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HomeMy WebLinkAboutMiscellaneous - 79 OLD VILLAGE LANE 4/30/2018LAWRENCE H. OGDEN, P.E. 198 EAST MAIN STREET GEORGETOWN, MA 01833 978-352-8318 fax 978 352-2558 cell: 978-502-5921 April 25, 2016 Mr. John Cahill 74 Old Village Lane North Andover, Ma. 01845 RE: Residence 180 Salem St_ North Andover, Ma. 01845 Dear Mr. Cahill As you requested I conducted various site visits during the progress of the framing to review the progress of the framing and the installation of the Engineered Materials consisting of LVLs, beams utilized in the framing of the above project. The Lvls and framing are shown on plans prepared by Classic Colonial Homes dated 9-1-15 with the fiaming plans sheets 1 and 8 to 11, certified by me 10/8/15 as well as Detail Sheets D -I to D-4 certified 8/20/15. 1 can certify that to the best of my knowledge the LVLs members and associated details utilized in the framing as shown on the drawings are installed properly and meet the loading conditions of the 8th Edition of the Massachusetts State Building Code for 1 &2 Family Residences. This certification is based on what l could visibly see at the time of these visits when the framing was in progress. The purpose of these site visits was to form an opinion and comfort level that the construction appears to be in compliance with the drawings. This certification should not be construed as a thorough detailed inspection of the construction and framing. . Nothing in this certification relieves the Licensed Construction Supervisor and or the permit holder of the responsibility for construction of this project per Section 11.0.115.2, and sub section I I O.R5.2.15 or of the Massachusetts Residential Code 780 CMR 51, or the proper execution of the details and framing requirements of the drawings, including but not limited to materials, blocking, manufacturers installation requirements and nailing schedules or other requirements of the code. Should you have any questions please do not hesitate to call. Yo truly, Lawrence H. Ogden P.E. Structural 27765 .9860 Date ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..........6.. C .......... Uztz-e-"-V.�.......... has permission to perform ......la. f'z! ........................ wiring in the building of ......... . A, 0.neo ............................................... at ......0.....Lam........... ,North Andover, Mass. .. Fee.k:��.. Lic. No. k7.0,,MK ........... j� ...... t Check # 3 24Y. EcriucAL INspEcToR ti Commonwealth oir massachusettS off�cialUseOnly Department of Fere Services Permit No. � BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked V_ [Rev. 1/07] (jP.AVP. hlanlri APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 C12.00 (PLEASE PRINT WINK OR TYPEALL INFO TION) Date: /J/1/7w City or Town of: W' To the Inspector of Wires: By this application the undersi ed gives not' e o' f hj or her intention to perform the electrical work described below. Location (Street �& Number) 7 1/11�G -k (fes Owner or Tenant <cc) (tea- T 19� Owner's Address Is this permit in conjunction with a building permit? Purpose of Building Existing Service Amps / Volts New Service Amps y / Volts Number of Feeders and Ampacity e ephone No. a2crfj tel' Yes [v' No H BLDG PERMIT # Utility Authorization No. ;Overhead [__J Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters Location and Nature of Proposed Electrical Work: Kl k kfol + 13" �- /Zll No. of Recessed Luminaires of Luminaire Outlets of Luminaires No. of Receptacle Outlets No. of Switches No. of Ranges No. of Waste Disposers No. of Dishwashers No. of Dryers Heaters KW No. Hydromassage Bathtubs � 1 ' 1A INo. of Ceil.-Susp. (Paddle) Fans No. of Hot Tubs Swimming Pool Above ❑ rnd. No. of Oil Burners / No. of Gas Burners 0 9,5 No. of Air Cond. l otai Tons Heat PumpNumber Tons I Totals: .. .................................................. Space/Area Heating KW Heating Appliances KW` No. of No. of SiLyns Ballasts wing table may be waived by the Inspector of Wires. No. of Total. Transformers KVA Generators KVA o. o mergency ig ting Batter Units FIRE ALARMS No. of Zones No. of Detection and Initiating Devices No. of Alerting Devices No. of Self -Contained Detection/Alertino, Devices Local Municipal ❑Connection E] other Security Systems:* No. of Devices or Equivalent Data Wiring: NO. of Devices nr Frrnivalanf of Motors Total HP l elecommunications No. of Devices or Attach additional detail f desired, or as required by the Inspector of Wires. Estimated Value of El ical Work: (When required by municipal policy.) Work to Start: / / // 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 cove�s e is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE IJT BOND ❑ OTHER ❑ (Specify:) I cert, render theyaws and penalties of perjury, that the information on this application is true and complete. FIRM NAME: (c, 41 a E/cc�n` pl Licensee: /(tG LIC. NO.: 71 d /�12. Q S Signature LIC. NO.: 02 6 04(6 -- (If applicable enter "exempt" 'n the license nu ber line, / Bus. Tel. No.: O 3 o2j ? Address: u/�%rtlyg �4� �/.�,�� /✓'H o3fy'/ Alt. Tel. No.r3 3d� S/ *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" Licen LIC. NO.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner Owner/Agent ❑owner's agent. Signature Telephone No. PERMIT FEE: $ ELECTRICAL PERMIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR - DOUG SMALL I 1. HOUGH JASPECTION: Passed — f Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) Date 3. UNDER GROUND INSPECTION: Passed — [ ] Failed — [ l Re -inspection required ($50.00) - Inspectors' comments: ' Signature - no Date `e..LLq 0r L' l_ 11V1`I — aL' .tC V ll,.pi: DATE CALLED NATIONAL GRID: NAME: Passed — [ ] Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) Date 5. INSPECTION - OTHER: Passed — [ ] Failed — Inspectors' comments: (Inspectors' Signature - no initials) Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF TBE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE -INSPECTION OF $50.00 IS TO BE CHARGED. a The Commonwealth of Massachusetts Department of Industrial.Accidents Office of Investigations 600 Washington Street Boston, MA. 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: builders/Contractors/)Electricians/Plumberg Applicant Information Please Print Legibly Name,(B.usiness/Organization/Individual): Address: City/State/Zip: Gly( ids �eG L1, N� �� 3' `l Phone #: o .9.3-/ ?� Are you an employer? Check the appropriate box: .1 ❑ I a employer with 4. ❑ I am a general contractor and I ployees (full and/or part-time).* have hired the sub -contractors 2. I am a sole proprietor or partner- listed on the attached sheet. I ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself [No workers' comp. c. 152, § 1(4), and we have no insurance required.] i employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. Remodeling . 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box 41 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. lContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employes that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins, Lie. #: Expiration Date: Job Site Address: City/State/Zip:. Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as 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 ofthis statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby eeerrt�tify.. unnder th pains andpenalties ofperjury that the information provided above is true and correct. sign 0: �1,e:�:1Date: Z/ /,//` t -- - Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Phone #: 75u4 Date..�/!! ........ �� 3r TOWN OF NORTH ANDOVER • PERMIT FOR GAS IATALLATION This certifies that ... ?. r. ;r! .�'.f .....) �.'�. ............. . has permission for gas installation ... B. A t- s.V............... in the buildings of ..%4...5 «H . . ............................ at ... —7 .. G s :.L..... F, North Andover, Mass. Fee.. 3k.: U Lic. No..a..7.?. ?... ... AS INSPECTOR Check # /_ y PIYTI IRRC W MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: N• X , MA. Date: 17 bl Permit# Building Location:% I C. iI I 5 ^ Owners Name: Veyy" Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: ❑ Alteration: ❑ Renovation: 21' Replacement: ❑ Plans Submitted: Yes ❑ No ❑ PIYTI IRRC W HY N Q V 2 = w W M 2 O W W N F O Z H rn z � W 0 w z W W O I— w � X W W W Cn v W Z W m Z Q = a o0 H W m W p= LL U W} W ZW J H J H O Z J W 0 u_ N = W W IX W W Z 0 v o o N Q = Q i m W O O a Z 0~ W Z 1-- O u- c9 H>>> a SUB BSMT. BASEMENT 1 FLOOR 2 FLOOR 3 FLOOR 4 TH FLOOR 5 FLOOR 6 FLOOR VH FLOOR -i 'FLOOR E �)[U^A k�C4: Check One Only Certificate # Installing Company Name: � S %h ��, El Corporation Address:/ 7 4(o City/Town: Z-n,J d c,ry State: // Business Te 664 J �i 9 3 Fax: ❑Partnership El Firm/Company Name of Licensed Plumber/Gas Fitter: IJA T6X[01, -P S INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes EJ'No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy ❑ Other type of 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 El Agent ❑ Signature of Owner or Owner's Agent By checking this box ❑; 1 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 Plum 'ng ode and Cha ter 2 of the General Laws. Type of License: By ❑ Plumber Title ❑ Gas itter ignature of Licensed Plumber/Gas Fitter aster Cityrrown [_]Journeyman License Number: 37G APPROVED (OFFICE USE ONLY) ❑ LP Installer y 8867 Date. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING L ,SSAc"Os This certifies that .. ......................... . has permission to perform ....(.'.�'�.�� �'1..' ` ` .'.............. . plumbing in the buildings of .. L..... . .... at ...7 c�...�� < < f �'�~ t North Andover, Mass. .�?��` .. ....... Fee. /.� .� .. Lic. No. �. .... ...... . . PLUMBING INSPeCTOR Check x %� .` FIXTI IRFC MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING F A t City/Town: N, d�/� , MA. Date: l aU /l Permit# Building Location:_ 7 0) 0 L-, Owners Name: r"1 DEDICATED Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: ❑ Alteration: ❑ Renovation: [ Replacement: ❑ Plans Submitted: Yes ❑ No ❑ FIXTI IRFC INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes No ❑ If you have checked Yes, please in icate the type of coverage by checking the appropriate box below. A liability insurance policy Other type of 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 ❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and tnat an plumbing work and installations performed under the permit issued for this application will be in compliance with all rerunum provision or the rviassacnuserts state rmmbmg L;oae and tmapter#42 of the venerayl_aws. By Title City/Town APPROVED (OFFICE USE ONL Type of License: ru umber Signature of Licensed Plumber aster rneyman License Number: M 11370 DEDICATED Z SYSTEMS LLi Y Z O W > V1 Z to in d' Z i- Y Q y N Z H 4A LU Q W Q C O t] Z Q z a O W = z F in m W H in Y z z N Z N z C9 -i a x Q&A J W W a w LL i- Q d' 3Q W i� O o w m LL w to U.= ? D: a' 3a 3 {W/1 W W U i- a in O r V Z Q O a Y Z in F F- W ' Q } VI a m m o c i Y g g°_� iQ- 3 3 3i o a 3 SUB BSMT. BASEMENT 1' FLOOR 2"D FLOOR 3RD FLOOR 4T" FLOOR 5T" FLOOR 6T" FLOOR 7T" FLOOR 8T" FLOOR p, Check One Only Certificate # Installing Company Name: ❑ Corporation Address: 1-) VU)14 - city/Town: w bur State: WK ❑ Partnership Business Tel:(( -4") oZ Fax: ❑ Firm/Company Av�GS Name of Licensed Plumber: f INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes No ❑ If you have checked Yes, please in icate the type of coverage by checking the appropriate box below. A liability insurance policy Other type of 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 ❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and tnat an plumbing work and installations performed under the permit issued for this application will be in compliance with all rerunum provision or the rviassacnuserts state rmmbmg L;oae and tmapter#42 of the venerayl_aws. By Title City/Town APPROVED (OFFICE USE ONL Type of License: ru umber Signature of Licensed Plumber aster rneyman License Number: M 11370 * ~ "COMMONWEALTH OF MASSACHUSETTS"LICENSED AS ASTER PLuMBItSUES THE AB VE LICENS34.SHASTA DRLONDONDERR'Y NHnt fni /19 812047 11 This certifies that ..... l,/ . Date. . L�111 i.... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING has permission to perform .... (J>..r?....................... plumbing in the buildings of ..l L`" .�.�� ...................... at ...... North Andover, Mass. —711 PLUMBING INSPECTOR Check # Z 8566 e/ MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location ? 0/, V1(l/�;, p l Owner K P /- New New Renovation ffr Replacement FiYWRi c Date�r / C/© Permit '# Amount Plans Submitted Yes ❑ No LJ (Print or type) �PJU^ s `"L Check one: Certificate Installing Company Name '10tnf—J to _ � Corp. Address F \ r� Partner. Business Telephone C u e — ()G)L2 UFirm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the twe of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Bond Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance ignature I Owner Agent F1 I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massacumbing Code and Chapter 142 of the General Laws. By: r 51. ilcenswurn Title Type of Plumbing License City/Town mg SLL um er Master Journeyman APPROVED (OFFICE USE ONLY . / The Commonwealth of Massachusetts Department of Industrial Accidents Office of investigations UT 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): Address: City/State/Zip: 2E Phone #: g-ig- `l L - d C' Type of project (required): 6. ❑ New construction 7. 21emodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other t Homeowners who submit this affidavit indicating they are doin___ —9 -r wo—ers: compensation poiicy information. g all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy information. I am an employer that is providing worz-ers' compensation insurance for my employee& Below is the policy and job site information. i i j � ► Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: J City/State/Zip:�/� Attach a copy ofthe 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 herebyce ' `undcf the_p pins and penalties of perjury that the information provided above is true and correcx 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 6. Other Contact Person: 16 4. Electrical Inspector 5. Plumbing Inspector Phone #: Are you an employer? Check the appropriate box: l.�] I am a employer with 4. ❑ I am a general contractor I _�_ employees (full and/or part-time).* and have hired the sub -contractors 2. E]employees am a sole proprietor or partner- listed on the attached sheet. I ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing all work officers have exercised their 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.] Any applicant that checks boxiul must also fill eut the section below v'- ;v Type of project (required): 6. ❑ New construction 7. 21emodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other t Homeowners who submit this affidavit indicating they are doin___ —9 -r wo—ers: compensation poiicy information. g all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy information. I am an employer that is providing worz-ers' compensation insurance for my employee& Below is the policy and job site information. i i j � ► Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: J City/State/Zip:�/� Attach a copy ofthe 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 herebyce ' `undcf the_p pins and penalties of perjury that the information provided above is true and correcx 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 6. Other Contact Person: 16 4. Electrical Inspector 5. Plumbing Inspector Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a.deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the 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 j 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 ci-ty 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 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 5-26-05 Fax # 617-72.7-7749 www.mass.gov/dia Date. . ........ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .... � � w has permission for gas installation .... t--/..(3 ................. in the buildings of ..... /. .0. ....................... at J North Andover, Mass. j �Fee. Lic. No......... . ' GAS INSPECTOR 0 Check# 3 7175 3 MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) NORTH) Building Locations Date, C `� a Owner's Name New11Renovation ❑ Replacement Permit # --.L_ Amount $ Plans Submitted n (Print or type) Name Check one: Certificate Installing Company ❑ Corp. 11 Partner. ® Firm/Co. Name of Licensed Plumber or Gas Fitter 1 hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachus s Stale Il Code and Chapter 142 of the General Laws. By: Title City/Town (APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter QP umber )"1 � Z gGas Fitter lcense 7umber Master Journeyman w � U � a H x ° C. w w w c o w Z H x z � U H w x zUZ w.w w pw U Q Q a a> in3 w a z a a0o wo SUB -BASEMENT a a> c a F o BASEMEN T 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8TH. FLOOR (Print or type) Name Check one: Certificate Installing Company ❑ Corp. 11 Partner. ® Firm/Co. Name of Licensed Plumber or Gas Fitter 1 hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachus s Stale Il Code and Chapter 142 of the General Laws. By: Title City/Town (APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter QP umber )"1 � Z gGas Fitter lcense 7umber Master Journeyman The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 TVashington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): Address: City/State/Zip: d 6V V 18 t O Phone #: 7 — RC1 a CI Type .of project (required): 6. ❑ New construction 7. [^Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.7 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.[] Roof repairs 13.❑ Other t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp policy information. I am an employer that is providing wor rs' compensation insurance for my employees. Below is the policy and job site information. I — Insurance Company Name:-A4l/ / ( Policy # or Self-inns..-7Lic. #: Expiration Date: 60—, Job Site Address: City/State/Zip:`7 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). 4 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 ce nder t e ai and penalties of perjury that the information provided above is true and correct Si afore: Date- WA ate: Wl��M I Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Issuinft g Authority (circle one): Permit/License # I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector 6. Other Contact Person: Phone #: Are you an employer? Check the appropriate box- ox:1• 52;Tam 1. am a employer with 1_ 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ 1 am a sole have hired the sub -contractors listed proprietor or partner- 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.] 3. ❑ I am a homeowner doing all work officers have exercised their 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.] `rsy applicant that checks box #1 must also fill out the section below -,-ov"_. t. Type .of project (required): 6. ❑ New construction 7. [^Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.7 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.[] Roof repairs 13.❑ Other t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp policy information. I am an employer that is providing wor rs' compensation insurance for my employees. Below is the policy and job site information. I — Insurance Company Name:-A4l/ / ( Policy # or Self-inns..-7Lic. #: Expiration Date: 60—, Job Site Address: City/State/Zip:`7 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). 4 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 ce nder t e ai and penalties of perjury that the information provided above is true and correct Si afore: Date- WA ate: Wl��M I Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Issuinft g Authority (circle one): Permit/License # I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing 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 ox- other legal entity, employing employees. However the owner of a dwelling house having not more than three apartrnents 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 notbecause 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 comnpliance 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 acceptableevidence of compliance with the insurance requirements of this chapter have been presented.to the contracting authority." h 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(g) 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 Departrnem 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 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 Invesdegations 600 Washington Street Boston, MA 0:2111 Tel. # 617-72.7-4900 ext 406 or 1-877-MAS.SAFE Revised. 5-26-05 Fax # 617-727-7749 wvrv,-mass ._gov/dia [PAD PER11IT NO. APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. C M2 t PAGE 1 MAP KJO. LOT NO. 2 RECORD OF OWNERSHIP !DATE BOOK !PAGE NE SUB DIV. LOT NO. LOCATION / �, �� G s1/r/� /T RPOSE OF BUILDING ll& OWNER'S NAMEn A' �V/J N /1G�/� LVA '7�� NO. OF STORIES 41ZE (O OWNER'S ADDRESS(�{',•=, p _(Jj.. / _ BASEMENT OR SLAB ARCHITECT'S NAME - SIZE OF FLOOR TIMBERS IST 2ND 3RD "BUILDER'S NAME SPAN DISTANCE TO NEAREST BUILDING 7 DIMENSIONS OF SILLS DISTANCE FROM STREET 'r POSTS �. DISTANCE FROM LOT LINES — SIDES REAR "' "' GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNES IS BUILDING NEW SIZE OF FOOTING % IS BUILDING ADDITION MATERIAL OF CHIMNEY \ IS tlUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAS D r. WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO T" N WA R i -----ffOWRD OF APPEALS ACTION. IF ANYnO ,/ IS BUILDING CONNECTED TO TO ',;N SEWE .' IS BUILDING CONNECTED TO NAT AL GAS INE t INSTRUCTIONS SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR .( r DATE FILED F A . t n l 2 / YLf SIGNATUR£OF OWNER OR AUTHORIZED AGENT F E E PERMIT GRANTED 19 TEL #-,/,,f TEL. # LIC. # 3 . PROPXRTY INFORMATION LAND BT EST. BLD&j COST 0 0 EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROO r SEPTIC PERMIT NO. APPROV BY l /tpv BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN augL alma INOP6GTOR BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY Si DRIES MULTI. FAMILY OFFICES APARTMENTS _ CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH a 1 2 13 PINE HARDW D PLASTER CONCRETE CONCRETE BL K. BRICK OR STONE PIERS DRY MALL _ _ UNFIN. 3 BASEMENT AREA FULL FIN. B'M:TAREA _ '!. '1/2 'h FIN. ATTIC AREA' _ NQ B M T FIRE PLACES HEAD ROOM MODERN KITCHEN 4 WALLS 9 FLOORS CLAPBOARDS CONCRETE EARTH B _ 1 2 3 �_ _ _ DROP SIDING WOOD SHINGLES ASPHALT SIDING ASBESTOS SIDING _ HARDII✓'D COMMON ASPH. TILE VERT. SIDING STUCCO ON MASONRY _ STUCCO ON FRAME BRICK ON MASONRY ATTIC STIRS. & FLOOR BRICK ON FRAME I_ CONC. OR CINDER BLK. WIRING STONE ON MASONRY STONE ON FRAME SUPERIOR I� POOR _ ADEQUATE NONE rj ROOF 10 PLUMBING GABLE I HIP BATH (3 FIX.) GAMBREL MANSARD TOILET RM. 12 FIX.) FLAT SHED WATER CLOSET — _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES TILE FLOOR _ TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. & COLS. _ STEAM STEEL BMS. & COLS. _ HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING _ RADIANT H'T'G UNIT. HEATERS 7 NO. OF ROOMS GAS OIL B•M'T 2nd _ lo 13rd ELECTRIC - NO HEATING THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES, GA- RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. w PER1(IT NO. i APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. � PAGE 1 MAP K40. t/ OWNER'S LOT NO. 2 RECORD OF OWNERSHIP IDATE BOOK 'PAGE ZONE SUB DIV. LOT NO. �} LOCATION `} f /' /---PURPOSE ('0�pG.,�rr%F I,, OF BUILDING OWNER'S NAME ,,,C j,`y NO. OF STORIES SIZE ADDRESS F7 BASEMENT O�2 SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD UILDER'S NAME �'°.y,�,p�i,1"'i q/ . t SPAN/i /.� l 1 DIMENSIONS OF SILLS 4''µ�Tif+ec.�'. 't/J DISTANCE TO NEAREST BUILDING DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES — SIDES REAR "' GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER _'WOARD OF APPEALS ACTION. IF ANY 17747 IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED � .. '�'�" '� .9 SIGNATURE F OWNER OR AUTHORIZED AGENT - F Pr E PERMIT GRANTED 19 3 PROPERTY INFORMATION LAND COST -EST. BLDG. COST EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN BUILDING RECORD I OCCUPANCY 12 SINGLE FAMILY STORIE MULTI. FAMILY [OFFICES APARTMENTS CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE B 1 2 13 CONCRETE BL'K.PINE BRICK OR STONE HARDW D _ PIERS PLASTER DRY -WALL _ UNFIN. 3 BASEMENT AREA FULL FIN. B'M'T' AREA _ '/. '/I 1/1 FIN. ATTIC AREA _ NO BMT FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS DROP SIDING WOOD SHINGLES ASPHALT SIDING B _ 1 2 �_ 3 _ _ CONCRETE EARTH HARDVV D ASBESTOS SIDING VERT. SIDING STUCCO ON MASONRY _ COMMON ASPH. TILE STUCCO ON FRAME BRICK ON MASONRY BRICK ON FRAME _ ATTIC STRS. & FLOOR I_ CONC. OR CINDER BLK. WIRING STONE ON MASONRY STONE ON FRAME SUPERIOR I� POOR ADEQUATE NONE rj ROOF 10 PLUMBING GABLE I HIP BATH 13 FIX.) _ GAMBRELMANSARD TOILET RM. 12 FIX.) FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. & COLS. STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING _ RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ I.t 13rd ELECTRIC NO HEATING THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. 0 0 0 w 0 r l • N Ln W N �� Lo t 0 f i 0 0 0 w 0 z • N Ln 0 0 0 w 0 Town of North Andover BUILDING DEPARTMENT Homeowner License Exemption (Please print) DATE JOB LOCATION Number Str�e^t "HOMEOWNER"OLj/y Name Hom ►-c, � //-7//f- Address e Phone PRESENT MAILING ADDRESS S�17?E: 1-72S ,//T ection of town ork Phone City Town 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 fthat the owner acts as supervisor. (State Building Code, Section 109.1.1) DEFINITION OF HOMEOWNER: 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 dwell- ing, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, 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) The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of .North Andover Building Department minimum inspection procedures and :'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. JUN 25 in' �;