investigations 600 wwhi tgton St wt Boston, MA 02111 Tel, # 617-7274100 ext 406 or 1-877:MASSAFB Revised 5-26-05 Fax # 617-727-7749 wv W-Mass,govfdia COMMONWEALTH OF MASSACHUSETTS -PLUMBERS AND GASFITTERS LICENSED AS A MASTER PLU B ISSUES THE ABOVE LICENSE TO: 'TIMOTHY A ,GIARD 60 SAUNDERS ST NO ANDOVER MA 0184 -24.14 .10301 05/01/14 83494 _ z � l i r Date. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ............ ........ ue,-,,� ......... has permission for gas installation . 3 . WG I t e, .... . in the buildings of ... .��� . at ..... l�..-.. ..................... ` .. North Andover, Mass. (.... !�M . . Fee M. ,".�1. Lic. No. �� �.� 6 .................... ... GASINSPECTOR Check # 45-H I'D I'll N 6�z-177 `x MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I North Andover MA DATE 05-03-13 PERMIT # JOBSITE ADDRESS 78-80 Union St OWNER'S NAME I Paul Dubois GOWNER ADDRESS 175 Meadow Lane TE FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION: REPLACEMENT: ® PLANS SUBMITTED: YES ❑ NOQ APPLIANCES Z FLOORS--+ BSM 1 2 3 4 5 6 7 8 910 11 1 12 13 14 BOILER 2 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 3 OTHER 17- F77 F771= INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES (D NO ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [D OTHER TYPE INDEMNITY ❑ BOND ® 4j 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 th7;;� NLY• WNE GET ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details information I have this lication tr the b and submitted or entered regarding ap are -C my nowledge and that all plumbing work and installations performed under the permit issued for this application ill be in lianc wi P in t pro ' ' n of the �f1 Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Tim Giard LICENSE # 10301 IGNATURE MP 0 MGF ❑ JP ❑ JGF ❑ LPGI ® CORPORATION ®# PARTNERSHI/,D# LLC ®# f� COMPANY NAME: Timothy A. Giard Plumbing & Heatin Inc ADDRESS I P.0 Box 782 CITY I North Andover STATE =ZIP[ 01845 TEL 978 689 8336 FAX 1978 689 8300 CELLI 978 490 7108 EMAILtgiardplb@yahoo.com 01 0 r v W F °z z U � a z �v z w C ❑ a Z z O W ❑ W r� � ~ W O W O F a *k z w �- w N Z a W C w w w Q W N a a Oa x J F a a Q � � w x w LL W F zz z 0 F U W C4 z C7 G7 O a The Commonwealth of Massachusetts Department oflndustritilAccidents Office of Investigations 600 Washington Street Boston, MA. 02111 qu www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractor5/Electricians/1'lumbers Applicant Information Please Print LeWbly Name Address: Fo. Qo",,Z �� v City/State/Zip: N6, Kc.- Ul7`iJ Phone#: iA.,--111 Are u an employer? Check the appropriate box: - Type of project (required): 1 am a employer with y 4. ❑ I am a general contractor and 1 6. (] New construction employees (fall and/or part-time).* 2. ❑ 1 am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. # �• Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. g, El Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its ME] Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' congp, c.152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] employees. [No workers' 13. ❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that checkthis box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that 1s providing workers' compensation insurance for my employees. Below is Aepolicy and job site information. MTM Insurance Company Name:. Policy # or Self -ins. Lie. Expiration Date:. Job Site Address: �60 U^iu^ City/State/Zip: N6� t -f&- 61 $Y) Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1, 500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the vio tor. Be advised that a copy of this statement may be forwarded to the Office of 'Investigations of thpMyor insurpVc coverage verification. Ido that the information provided a ove 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 COMMONWEALTH OF MASSACHUSETTS . . .. WiA PLUMBERS AND GASFITTERS LICENSED AS A MASTER PLUj .B ISSUES THE ABOVE LICENSE TO: TIMOTH' A GIARD GO SAUNDERS ST L..; NO ANDOVER MA 0184 -2414 i 10301 05/01/14 83494) Date . A TOWN OF NORTH ANDOVER PERMIT FOR WIRING -,;Q� A7, ��, This certifies that-� ................fT".......................................�................................................ has permission to perform . ' wiring in the building of.... � , .................................................................................... rat ......... �..".... .... I V-`..... ............... . North Andover, Mass. Fee.?qb ....... Lic. No 5Z210-, m� ELECTRICAL INSPECTOR Check # bq M Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official tUse Only ` Permit No. I 1 • J M Occupancy and Fee Checked [Rev. 1/071 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (NEC), 527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATIOA9 Date: 4 11 V City or Town of: In pe NORTH ANDOVER To the ctor of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) % R - SO U o--) ti S 1 y, -A t— Owner or Tenant (�,") l D U 6 0 i `'S Telephone No -i )S ? i 15�, Owner's Address Is this permit in conjunction with a building permit? Yes ® No ❑ (Check Appropriate Box) Purpose of Building I46. 1• tq ajZj.b1A.4 - Utility Authorization No. - Existing Service 2,Q,)- Amps . 1Xy � 2,N D Volts Overhead ®' Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Y_Ll' 0 P L- -706/9 Location and Nature of Proposed Electrical Work! 2 ,, )-VC ,+- d (ti DC 1`°fMh Cmmnlotinn nfthe fnllnwinQ table may be waived by the Inspector of Wires. No. of Recessed Luminaires j� No. of Ceil: Susp. (Paddle) Fans Tr s Total Transformers KVA No. of Luminaire Outlets 2, No. of Hot Tubs Generators KVA �/ No. of Luminaires 3 / Above In- Swimming Pool rnd. grnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets 51 No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches (p No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Tot Tons No. of Alerting Devices No. of Waste Disposers 0 P Heat Pump Totals: Number I .Tons . KW No. ofSelf-Contained Detection/Alerting Devices No. of Dishwashers 2— S ace/Area Heating KW P g Local ❑ Municipal ❑ Other Connection Dryers No. of Dr y ,- Heating Appliances KW Security Systems:' No. of Devices or Equivalent No. of Water KW Heaters i) 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 detau q desired, or as required by [ne lmprow. Vj r.. Estimated Value f El e trical Work: /0, e O (When required by municipal policy.) Work to Start: N Zr 7,6) 3 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE OVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE N BOND ❑ OTHER ❑ (Specify:) X certify, tinder thXL.– ins rend penalties o perl`urv, that the information on this application is true and complete. FIRM NAME:.� � +�l-[.C�,Z> 7�n LTC. NO.: Licensee: Yom, Signature LIC. NO.: 6 2 (If applicable, enter 'e empt" in th licen ta�mber line) Bus. Tel. No.. Z21 Vltb Address: ?q 1.4 ,.1r,Kl Y 14 ©le3o Alt. Tel. No.: *Per M.G.f c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE. $ j%� o,,.,.,,�,..... TP]onhnne Nn- q d , ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the 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 Inspection Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: 62L� /V -1W Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M I Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: 3 0 (( en Inspectors Signature: Date: FINAL INSPECTION: Pass F?] Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts - Department ofIndustria. Mccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/El Please Print mbers ibl Applicant Information Name (Business/OrganizatiorAndividual): 1 i��^ t ►^'� "�` , � Address: 2W Y City/State/Zip: Pone #:176— 37? - 52,66 Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have Hired the sub -contractors t listed on the attached sheet.These 2.&1 I am a sole proprietor or partner- sub -contractors have ship and'haveno employees working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its officers have exercised their required.] 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no employees. [No workers' insurance required.] t comp. insurance required.] Type of project (required): 6. ❑ New construction 7. Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they ate doing all work and then hire outside contractors must submit a new affidavit indicating such. eet showing the name of the sub -contractors and their workers' comp. policy information. #Contractors that check this box must attached an additional sh Jam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy # or Self -ins. Lic. #: Expiration Date: lob Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under t Sze pains and penalties of perjury that the information provided above is true and correct. Phone #: q?62z5D Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - Contact Person: Phone Information and Instruction's Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more Of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The COmmoawealth. 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 5-26-05 Fax # 617"7277749 www.mass,govfdia I Commonwealth of Mss usetts . `.:. 'j, Division of Regis ti Board of Electri HARLA r 24 MACO W r; a HAVERHIL, 8 Journeyman`•e 52210 B 07/31/2013 °�M See 008357 Serial;l�4O;`; iven 'e—No: j`•,': Expiration Date: I i 1 This certifies that ..�. �l! ✓1.. �� cJ r'.� has permission to perform_ 7�P... ..S'P �i .. _ ....... . wiring in the building of f�tr .tel f; j.5 ......................... . at ...... gin, .5 ...... . ,Nprth Andover, Mass. Fee -, :... Lic. No21'-I(W 4 �... . r ELECTRICAL INSPECTOR Check #X0 30 10934 A U Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 6 q .3V Occupancy and Fee Checked [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: I City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned givesotice of his or her intention to perform the electrical work described below. Location (Street & Number) '71F /�6'Cy /yi p /'1 5 Owner or Tenant Owner's Address 3 6 J CCp!W f S t' Is this permit in conjunction with a building permit? Purpose of Building Existing Service Amps / Volts New Service / 00 Amps D / ZqOolts Telephone No. it ir-L/d0 0 Yes ❑ No Y (Check Appropriate Box) Utility Authorization No. t-�i / � y T�� Overhead ❑ Undgrd ❑ No. of Meters Overhead Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �f' n/V '�/� C- v Comnletion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- 1:1o. rnd. rnd. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges Tot No. of Air Cond. Tons No. of Alerting Devices Heat Pump Number Tons KW No. of Self -Contained No. of Waste Disposers P Totals: - � ...... ......... ... .�����������........... Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW P g Local ❑ Municipal ❑ Other Connection No. of Dryers Y Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of WaterNo. KW of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability i ante 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 ET BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties orf perjury, that the information on this application is true and complete. FIRM NAME:. �r— / Gr f,,e4 % t/tt LIC. NO.: Licensee: RAP -,I, -]— 6" � Signature LIC. NO.:021 y46 (If applicable, enter"exempt" in the license number li .) Bus. Tel. No.: ? 7 t?- q %I 11 Address: P./2Y 10-72- jAl 9 3r!? Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ j Signature Telephone No. i ... • ��JiJ�JS.J.ut.�F�i��•��-'{��(,(�.•f��)('(.L�'��-llf��..+Jj-t.AA�•efd.�l��®j�•f�f PjQ{-{�.��/! `[�� ,��1�JU`l.sJtA�J.• J.'o.+xJ1. ®��i � • �spectoxs' �opaxneuts: - ter e a �.'. �. 9. • (Cnspectoxs'zgaatuxe �x�ottaTs) _ Pate �.�N�r�7uJP�C7f'ZON•; �'asse�•-- �+'aiSec��j }' � ��-�ns�ecfio�,xea�uixe� ($0.00)-• j � . �nspeeto�rs' comm.extfs: - Ps&dors'gignature. ' 'fials) Slate Passed --j � �af�ec�--j � - �te�fnspeciio�xequixe�(��0.40)�j ] bnspectoxs' Comment. , Ci spectoxs:L,Oignatura-ao blffalls) ]ate WX assets — [) a'rle�i.- j Xte-impection required ($60.00) - Is�ectaxs' eoJo�tept�s: (fuspectoxs' ftaature io initials) Date ;sett• -j � �`azXer��j )- '�t.e xnspectioxtxe��ix'ecl ($�O.OD) � j � pectaxs' cozaixntents: - - . i �W-sp eefoxs'ignair�xe xto initials} - Pate :P OR TAUS An TOM, FffTF,-D ffff".Mff ON RITE N M "XA TO BE WRECTUD YO NOT The Commonwealth of Massachusetts Ln Department of IndustrialAccidints Office of Investigations UT 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ) Please Print Legibly Naive (Business/OrganizatiorAndividual): C�(,ti(>'l�i/ �� G- /� rl'ccli L/ 5etyl ce— s Address: P, �, 6 � '1(27,21 City/State/Zip: JJf m & '6 � 0 Z ?Phone #: q 7 $ ` q % ? — & an employer? Check the appropriate box: A710:1in 1. a employer with % 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. # ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. F1 Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. El Electrical repairs or additions 11. El Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. l Insurance Company Name:. 94 A, S Policy # or Self -ins. Lic. M Expiration Date; Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert under the pains and penalties of perjury that the information provided above is true and correct. Signature: r Z - Date: i/ ` 30 Phone #: 7 D LM —/// Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (ifnecessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to 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, M.A. 02111 Tel, # 617-727-4900 oya 406 or 1-877rMASSAF8 Revised 5-26-05 Fax # 617-727-7749 vww.mtass,govldia W. Elate. / :�! .?. . (.. .... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION s o •.,5 This certifies that .. !/..... i l.> ......... Vz; has permission for gas installation .'.�.'.�. �.;.:. y. /.�1.�. y..��......�. . in the buildings of ................................ at . 7.� .... 't /'t::..�.... ....... North Andover, Mass. Fee.. �e . :. Lic. ........ GAS INSPECTOR Check # 01 4179 MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FTrnNG (Type or print) Date 16 2 26(,,' 2 NORTH ANDOVER, MASSACHUSETTS Building Locations —4�b (� �I 7 6 L S Permit # Amount $ Y7 Owner's Name New ❑ Renovation LLf Replacement ❑ Plans Submitted ❑ (Print or , , .. Address�� k)6. Business Telephone Name of Licensed Plumber or Gas Fitte--t i-- Cr *a- Qhemk one: Certificate Installing Company Corp. ❑ Partner. Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No❑ If you have checked ye .please indicate the type coverage by checking the appropriate box. Liability "ce policy I ❑ Other type of indemnity ❑ Bond ❑ r's saiIam aware t the licensee does not have the Insurance coverage required by Chapter 142 of the ;',e eral , an that my si natute on this permit application waives this requirement. L� Check one: ignat of er or er's Agent Owner ❑ Agent ❑ i hereby certify that all of the details and ' on I ha . submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing w and install 'ons perf ed t Issued for this application will be in compliance with all pertinent provisions of the assach State Gagn94 d er 142 of the General Laws. VED (OFFICE USE ONLY) - Signature o ice ed Plumber Or Gas Fitter Plumber `0 If ❑ Gas Fitte icense um er ❑ Master ❑ Journeyman oil 17TH. FLOOR (Print or , , .. Address�� k)6. Business Telephone Name of Licensed Plumber or Gas Fitte--t i-- Cr *a- Qhemk one: Certificate Installing Company Corp. ❑ Partner. Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No❑ If you have checked ye .please indicate the type coverage by checking the appropriate box. Liability "ce policy I ❑ Other type of indemnity ❑ Bond ❑ r's saiIam aware t the licensee does not have the Insurance coverage required by Chapter 142 of the ;',e eral , an that my si natute on this permit application waives this requirement. L� Check one: ignat of er or er's Agent Owner ❑ Agent ❑ i hereby certify that all of the details and ' on I ha . submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing w and install 'ons perf ed t Issued for this application will be in compliance with all pertinent provisions of the assach State Gagn94 d er 142 of the General Laws. VED (OFFICE USE ONLY) - Signature o ice ed Plumber Or Gas Fitter Plumber `0 If ❑ Gas Fitte icense um er ❑ Master ❑ Journeyman Location 17k- .YOyti 16m) No.� Date �b —�� U 0--2 o� N0�T1�n TOWN OF NORTH ANDOVER f w P y } �a •; ; Certificate of Occupancy $ CMUSQ O �ssAEt�•' Building/Frame Permit Fee $ 13 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ '300 Check # 15921 /hi ,, / Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING W�•u* BUILDING PERMIT NUMBER: DATE ISSUED:, t)7 SIGNATURE: Building Commissioner for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 79 - 96 491'W1 (;� 1.2 Assessors Map and Parcel Number: o 39 Map Number Parcel Number U .Aj'ef- �1 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area (so Frontage ft 1.6 BUILDING SETBACKS 00 Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.I-C.40. 54) 1.5. Flood Zone Information: Public ❑ Private 0 Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner f Record / �^ l loom ��i6 c� Name (Print) Ad,+dres for Service s- 7 /S �• Signature Telephone 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 Signature Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable 0 Company Name Registration Number Address Expiration Date Signature Telephone OU rn X Z O w 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 ....... 11 No ....... ❑ SECTION 5 Description of Proposed Work check all applicable= New Construction ❑ 1 Existing Building ❑ I Repair(s) Alterations(s) ❑ I Addition ❑ Accessory Bldg. ❑ I Demolition ❑ I Other ❑ Specify Brief Description of Proposed Work: OJP-J ':� KSI A ovv� SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY ., 1. Building 3©� (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) C� 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SEUIION 7a OWNER AUTHOKIZATION TO HE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION Date 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 of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINIBERS IST2 ND 3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY 1S BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 4 North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: lc (L(3cation of Facility) Signature of Permit Applicant j� A 02, Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector The Commonwealth of Massachusetts Department of industrial Accidents Office of Investigations Boston, Mass. 02911 Workers' Compensation Insurance Afdavit I nratinn- �� �5 V Vl io O XI r X / l a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Company name: Address City Phone #: Insurance Co. Policy # Com an name: Address City Phone #: Insurance Co Policy # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of.a fine up to $1,500.00 and/or one years' imprisonment_as v elLas_civiLpenaltiesinkeimnd-a STOP.W. _ORK ORDERand-afine.af�.$IDOM)-aAay against -me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. 1 do hereby certify under e paip9Vd penalties of perjury that the information provided above is true and correct. n�+o /d/ 4t /a Print name AQ 4t / 1) lr 40, Official use only do not write in this area to be completed by city or town officiar d- ,72 9 City or Town Permit/Licensina El Building Dept ❑Check if immediate response is required ❑ Licensing Board ❑ Selectman's Office Contact person: Phone #: ❑ Health Department 0 Other C/) m m Cf) 0 m CO) CD.p C Z CD O ar d O O.� a� O o p CL cr go CD o cL to CD CA 10 CD O Col) d d O CO3 C�� 0 CO) d CD 0 c� cD CO) CDCO2 CCD O CD I woo= "0 3=O 2 • d� O QN .o CO) S43 m � m n Cm rce 0 9 m Z ?m N O � °: m ti X. m 2r O n?d = y O -40 m y p O .*= N ?m _ IG mp=' O N. 0 IN c ao Q CL :-'► c A o C ? ' O m m CIO: ` n -+ : _ CA O Dt co) N CL d :� G 0 _ d ; 0 fib= o 1 O : °'►. N� � �m coa 0 0 oar .� co) CD SCD, CL V Col _ 1 0 � cn cn co � J• w p w O -X Q1- cpcn (D o�n n � X77 ?r 0 oGa rd O x w- n ` o�c Q :1b• z � (D y O n. O o x 7d � � et omi 0 0 c D. Robert Nicetta Building Commissioner (978) 688-9545 (978) 688-9542 Fax Town of North Andover Building Department 27 Charles Street North Andover, MA_ 01845 HOMEOWNER UCENSE EXEMPT1pN Please print DATE IO o iOe LOCATION_ l6 r - Number IOMEOWNER 2f{ I Name ESENT MAILING ADDRESS .ghio11 Street Address City Town Home Phone 6, 1 dVek Map / lot Work Phone Zip Code The current exemption for "homeowners" was extended to include Owner at two units or less and .to allow such homeowners to engage an individ y�� not possess a license,. provided that the owner acts as su Poor (Stade Building Code section 1'08.3.5. t) .DEFINITION OF HOMt=11VOWNER_ Person(s) who owns a parcel of land on which he/she resides or intends to reside on there is, or is intended to be, a one or two which es cessory to such use and/or farm � ,4,gtin9. attached or detaches! stnr- tw10-year period snail not be considered a person e °rw home in a harr>eoKvner_. The undersigned "homeowner" assumes responsibility for co Applicable codes, by-laws, rules and regulations, MPbance with theState Building Code and other The undersigned "homeowner" certifies that he/she understands the Town cfNo. 4,ndou Building Departrnent minimum inspection proer procedures and requirements and �PtY with said procedures and requirementstfrat helshe ewill r _ IOMEOWNER'S SIGNATURE 'PRO',,/,,'Al- OF BUILDING OFFIC I 4.161 Date /,/)- a.5... °. 2-- ``° TOWN OF NORTH ANDOVER p PERMIT FOR WIRING Thiscertifies that ... 5...............�� . �. -......................................... has permission to wiring in the building of .... .......................................... at 21 ...h........<�..��....... ................. .North Andover, Mass. ........ /11111 fr ....Lic. No. .. ..... ....................Fee.1 Check # /G `_ELECTRICAL INSPECTOR � Z_--'__ C/f ThECOAWONWEALTHOFAWSACHUSETTS ffice Use only DEPAffMENTOFPUBUCSAFETYV C(/ nl BOARD OFFMPREVEVHONREGUTA770NS527CMR12W Permit No. v Occupancy & Fees Checked �^ APPUCARONFOR PERMIT TO PERFORMELE=CAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date/ (.% 2 y`�D Town of North Andover No. of Disposals No. of Dishwashers No. of Dryers No. of Water Heaters No. Hydro Massage Tubs OTHER No. of Heat To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street &Number) 91 •- �� 1 t S Owner or Tenant VAv L, 6 f,✓ Z Owner's Address $ ZHeating Is this permit in conjunction with a building permit: Yes No E3 (Check Appropriate Box) Purpose of Building No. of Existing Service zoo —Amps /220 / yUvolts Bailasis Utility Authorization No. Overhead r7T:�' Underground No. of Meters New Service 2,oO Amps J 20 / Z YDVolts Total HP Overhead EM'Undergiound No. of Meters Number of Feeders and Ampacity rV/(f e f „� "K Off' z f� t / �j Location and Nature of Proposed Electrical Work No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total No. of Lighting Fixtures Swimming Pool Above Below KVA Generators No. of Receptacle Outlets No. of Oil BurnersEmergency round round KVA Lighting Battery Units No. of Switch Outlets No. of Gas Burners No. of Ranges No. of Air Cond. Total FIRE ALARMS .r.-- No. of Zones No. of Disposals No. of Dishwashers No. of Dryers No. of Water Heaters No. Hydro Massage Tubs OTHER Total No. of Detection and KW Initiating Devices • KW No. of Sounding Devices No. of Self Contained Detection/Sounding Devices KW LocalC1Municipal ED Connections .�.ww.... w...�.�.,. i u.xw,lwuiclaltrlrClrYlil (x1V1aSS�11)�jj$l.aWS baveaomw'iab6lyPblicymlxlagcMPIte CoWWOritssubsUialegttivalai YES NO havesubr &dvabdproofof tottteOlbiM YES ' ' /'EyouhavedrdadYES,plea9eirrlic*thetypeofw�ageby he�gthe `"` JJI � VSURANCE BOND MIER M (Pt=Spec�y) r ! f0 �1J %1q1i / ,( vA. / o r�j/y 3 /oiktoshatt �,� ignedunderlieP nabesofpetjtay. RMNAME 0 ed Chat o iJ r / C /4Ct f j ,C`�� Sigtrahne ` Fsitr>dvalueofElactdralwotk$ � _ Fmal IkmseNo. 2_ > 2 a` LmwNo irhPcc j% Q V �' L (o d �/! / c / ?0 ? 7 Buso�essTel No. .` AITUNo. $ V17—/1116' N-NM'SINSURANCEWAIVEI;Iamawatethatt Lxm,edoesrothavetheirtstuaricemvetageoritsatstantialequivalaffastagttiredbyNlasachumGenawLawS � ithatmysign<�ttneonthisl�enmtapplication waivasthis� lease check one) Owner a Agent p , rgna ure owner or Telephone No. PERMIT FEE $ gen No. of Heat Tota] Pumps Tons Space Area Heating Z ZHeating Devices KW No. of No. of Si ns Bailasis No. of Motors Total HP Total No. of Detection and KW Initiating Devices • KW No. of Sounding Devices No. of Self Contained Detection/Sounding Devices KW LocalC1Municipal ED Connections .�.ww.... w...�.�.,. i u.xw,lwuiclaltrlrClrYlil (x1V1aSS�11)�jj$l.aWS baveaomw'iab6lyPblicymlxlagcMPIte CoWWOritssubsUialegttivalai YES NO havesubr &dvabdproofof tottteOlbiM YES ' ' /'EyouhavedrdadYES,plea9eirrlic*thetypeofw�ageby he�gthe `"` JJI � VSURANCE BOND MIER M (Pt=Spec�y) r ! f0 �1J %1q1i / ,( vA. / o r�j/y 3 /oiktoshatt �,� ignedunderlieP nabesofpetjtay. RMNAME 0 ed Chat o iJ r / C /4Ct f j ,C`�� Sigtrahne ` Fsitr>dvalueofElactdralwotk$ � _ Fmal IkmseNo. 2_ > 2 a` LmwNo irhPcc j% Q V �' L (o d �/! / c / ?0 ? 7 Buso�essTel No. .` AITUNo. $ V17—/1116' N-NM'SINSURANCEWAIVEI;Iamawatethatt Lxm,edoesrothavetheirtstuaricemvetageoritsatstantialequivalaffastagttiredbyNlasachumGenawLawS � ithatmysign<�ttneonthisl�enmtapplication waivasthis� lease check one) Owner a Agent p , rgna ure owner or Telephone No. PERMIT FEE $ gen Leathe, Brian From: Thomas E. Donovan [tdonovan@napd.us] Sent: Thursday, May 15, 2008 8:22 AM To: Eugene H. Salois; Leathe, Brian Cc: Paul J. Gallagher Subject: FW: Please help,'us thwart flagrant violations on Union Street.. Foulds_Property_S AT120162.txt ynopsis.pdf Brian, Can you assist us with this? I have heard about this front two different sources. Thanks, T. donovan -----Original Message ----- From: Warren Crossfield [mailto:warren@crossfield-usa.com] Sent: Wednesday, May 14, 2008 4:51 PM To: Thomas E. Donovan Cc: Richard M. Stanley; JYarid@townofnorthandover.com Subject: Please help us thwart flagrant violations on Union Street.. Officer Donovan, Can you advise as to the progress made in bringing the owner (Maurice Foulds) into compliance with the MA CMR building codes for his improperly permitted 3 -family house located at 78-80 Union Street? Several of the neighbors (including the Block Captain for the newly formed Neighborhood Watch Program on Union Street) are not getting any satisfaction given that their FILED complaints to the Town's Building Inspector have gone unanswered for over 12 months. In speaking with Brian Leathe, he has said that they have been as aggressive as his office can be with the owner to apply for the proper variances he needs to legally operate the property as a 3 -unit dwelling. It seems fairly evident the owner has been 'thumbing his nose' at the building department and as such, I would like to request we search for more aggressive means by which to get Mr. Foulds' attention..the status quo is just not working. If we (the residents) are to 'take -back' our neighborhood we need as much help and support from every official as possible. To date, your involvement in our community has been exemplary and we are all truly grateful for all your assistance. We are hoping that there might be tools at Jennifer Yarid's discretion she may be able to wield in assistance to this problem. We await your reply. Kindest regards, Warren Crossfield 978-794-9174 Reference Attached: "Foulds_Property_Synopsis.pdf" - showing the Town thinks this is a 2 -family home. 1 Date .......... els`:...... . SORTk 16 6 TOWN OF NORT ANDOVER ST 0 - I/ v PERMIT FOR GA NSTALLATION This certifies that..fV ............... has permission for gas installation .......... in the buildings of ......................... at o7i . . 1!�.- . �. ... "Ibil ..... North Andover, Mass. Fee......... Lic. No.162 GAS ........... Check 4 4-1,91 573` MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Typ i Mass. Date N 20 6� Permit N Building Location � --a, �((i�) ,5.�-t Ownet's DameAt,(C V6r Type of Occupancy t°) Ne Wi Renovation ❑ Replacement❑ Plans Submitted: Yes ❑ No ❑ Installing Company Name ln,t Address ICU • ca•-. easiness Telephone Name,pfLicensed Plumber. orGas Fitter � Check one: Certificate ❑ Corporation ❑ Partnership or-Firm/co. INSI TRANCE COVERAGE: 1 have a current bility insurance policy or its substantial equivalent, which meets the requirements of MGL Ch. 142. Yes,,Ar No ❑ ?. If you have checked yes, please indicate the type of coverage by checking the appropriate box. A liability Insurance policyp% Other type of indemnity ❑ Bond ❑ OWNER'S INSURNACE WAIVER: 1 am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on is permit application waives this requirement signature of owner or owners Agent Check one: Owner ❑ Agent i hereby certify that all of tate details and Information I have submitted for enterfcD in above applic tion are tr nd occur my knowledge and that all plumbing work and Installations performed under the rmit Issued fo this app11 in c all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the a Type of License: By member Signature of L ensed ber or Gas Fit Title ❑ Gas fitter 1I cityrrowntdtaster tkense Nu er /`r3o I APPROVED (OFFICE USE ONLY) I ❑ Journeyman {est of e wi th s : • 0 . • ■■■■■■■■■■■■■■■■■■■® '' ■■■■■■■■■■■■■■■■■■■® .. • ■■■■nMMWM■■i■■■■■■■■■� pik,lillgK-OTol.-lommmmmmmmmmmmMEMEME■® • ... • ■■■■■■■■■■■i■■■■■■■■■■ .•• ■■mmmmm■■■■■■■■■■■■■■ Installing Company Name ln,t Address ICU • ca•-. easiness Telephone Name,pfLicensed Plumber. orGas Fitter � Check one: Certificate ❑ Corporation ❑ Partnership or-Firm/co. INSI TRANCE COVERAGE: 1 have a current bility insurance policy or its substantial equivalent, which meets the requirements of MGL Ch. 142. Yes,,Ar No ❑ ?. If you have checked yes, please indicate the type of coverage by checking the appropriate box. A liability Insurance policyp% Other type of indemnity ❑ Bond ❑ OWNER'S INSURNACE WAIVER: 1 am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on is permit application waives this requirement signature of owner or owners Agent Check one: Owner ❑ Agent i hereby certify that all of tate details and Information I have submitted for enterfcD in above applic tion are tr nd occur my knowledge and that all plumbing work and Installations performed under the rmit Issued fo this app11 in c all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the a Type of License: By member Signature of L ensed ber or Gas Fit Title ❑ Gas fitter 1I cityrrowntdtaster tkense Nu er /`r3o I APPROVED (OFFICE USE ONLY) I ❑ Journeyman {est of e wi th � o s.. Date. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ....................... has permission to perform ....I) ': :. `. ' .'.`..`............... . plumbing in the buildings of ...1.. .'......'.................... at ...!!� :.'..`.... ! ."- '..:............. North Andover, Mass. I C' Fee . G% �." .. Lic. No.. �.� ?.... ....... � .. -'' :� , `-...... . �. :PLUMBING INSPECTOR Check # 161' 5 4 At I V�001 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date Building Location (�� � Ij t� Owners Name P<Penm it # //.%// Amount Oj Tyne of Occupancy �tl-f I r .- �7+ ( New Renovation 14 Replacement Plans Submitted Yes No El FIXTURES (Print or type) 4 Check one: Installing Company Name 11146, t. �. ri, �'YY� 11 Corp. Addr ss FA,✓��-f rl Partner. , Business Telephone — Firm/Co. Name of Licensed Plumber:1 4j JX i ( 7 Certificate Insurance Insurance Coverage: Indicate the type of insuranCe coverage by checking the appropriate box: Liability insurance policy ❑ Other type of indemnity Bond ❑ In Wrciwaivenl, th unksigned, have been made aware that the licensee of this application does not have any one of the above ignat d Owner1:1 Agent I El I hereby certify that all of the details and informatio have spbmitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work d installations perfo ed der Pe t Is d for this application will be in compliance with all pertinent provisions of the M sachjpsetts State Plu bin Cede a d Ch er 142 of the General Laws. �� wr r k BY Signature Of 1cense um er Type of Plumbin icenp Title 36 City/Town icenseumum er Master Journeyman ❑ APPROVED (OFFICE USE ONLY • Date..Z7—A4'.." .r. 4... .. ... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...... ..... .................. A..................................... has permission to perform --7-6 wiring in the building of .............................. at............. . North Andover, Mass. Fee ..\,� ........... Lic. NdW_�, G ELECTRICAL Check # ep-Y�� Commonwealth of Massachusetts Official Use Only • �' Department of Fire Services Permit No. Occupancy and Fee Checked a BOARD OF'FIRE PREVENTION REGULATIONS [Rev. 9/05] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFQRMATION) Date: ��— / -'O G City or Town of: "/VAr a 40 ✓eA� 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) "7 '$ hT e Owner or Tenant ✓ V 601, 5 Telephone No. Owner's Address —� �Y 7 Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility ,,Authorization No. Existing Service 16 D Amps 1_7o /L Volts Overhead Utility ❑ No. of Meters o2 -- New Service 2,00 Amps /?_.D /Z yQ Volts Overhead Undgrd ❑ No. of Meters 3 Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: .Jer'V , ce the -lel- 50 61ee 1 for Completion of the following table may be waived by the Inspector of Wires. A ri 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. rnd. o. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pum Number Tons KW ..I No. oSelf-Contained Totals Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems: No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Estimated Value of Electrical Work: Attach additional detail if desired, or as required by the Inspector of Wires. (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liabili insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cov age is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, tha{ the information on Nus application is true and complete. FIRM NAME: G Y -t G LIC. NO.: Of 7a � Licensee: Ro Signature NO.: 2 79 42 G (If applicable, enter "exem license number lin t " in the licg) q Bus. Tel. No.: Address: f� 01 C,/ e. -K pV // U 3® 7 / Alt. Tel. No.: *Security System Contractor License required for this work; if applicable, enter the license number here: 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, 1 hereby waive this requirement. I am the (check one) ❑owner ❑ owner's agent. Owner/Agent . PERMIT FEE. $ Signature Telephone No.