HomeMy WebLinkAboutMiscellaneous - 80 COURT STREET 4/30/2018%� 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.
AAle 8 — Permit/Date Closed: - /� / * * Note: Reapply for new permi�
❑ Permit Extension Act —Permit/Date Closed:
A
Date ... -. � �/--x�-
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
Isis certifies that ........ C.""'"� r ... GO f��a bj
has permission to perform ....
wiring in the building of ....i �!!!H s %'°y . .............
at. r....S;............. North Andover, Mass.
�--- Gi
Fee . 3-s .... Lic.eELECTRICAL
INSPECTOR
Check
11120
.0
s
Commonwealth of !Massachusetts
Department of Fire Services
a BOARD OF FIRE PREVENTION REGULATIONS
A
I
Official Use Only
Permit No. 6 f I
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 (ME ), 527 MR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 032'r 112—
City or Town of. NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intentionto perform he electrical work described below.
Location (Street & Number) W CC'ust &L N,
A, .3eS-
Owner or Tenant tcy,l QK Telephone No.
Owner's Address
Is this permit in conju etion ith a building permit? Yes � No ❑ (Check Appropriate Box)
Purpose of Building ` �` Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: l� .
\E
rmmnh,tinn nfthe fnllnwinQ table may be waived by the Inspector of Wires.
Attach additional detail ty desired, or as required by me tnspecwi q/ rr of en.
Estimated Value of �llec�^tr, al Work: ��� (When required by municipal policy.)
Work to Start: �q 2-e 12 Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such cover e 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 pe alties of perjun:uec&�-,
t t the information on this application is true and complete.
FIRM NAME: . c�S' LIC. NO.:
Licensee: Signature Nlni�LIC. NO.: �23�
(If applicable, en t exem tt" in the license nier line.) Bus. Tel. No.:_
Address: L --I c�'�'^��v�C �
mi 0C 021�g Alt. Tel. No.:
*Per M.G. 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: $ 3S�
Signature Telephone No.
of Total
No. of Recessed Luminaires
No. of Ceil: Susp. (Paddle) Fans
Trsformers KVA
Trans
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires 2
Above In-
Swimming Pool rnd. ❑ rnd. 1:1
o. o mergency Lighting
No.
Units
No. of Receptacle Outlets �.
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Detection and
No. of Switches
No. of Gas Burners
Initiating Devices
No. of Ranges
Tot
No. of Air Cond. Tons
No. of Alerting Devices
Heat Pump
Number
I Tons
I KW
No. of Self -Contained
No. of Waste Disposers
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 E uivalent
No. of WaterKW
No. of No. of
Data Wiring:
Heaters
Signs Ballasts
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Attach additional detail ty desired, or as required by me tnspecwi q/ rr of en.
Estimated Value of �llec�^tr, al Work: ��� (When required by municipal policy.)
Work to Start: �q 2-e 12 Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such cover e 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 pe alties of perjun:uec&�-,
t t the information on this application is true and complete.
FIRM NAME: . c�S' LIC. NO.:
Licensee: Signature Nlni�LIC. NO.: �23�
(If applicable, en t exem tt" in the license nier line.) Bus. Tel. No.:_
Address: L --I c�'�'^��v�C �
mi 0C 021�g Alt. Tel. No.:
*Per M.G. 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: $ 3S�
Signature Telephone No.
6f
� i 9
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Asp ectpxs'ope�ts: '
(nsp eetoxsyx�natuz e- o Yniiials), ry y u r % s Pate
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(ffispedoxs° gzgnature •-)to Wars) date
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
, www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information 1 Please Print Legibly
Name (Business/Organization/Individual): � { Cft— J— ✓� Q —
Address: � S Sf 4,
City/State/Zip: PJAQ,, O keL 02(LL% Phone #: 6 r -�,57 ( 9 '�-
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. I am a sole proprietor or partner-
listed on the attached sheet. t
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
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. F1 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.
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 workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #:
Expiration Date:
b
Job Site Address: 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.
r do hereby c r under d r and penalties of perjury that the information provided abov is tru and correct.
Signature: Date: 2 12
Phone #:1 V —1 7.1f\K
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
IL Contact Person: Phone #:
Y�X
n
A
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-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' i
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.
I
The Department's address, telephone and fax number: z
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
TO. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05
Fax # 617-727-7749
www.mass.gov/dia
i
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I
4J
k
comio7NWr=ALin yr i4imz�z)i4Urillo'
CONTROL # H 0`3 6 7 5 9
IMPORTANT
if this license is lost or destroyed, notify your. Board at the.
Suite 710,Division f Professional
l 2X1-6100, 1000 Washington St.,
+Ri if. your name or address shown is changed, notify your board
of correct name or address to insure proper mailing of next
Renewal Application. Always refer to your license number.
This license is subject to the provisions of the General Laws
as amended. it is a personal privilege, and must not be loaned
or assigned to any other person. Keep this license on your
i person or posted as required by law.
N° 9595 Date. �.
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies thatOR:
has permission to perform .��...�
a
plumbing in the buildings ofl .. I .................
wat ...........4 (�`^ I . Ile , North Andove ass.
Fee .. Lic. No.&j ... .. ...... .. .
n 6-b
� PLUMBING INSPECTOR
Check # "it jv�
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
1-1-2,-�-)
V V
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY j MA DATE9-d `� / �- J PERMIT #
JOBSITE ADDRESS ( -O a :-"7" s' OWNER'S NAME
POWNER
ADDRESS S' ✓�- _ TEL FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL M EDUCATIONAL ® RESIDENTIAL —
PRINT
CLEARLY
r�-
NEW: Q RENOVATION: 2I REPLACEMENT: Q PLANS SUBMITTED: YES NO
FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8
9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE!
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOILISANDSYSTEM _f
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM i _..__ _f f .__J _ I
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN I .-_._....J ! f ___f _ _f
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR (INTERIOR) —& ! ! � _..__ _f I ..___.I I f _ ..___._.__!
KITCHEN SINK I — _--_._1 _.___..i ._.._..J .._ _.....__! ._.._._-I ......... _.-J
LAVATORY
ROOF DRAIN ! J I ' ! i ! I � _.__. i f .___._. l _.—._J J=
SHOWER STALL
SERVICE / MOP SINK
TOILETI--- --- —._.._I
URINAL ! ...____J _ ! _._..-! _..__.J I ........_...! ---_----__J _.....__J ___.__f ._._.._.-.! ._-___._i .___.-._._I _..._..- ► .--.._..
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPESI L-1 ....-_-J
WATER PIPING
OTHER _I ...._.----_-
-I ------ __--_-_f I=[-. 711 ._.._ _! _...__..{ _I ____-! --- f . _- I __!
- --
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Q O
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Int-- OTHER TYPE OF INDEMNITY Qi BOND 0
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER Q AGENT 10
SIGNATURE OF OWNER OR 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 that all plumbing work and installations performed under the permit issued for this application will be in coliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME ^�_ _�✓f e - LICENSE # _ 67 7 1 SIGNATURE
MP51""JP 0 CORPORATION .. , PARTNERSHIP O# __ LLC Ej _-_ _ _j
COMPANY NAME�0 ADDRESS
CITY O c1[_� _�_.......__....____.._..._..1 STATE I ZIP 1 TEL
FAX € CELL _._ EMAIL y1
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I The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
, www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): J J—C, O w— `--
Address: a `f /''' l et,_. S�, a.. i f S T
ty p �. v w -P f rz Phone #:
Ci /State/Zi
9 2 S�, o- s'd 9,o
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with C,9 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub -contractors have
working for me in any capacity. workers' comp. insurance.
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. ❑ Electrical repairs or additions
11.lumbing 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 a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #:
Expiration Date: !-�-
Job Site Address: 9 b L o v r-% /,R, A City/State/Zip: /t . VY, CJa— 1- 1 -,—
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
1 do hereby certifyAinder the pains and penalties of perjury that the information provided above is true and correct.
Phone #: i k 1—f fd 0
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License
W
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-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia
CONTROL #H355871 H35587i
IMPORTANT
If this license is lost or destroyed, notify your Board at the:
Division of Professional Licensure, 1000 Washington St.,
Suite 710, Boston, MA 02118-6100.
If your name or address shown is changed, notifyI
of correct name or address to insure proper mailing off next
Renewal Application. Always refer to your license number.
This license is subject to the provisions of the General Laws
s t is a personal r
assigned toany other peson• duloaned
Ke p th slicense on
oryour
person or posted as required by law.
CONTROL# H338693
IMPORTANT
If this license is lost or destroyed, notify your Board at the:
Division of Professional Licensure, 1000 Washington St.,
Suite 710, Boston, MA 02118-6100.
If your name or address shown is changed, notify your board
of correct name or address to insure proper mailing of next
Renewal Application. Always refer to your license number.
This license is subject to the provisions of the General Laws
as amended. It is a personal privilege, and must not be loaned
or assigned to any other person. Keep this license on your
person or posted as required by law.
J
i
`COMMONWEALTH OF MASSACHUSETTS y
PLUMBEK AND (,,ASFITTERS
LICENSED Al' A JOU.GNEYMAN PLUMBER
ISSUES THE ABOVE LICENSE TO:
JOHN -P TURC :1
i
1`0 PRINCESS AVE P
CHELMSFORD MA 01824-0000
17168 01,/01/14 147656 ! .
I
;COMMONWEALTH OF MASSACHUSETTS
-BEPLAND GASMITTERS • /
:RE=GISTERED AS A PLUMBIN&CORP Leo
ISSUES THE ABOVE LICENSE TO: E
i
JOVK P TURCO L.
t TURCO PLB ;& HTG INC M.8677
10 PRI`NCE.SS AVEm
CHELMSFORD r,
' MA 01824-0000. -
1.839 05/01/14 1425.41
COMMONWEALTH OF MASSACHUSETTS
(�;TiT�3. tai 771 Imps, � •
— � �CUM$ER5 AND GASFITT•,�
CONTROL #H355872 H355872
IMPORTANT
If this license is lost or destroyed, notify
Division of Professional Licensure, 1000 Washington St.,
Suite 710, Boston, MA 02118-6100.
If your name or address shown is changed, notify your board
Of correct name or address to, insure proper mailing of next
Renewal Application. Always refer to your license number.
This license is subject to the provisions of the General Laws
as amended. It is a personal privilege, and must not be loaned
or assigned to any other person. Keep this license on your
person or posted as required by law.
LICENSED AS A MASTER RLUI:ABER ;.
I
'ISSUES THE ABOVE LICENSE TO:
JOHN P TURCO
1:0. PRINCESS AVE05
m`
`CHELMSFORD MA 01824-0009
8677 05/01/14 14765
i . • . ,�
k
f'
F
Location Four+ 5�--
No. t L9 t Date ci O Ci
NORTH TOWN OF NORTH ANDOVER
i • O�
S
Certificate of Occupancy $
'� s',^° • t<� Building/Frame Permit Fee $ /C)NUS
AC
Foundation Permit Fee $
Other Permit Fee $
TOTAL $—
Check # 1-5-
i 7538 AR�-
Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER: ®` DATE ISSUED: g
SIGNATURE:
Building Commission /I for of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address: L
1.2 Assessors Map and Parcel Number:
Map Number Parcel Number
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Areas Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Requircd Provide Required Provided
Required Provided
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information:
Public ❑ Private ❑ Zone Outside Flood Zone 0
1.8 Sewerage Disposal System:
Municipal ❑ On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
t isrrict:es NO
2.1 Owner of Record
Tvi'Ay 6Z'�'
Name (Print) Address for Service:
'7-7g—'76 Z - 3 LSr—
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor,
Licen�ruction Supervisor.
iy45 ,4, 0. A— CAM—
Addres p�c�0 `f p
A O — 80 os /
GSig U Telephone
,j
Not Applicable ❑
License Number
-?-/,6� b 6
Expiration Date
3.2 Registered Home Improvement Contractor
� S
Pe l/4 � , , �.'a.�
Not Applicable ❑
`
l
Company Name
j, 1 ' I �� ()1$3 �`
tt ["�
Registration Number
l %
Address
o t�
qn
Expira/tion Date
Signat-ur-e I Tele hone
0
M
SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 4 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes .......❑ No ....... ❑
SECTION 5 Description of Proposed Work check au applicable)
New Construction ❑
Existing Building ❑
Repair(s)
Alterations(s) ❑
Addition ❑
Accessory Bldg. ❑
Demolition ❑
Other ❑ Specify
Brief Description of Proposed Work:
Ips ll 33�4�,.t;-�
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
UFF ICIAL USE ONLY
1. Building
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (e) X (b)
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5
3 , ° °
Check Number
SECTION 7a OWNER AUTHORIZA ION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, , 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 Date
SECTION 7b OWNER/AUTHORIZED AGENT
\DECLARATION
I, S� i 1 "U� �D �� i 1 n -C' f ,as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
Print Name
Signature of Owner/A ent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 1 ST 2 ND 3
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL, OF CHI10NEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
A
V
Sold To:�"
Address:
City:I" '- ,
Job site Address (If different):
HIC Registration #129774 Federal ID #04-3277886
Pella Windows & Doors
Pella Windows & Doors of Boston 45 Fondi Road
01832
"Viewed to be the Best" Haverhill, -9886
PH: (800) 86 866-9886
WINDOW CONTRACT
Approx. Start Date:
Service: Ext. 124
..
Fax: (978) 373-7274
YES
Sal s: (866) Pella06
PLEASE READ CAREFULLY: ONLY THE ITEMS CHECKED YES ARE INCLUDED
}y�-
Wj Pu� � ;.J
33 ll1
I
_ Date:
[]"Raise & Lower Slimshade Low E (Gold) (n/a on DH) ❑ Tilt Only White
Sold To:�"
Address:
City:I" '- ,
Job site Address (If different):
HIC Registration #129774 Federal ID #04-3277886
Pella Windows & Doors
Pella Windows & Doors of Boston 45 Fondi Road
01832
"Viewed to be the Best" Haverhill, -9886
PH: (800) 86 866-9886
WINDOW CONTRACT
Approx. Start Date:
Approx. Completion Date:
Service: Ext. 124
Fax: (978) 373-7274
YES
Sal s: (866) Pella06
PLEASE READ CAREFULLY: ONLY THE ITEMS CHECKED YES ARE INCLUDED
I
_ Date:
[]"Raise & Lower Slimshade Low E (Gold) (n/a on DH) ❑ Tilt Only White
Phone (Home)
075) 9O a` ' 37057 1
# of Units Location of Units
Phone (Work)—
;7�
Phone (Cell)1-76
�° � � -*
Approx. Completion Date:
NOT ;%ESPQ- isiei;i_.} OA Aiq.y �et;1S i l:;Ci;3f:Civ NITY:SY.-STERAS. .'.. SALkSh4AM IiAS NO AUTilORIZATION t'O (rPAt AGE AN'dAAK'i
P=P0V!:: . �t_ .-. -d.rADFS..VF. RTK ALS. BIJI40S:C:i3 l"A<ils,.l3RAPES ANY REPWF:r .{`!?l1TlONS fJTHERTIIAN r'Oi Ts3INF.D 1ieTliiS �YOiEEA4ENT
Uri vvinUow MOUN f EJ AIM GUiVU,I,UNtnzi, H-HiUrt W THE iNStALLAi IV,V ANU ' UWNER" HkPHEsLNia I HAI NUtvc navy ocCry MAUI ti, un
OFYOUR NEW WINDOWS. INSTALLERS ARE NOT RESPONSIBLE FOR THE RELIED UPON BY "OWNER". YOU ARE ENTITLED TO A COMPLETELY
REMOVAL OR INSTALLATION OFTHESE TYPES OF ITEMS. FILLED IN DUPLICATE OFTHIS AGREEMENT.
CONDENSATION INSIDE THE HOUSE DOES NOT INDICATE A CONTRACT SUBJECTTO FINAL INSPECTION BY PELLA CONSTRUCTION
WARRANTY PROBLEM. DEPARTMENT.
TERMS AND CONDITIONS THAT GOVERN THIS CONTRACT ARE PRINTED ON THE REVERSE SIDE.
This contract is a legal document. Your Pella products will be specially made-to-order for you. UNDER NO CIRCUMSTANCES WILL REVISIONS OR
Pella Rep. Signature: Date:
/�F7,-czr
Customer Signature: Date:
White - Original Yellow - Customer Pink - Store
Pella Boston Will Furnish and Install:
YES
NO
PLEASE READ CAREFULLY: ONLY THE ITEMS CHECKED YES ARE INCLUDED
[]"Raise & Lower Slimshade Low E (Gold) (n/a on DH) ❑ Tilt Only White
# of Units Location of Units
19.
❑
New Window Units to have Cordless Pleated Fabric Shades
❑ Lily ❑ Taffy ❑ Bone ❑ Celadon ❑Mocha ❑ Golden Oak
# of Units Location of Units
20.
❑
Interior of Units to be Unfinished (Ready to Pr9tatnj—
Painted ( ❑ Pella White cc Linen White) ❑ Primed Only
❑ Stained
❑ Natural ❑ Provincial ❑ Cherry ❑ Early American ❑ Clear Polyurethane
❑ Golden Pecan ❑ Golden Oak
21.
Roof on Bay/Bow to be: ❑ None (Within 18" of Soffit) ❑ Asphalt ❑ Cedar
22.
Clean up and vacuum nightly and remove all debris at completion of job site
23.
❑
Remove and Dispose of existing Windows and/or Storm Doors
24.
❑
All workman's compensation and liability insurance maintained
25.
❑
Warranty mailed to customer upon c mpletion when full payment is received
26.
❑
11
Total Project Amount $ (
27.
❑
❑
Financed If Yes: Amount Financed $ (Reference # )
28.
❑
❑
Deposit Received $ '�,, -7(lo . "1
29.
El
11Balance
on Substantial Completion $ Z0/ ~I j ID .1 (Payment is payable to installer at completion of job)
30.
❑
❑
Additional Comments: 6A)&r—� G'(
NOT ;%ESPQ- isiei;i_.} OA Aiq.y �et;1S i l:;Ci;3f:Civ NITY:SY.-STERAS. .'.. SALkSh4AM IiAS NO AUTilORIZATION t'O (rPAt AGE AN'dAAK'i
P=P0V!:: . �t_ .-. -d.rADFS..VF. RTK ALS. BIJI40S:C:i3 l"A<ils,.l3RAPES ANY REPWF:r .{`!?l1TlONS fJTHERTIIAN r'Oi Ts3INF.D 1ieTliiS �YOiEEA4ENT
Uri vvinUow MOUN f EJ AIM GUiVU,I,UNtnzi, H-HiUrt W THE iNStALLAi IV,V ANU ' UWNER" HkPHEsLNia I HAI NUtvc navy ocCry MAUI ti, un
OFYOUR NEW WINDOWS. INSTALLERS ARE NOT RESPONSIBLE FOR THE RELIED UPON BY "OWNER". YOU ARE ENTITLED TO A COMPLETELY
REMOVAL OR INSTALLATION OFTHESE TYPES OF ITEMS. FILLED IN DUPLICATE OFTHIS AGREEMENT.
CONDENSATION INSIDE THE HOUSE DOES NOT INDICATE A CONTRACT SUBJECTTO FINAL INSPECTION BY PELLA CONSTRUCTION
WARRANTY PROBLEM. DEPARTMENT.
TERMS AND CONDITIONS THAT GOVERN THIS CONTRACT ARE PRINTED ON THE REVERSE SIDE.
This contract is a legal document. Your Pella products will be specially made-to-order for you. UNDER NO CIRCUMSTANCES WILL REVISIONS OR
Pella Rep. Signature: Date:
/�F7,-czr
Customer Signature: Date:
White - Original Yellow - Customer Pink - Store
d
,1�.
`�
The Commonwealth of Massachusetts
Property Owner Mame: V1 0,
Department of Industrial Accidents
'
Office of Investigadons
City: ,/ , _��
! v � � i '"
600 Washington Street
=- y ' : %`
Boston MA 02111
❑ I am a sole proprietor and have no one working in any capacity.
'iii•::.�.�:::.�:.:
Workers' Compensation Insurance Affidavit
Appiicanf Informations
Property Owner Mame: V1 0,
Job Location: O V
City: ,/ , _��
! v � � i '"
Phoneii
❑ I am a homeowner performing all work myself.
❑ I am a sole proprietor and have no one working in any capacity.
'iii•::.�.�:::.�:.:
::: ...... ...........:... .........- :......:...................... ................. ................ ..............:..-..:..............-..................
s>��::,>
am an m.io e�:
e-� p�rovd�in<g:>workers'
Wor co
- pensation for my employees working on this job.
�:::.:: �::::. �:.::�::nw.: �::::
......::................................
Company Mame: (5WCWS QKJ
Address: � 5 ,
Cit.':TO
� 'qVe 1 k d
M /� 3 Z
Phone 0
insurance Co. j - Ac-+ f ® r• d
Policv f OR W 8x L y*Z 6 Y
............................................. .
r;.;;:.:........................................................................................................................................................................................ .
1] 1 am a soic pro.o e tor, generai contractor, or homeowner (circle one) and have hired the contra ctors. listed below who have the following workers'
compensation oouces:
Cumpany 'Mame:
.-address:
Ciry:
Phone
Insurance Co.
Policv #
:...............................................................................................
ComanyName: .............................................................................................................................,.......................
p
Address:
Ciry:
Phone r
Insurance Co.
Policv #
to >� s
till � dt.:•
aiiure to secure co; e age as required under Section 25A of MGL 152 can lead to the imposition of crimirrai penalties of a fine up to $1,500.00 and or
one years' unorisonmert as well as civil penalties in the form of a STOP WORK ORDER and a fine of $100.00 a day against me. I understand that a
copy of this statement rnav be forwarded to the Office of Investigations of the DIA for
coverage verification.
i do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
S 2namre •-++��✓
Date
Print Name #mafe — pp_ �Gt/ .s
R 00 - 844 - M (A
Phone #
Official use oniv. Do not write in this area, to be completed by city or town official
T
iry or Town: Permit/license #
11Building Department
❑Licensing Board
C heck it :-rnmec:atP resnnnse is required
❑ Selectmen's Office
❑ Health Department
'•.ontact person: _ Phone #:
0 Other
A
LE
91te \%
il_.
c� Board of Building Regulations and Standards
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement Contractor Registration
Registration: 129774
Type: DBA
Expiration: 11/2/2005
PELLA WINDOWS AND DOORS
RAYMOND ADAMS
45 FONDI RD.
HAVERHILL, MA 01832
a, �ize �om�nrwozuuru� a� Olaw¢cfucJr,�4
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
-.; Registration: 129774
Expiration: 11/2/2005
Type: DBA
PELLA WINDOWS AND DOORS
RAYMOND ADAMS
45 FONDI RD.
HAVERHILL, MA 01832 Administrator
Update Address and return card. Mark reason for change.
Address Renewal J Employment ❑ Lost Card
License or registration valid for individul use only
before the expiration date. If found return to:
Board of Building Regulations and Standards
One Ashburton Place Rm 1301
Boston, Ma. 02108
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 081843
Birthdate: 02/06/1966
Expires: 02/06/2006 Tr. no: 81843
'Restricted: 00
STEPHEN T DICKINSON
17 BURNSIDE LANE L4---6
MERRIMAC, MA 01860 Administrator
11
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:
(Location of Facility)
Signature of Permit Applicant
�/���
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
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