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HomeMy WebLinkAboutMiscellaneous - 80 HUCKLEBERRY LANE 4/30/2018Date ...�/���,,�..... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING �� ...............................J.......................................................... �l �J t � �i o...'`�..... has permission to perform.. �.�... �:................j.1............................... . plum 'gin the buildin s f......Pn...T"................................................ /j at ..... .............��../.............. P.. ...Gn...'........., North Andover, Mass. Fee `C7....... Lic. No. a................................................................................. . . ��° PLUMBING INSPECTOR Check # 13 CIT WATER HEATER ALL TYPES J�=l WATER OTHER .___.! _ -( ____---:_1 _--_--_1..__--__f I --_j __...._._I -__.._7-1117---j..i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK • POWNER TYPE OR PRINT CLEARLY CITY { MA DATE I-0 PERMIT # JOBSITE ADDRESS moo^ G r'>! OWNER'S NAME LGr d% ADDRESS TEL FAX OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL ® RESIDENTIAL NEW: F11 RENOVATION: 0' REPLACEMENT: PLANS SUBMITTED: YES ® NO[�I FIXTURES -1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CHECK ONE ONLY: OWNER R AGENT IR 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 a curate to the best of my knowledge CROSS CONNECTION DEVICE PLUMBER'S NAMEy1 `� t/s7 IILICENSE # -� _� I SIGNATURE IMP U'-' JP n( CORPORATION MI # PARTNERSHIP EJJ# LLC DEDICATED SPECIAL WASTE SYSTEM CITY � <<s � ;STATE I ZIP -A2 Cv� TEL -,7 . FAX L CELL 1 EMAIL ��s�C/r�r�-- �o. -12 _ _�_. �...G�">✓_.__...... �_.__. DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM _.__.� _._ 4 DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN —11= --_-_! __f _-...._( FOOD DISPOSER FLOOR/ AREA DRAIN INTERCEPTOR (INTERIOR)I ______ ___ . _ _ __ I I _., _I .__-__! ___._ € ._._ __.__ 1 .__._ I .___( •_.__._[ KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/ MOP SINK TOILET URINAL WASHING MACHINE CONNECTION f i _ 1 .�_ _.. WATER HEATER ALL TYPES J�=l WATER OTHER .___.! _ -( ____---:_1 _--_--_1..__--__f I --_j __...._._I -__.._7-1117---j..i __--_-_-€ _...._ 1 INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES ,.I NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY JA""" OTHER TYPE OF INDEMNITY © BOND Ell. 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 R AGENT IR 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 a curate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be inc lianc th all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAMEy1 `� t/s7 IILICENSE # -� _� I SIGNATURE IMP U'-' JP n( CORPORATION MI # PARTNERSHIP EJJ# LLC COMPANY NAME �a �'1 cl f1 n A ADDRESS CITY � <<s � ;STATE I ZIP -A2 Cv� TEL -,7 . FAX L CELL 1 EMAIL ��s�C/r�r�-- �o. -12 _ _�_. �...G�">✓_.__...... �_.__. c.; o� z N ❑ i 61 The Commonwealth of Massachusetts F Department of IndustrialAccidents 1 Congress Sheet, Suite 100 02114-2017 Boston, Y www mass.gov/dia iiM SV�V C ensation Insurance Affidavit: Builders/Contractors/Eleciricians/Plumbers. • Workers omp TO BE FILED WITH THE PERAUTTING AUTHORITY- please Print Le 'bl A licant Information Name (Business/Organization/Individual): Address: f City/State/Zip: Are you an employer? Check the appropriate box: Type of project (required); _em to full and/or parttime). 7. ❑ New'doristriiotlon ees 1' �I am a employer with P y 2Q am a sole proprietor or partnership and have no employees working forme in $. Remodeliiig any capacity. [No workers' comp. insurance required.] 9. Demolition 3.[] I am a homeowner doing all work myself [No workers' comp. insurance required.] t 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all coritmetots either -have workers'_ compensation insurance or are sole proprietors with no employees. 5.❑I am a general contracto 4and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.l 6.Q We are a corporation and its, officers have exercised their right of exemption per MGL c. 152 § 1(4) and we have no employdes [No workers' comp. insurance required.] 10 ❑ Building addition 11.[jElectrical rppavrs or additiggs 11[] Ro6frepairs 14.[] Other *Airy 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 anal then hire outside contractors must submit a new affidavit indicating such �: Contractors that check this Box must atta-hed'an additional sheet showing the name of the sub contractors and state whether or not (hose entities ve employees. If the sub contractors have employees, they must provide their workers' comp. policy number. lam an employer that is ps oviding workers' compensation insurance for my employees. Below is the policy and job site information.��� � Insurance Company Name,: l Expiration Date, Policy # or Self -ins. Lemic. #:City/State/Zip: Job Site Address. /l /Tr/�/Z��'��� �' Attach a copy of the workers, compepsation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL e. 152, §25A is a criminal violation punishable by a fide 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 fins of up to $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DTA- for insurance coverage verification. X do I ter eby cert! A the p ins and penalties of perju� y that tlae information provzdea� i— � Official use only. Do not write in this area, to be completed by city ortown official. City or Town: Permit/License # Issuing Authority (circle one): i 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instrnctions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their pnip%yees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hi�'re, 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 receivet'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 Iicensing 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 xequired. " Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter intp any contract for theperformance 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-numb er(s)-along-with-their -cri tif icate(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 burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 wwwmass.gov/dia r Date ....23 ... �, TOWN OF NORTH ANDOVER PERMIT FOR WIRING ZThis certifies that .......... "....`s�',�� '�� Y/ .................................................................................................. has permission to perform (.G -r/ ......... .. ..�f:.'..)14, ✓2o A!!e.-, e J� ......................... wiring in the building of....` 'F'"� �.... /� ......................................................................................... ...................... . North Andover, Mass. at................................................................................7 Fee ...... �7. ..... Lic. No :�?..... .TY // ............................................................................... ELECTRICAL INSPECTOR Check # f Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. p Occupancy and Fee Checked 'aM BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) QQ I�. / e &yk Ale Owner or Tenant g,t/A t/ --r Telephone No. Owner's Address lL Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: A4 90016E JXA�� c,460I MA A6 "A31,y 4AvedX-- c IA,e,-;t 1k=",1,J5, Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires P• (Paddle) No. of Ceil: Sus addle Fans s Total of TransKVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- F1No. rnd. rnd. o meLighting 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 No. of Self -Contained No. of Waste Dis osers P Totals: I.KW Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW S P g Local ❑ Municipal E] other Connection No. of Dryers Heating Appliances KW Systems:* SecN o evi es or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, oras required by the Inspector of Wires. Estimated Value of Electrical Work: �, pya _ 'a (When required by municipal policy.) Work to Start: ? 2 dg (, Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE C GE: 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 overage ism force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURA=NCE BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: _ v LIC. NO.: a7 7y��S Licensee: JJ& A- L�gl�tbleLt. Signature LIC.NO.: (If applicable, enter "XMP in the license number line. Bus. Tel. No.: Address: tl S3 Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of P lic 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 PE$NIIT FEE: $ g Signature — Telephone No. _ ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the ' 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 conceming 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 M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH SPECTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: 444 Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSP TION• Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: 4 oto Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com I Id Clx The Commonwealth of Massachusetts Department of IndustrialAceldents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): J6541A. ZMiLiUlGr e t� Address: ,�Q AAZ 15Xd, City/State/Zip:_k6,4et Are you an employer? Check the 1:R I am a employer with (..: employees (full and/or part-time).* 2.FJ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] #: 6Q?, - 5��- �fa�/ 3.Q I am a -homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.$ 6.FJ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no. employees. [No workers' comp, insurance required.] Type of project (required): 7. ❑ New construction 8. E] Remodeling 9. ❑ Demolition 10 Building addition I ] Electrical repairs or additions 12.0 Plumbing repairs or additions 13. FJ Roof repairs 14. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees.' Below is the policy and job site information. L Insurance Company Name: ' / /4A `�` MA F—r AU Policy # or Self -ins. Lie. #: ��//G T�7�� Expiration Date: 6 O 14�1 Job Site Address:�d �I� i Is in/ City/State/Zip:,��U%5��: Attach a copy of the workers' compensation policpdeclaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify ugod'er t.Ye pains and penal IfZoury that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: 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 ofhire, 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 fon• confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the cityor town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should'enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia H. Z. LU w le;,. ZItJ s W'= ( w cn C� J • Q D: Z Ln py 0 O • F= d V Z : w �.. • m ui p' LLJ W ._..O N o >. oo -7 + T!, 1202 Date... TOWN OF NORTH ANDOVER PERMIT FOR WIRING t -v W n-eu c f V—,-- -- !. f �- (c) This certifies that........................................................................................... has permission to perform ..... N-fnw./....... �'i .U. ✓ ?.'...................................... wiring in the building of ..Pt ',4. :t.. Q. ...........e..��... ...................... at.Zdf.K 1► //u CIVY110"I ............. . North Andover, Mass. Fee. 5Z.7..c .. Lic. No �*............................................................... ELECTRICAL INSPECTOR 10/10/47 11:14 290.00 RAI? WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 011t &M1110It1 alfij Df Maliliadjuattli 0epartutent taf public lettft:tU Office Use Only Permit No. n Occupancy & Fee CheckedT° BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 1 J't u (leave blank) \ APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Za - 1- 9-7 City or Town of NORTH ANDOVER To the Inspector of Wires: The udersigned applies for a permit to perform the electrical work described below. Location (Street & Number) e61- Owner onOwner or Tenant �i f +ex. Owner's Address o> Ob ��t`- fC Is this permit in conjunction with q building permit: Yes No ❑ (Check Appropriate Box) Purpose of Building SIN Vl� Utility Authorization No. `70-7 Rx 7 Existing Service Amps / Volts Overhead ❑ Undgrnd ❑ No. of Meters New Service 00 Amps /&'I �- k© Vc is Overhead � Undgrnd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work AIPe.J dc' )P�i% No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above In- ❑ ❑ grnd. grnd. Generators KVA No. of Emergency Lighting No. of Receptacle Outlets No. of Oil Burners - Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and No. of Ranges No. of Air Cond. Total tons Initiating Devices No. of Disposals No.of Heat Total Total Pumps Tons KW No. of Sounding Devices No. of Self Contained No. of Dishwashers Space/Area Heating KW Detection/Sounding Devices LocalMunicipal ElOther ElConnection No. of Dryers Heating Devices KW No. of No. of Low Voltage No. of Water Heaters KW Signs Ballasts Wiring No. Hydro Massage Tubs No. of Motors Total H'r OTHER INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws I have a current Liability Insurance Policy including Com leted Operations Coverage or its substantial equivalent. YES NO ❑ 1 have submitted valid proof of same to the Office. YES d( NO ❑ If you have checked YES, please indicate the type bf coverage by checking the appropriate box. INSURANCE .d BOND ❑ OTHER ❑ (Please Specify) (Expiration Date) Estimated Value of Electrical Work $ _ Work to Start 4,6 - -7- S ;�— Signed under the Penalties of perjury: FIRM NAME Xnw:_] ry,VC_Q_ i Inspection Date Requested: Rough 4&11 l/ CCie(( Final LIC. NO. ZZ9974 Licensee L"Gtl+iS 6RWrl-AjC4 Signature 1".44 4 LIC. NO. Bus. Tel. No. Cis - /� ts`lF, Address 92 f n S 1� ; e �2 AC.c Alt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as re- quired by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) Telephone No. PERMIT FEE $ (Signature of Owner or Agent) x-6565 Q w O z Q H O z _J is O f- w CL w O LL z O F- Q Q J a a O z w CL of bi z O in � V [Z' O LL z F- F- w CL O CL O U O 0 U J O m z w LLO O O x a a O z Cl) in F- U O :E U x b U w a 0 O U m m � w w w V ------------ Z O 0 0 � w w F - w W w z (r "- w ~ H - z o J � M m O 4 � o Z p 0 (Y N ? 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C.3 o C �;06 C E Ic Ma N 0 N C O n m cc CO C cc 0 n C •C A t 0 Z O s 0 6 • • • Pl M/ FORM U - VERIFICATION FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant ills out this- ection********L*�****/**** APPLICANT: Phone LOCATION: Assessor's Map Number Parcel Subdivision ALot(s) _ Street St. Number *************d1V*ek**sir �Of dlM� Us only************************ A I urillit uATIO TO AGENTS: Date Approved'J Conservation Administ/'ratT", Date Rejected Comments `7100' Food Inspector -Health Septic Inspector -Health Comments Date Approved Date Rejected Date Approved Date Rejected Public Works - sewer/water connections 21�_-I -7/3/27 - driveway permit( �( 7/-3 Y �E�di,CGJ %1.9�q�lUrl F./ cT/yXJ.�c F�"ZY[.1 9/�ci RFS inTi-sR� Fire Department ,r, Received by Building Inspector Date Growth Management Bylaw Exemption Statement Town of North Andover Building Department This form shall be used to assist the Building Department in their determination of exemptions under section 8.7.6 of the Town of North Andover Growth Management Bylaw. The building applicant shall provide all of the necessary information as requested below. Name of Applicant on Building Permit below) Address of Property for Permit (below) So U Map and Parcel: Purp se of A .plicati n (check below) Pho a NNu�mb r of ,q-plicant: ingle Family — Two Family F�/ - . 2 I the undersigned applicant for the above property attest that the attached building permit for which this form is completed does comply with the EXEMPTION section 8.7.6 of the North Andover Growth Management Bylaw. I also understand providing this form does not absolve me or any party to this permit from the requirements of obtaining other permits required prior to the issuance of the Building Permit. Further I understand that my interpretation of the EXEMPTION status is subject to review by the Building Department and is only officially accepted when the Building Permit is issued. Based on section 8.7.6 of the North Andover Growth Bylaw the above lot and the work as applied for on the above lot, in the building permit application and associated attachments, complies with one or more of the following sections as indicated by a check mark. This is an application for a building permit for the enlargement, restoration, or reconstruction of a dwelling in existenceeaa of the effective date of this by-law, provided that no additional residential unit is created. /The lots) were/was created prior to May 6, 1996 are exempt from the provisions of this Section 8.7 of the Zoning Bylaw. This application is for dwelling units for low and/or moderate income families or individuals, where all of the conditions of 8.7.6.c are met and/or represents Dwelling units for senior residents, where occupancy of the units is restricted to senior persons through a properly executed and recorded deed restriction running with the land. For purposes of this Section "senior" shall mean persons over the age of 55. This application is a part of a development project which voluntarily agreed to a minimum 40% permanent reduction in density, (buildable lots), below the density, (buildable lots), permitted under zoning and feasible given the environmental conditions of the tract, with the surplus land equal to at least ten buildable acres and permanently designated as open space and/or farmland. The land to be preserved shall be protected from development by an Agricultural Preservation Restriction, Conservation Restriction, dedication to the Town, or other similar mechanism approved by the Planning Board that will ensure its protection. This application represents a tract of land existing and not held by a Developer in common ownership with an adjacent parcel on the effective date of this Section 8.7 shall receive a one-time exemption from the Planned Growth Rate and Development Scheduling provisions for the purpose of constructing one single family dwelling unit on the parcel. This application represents a lot which is ready for building permits,(i.e. all other permits from all other boards and commissions have been received and the project is in compliance with those permits), and the Development Schedule does not accommodate issuing a building permit in that Year, one building permit will be issued per Year per Development until such time as the Development Schedule accommodates issuing building permits. Applicant must supply approved form U with this EXEMPTION. Please provide any and all information that would assist the Building Department in making a determination that your application is allowed one or more of the above EXEMPTIONS. By signing below I attest to the accuracy of the information provided and that the attached building permit allowed an EXEMPTION as cited above. Further I understand that the submittal of misleading and or inaccurate information, or the checking off of an above item which does not comply, whether done to my knowledge or not, is grounds for refusal by the Building Department to issue a Building Permit. rture of Owner or Authoriz d g t who signed Attached Building Permit Date form must be attached to the uilding PerrV upon application for such permit. 08/12/1997 12:25 508-47514,48 MERRIMACKENGINEERING 'AGE 02 G g-�IO PINEWOOD DEVELOPMENT CORP. D/B/A FOXWOOD PLACE 1 �J 51 VENDOR ID: TOWNHALL ' CHECK NO.: 1051 DATE: 08/19/97 PAYEE: TOWN OF NORTH ANDOVER MEMO: LOT 8 BUILDING PERMIT LR2204.1 BEACON SYSTEMS INC. 508-879-3700 CHECK TOTAL: *****$1,019.00 PRINTED IN U.S.A. PINEWOOD DEVELOPMENT CORP. D/B/A FOXWOOD PLACE VENDOR ID: TOWNHALL CHECK NO.: 1993 DATE: 08/07/97 19 93 PAYEE: TOWN OF NORTH ANDOVER MEMO: LOT 8 FOUNDATION PERMIT 1 CHECK TOTAL: *****$2,232.00 LR2204.1 BEACON SYSTEMS INC. 508-879-3700 PRINTED IN U.S.A. OW . 10 C, 14 lom 2 MLDFORD SANINGS BANK PINEW000 DEVELOPMENT CORP. MEDFORD, MASSACHUSETTS 0/131A FC)XWC)Orj PLACE 733 TURNPIKE ST, SQiTE 311 NORTH ANDOVEP, MA wit!4S 57-7C5".2153 . ONE THOUSAND NINETEEN DOLLARS PATE 08 /19/97 TO THE TOWN OF NORTH 1114DOVER ORDER Town Hall 'TWO SIGNATURES REQUIRED IP IN F:XC;ES$ OF OF --1 1) G L3 6 25— 5 4 . 2 t 040—.;=x..-3 . 1q. Andover, MA 01845 11�nn i. o s i el, 1: 2 1 L 3 70 s 461: 0? 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