HomeMy WebLinkAboutMiscellaneous - 80 PATTON LANE 4/30/2018N
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Date ...... .....�..�.... -'
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that........./..I:..�..,.............../Z'/��G../...........................................
has permission to perform ..... 1'�...-...... '`........��r ell '`� _ -
..................
wiring in the building of.;"v w�
p... ................................... ... h.�.......................�..
at............'r.......... ............................. .North Andover, Mass;
r
Fee. .:�� Lic. No.l.. .................: �....�.....
...::.
ICAL INSPECTOR
Check # / j'p /
, 11614
4. Commonwealth of Massachusetts
a Department of Fire Services
I BOARD OF FIRE PREVENTION REGULATIONS
,•M
Official Use Only
Permit No. %/ /
Occupancy and Fee Checked
[Rev. 1/07] (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code ), 5 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATIOA9 Date: � ! a
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives ptice of o er intention to perform the electrical work described below.
Location (Street & Number)
Owner or Tenant
Owner's Address
K
Telephone No.
Is this permit in conjunction with a uildirlg permi ? Yes 9�f' No [I(Check Appropriate Box)
Purpose of Building 1'►'!S
4
Utility
Authorization No.
- Existing Service Amps
/ Volts
Overhead ❑
Undgrd ❑ No. of Meters _
New Service Amps / Volts Overhead ❑ Undgrd ❑
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
No. of Meters
N
Com le"tion of the following table maybe waived by the Inspector of Wires.
No. of Recessed Luminaires
No. of Ceil: Susp. (Paddle) Fans
s Total
Trsformers KVA
Tran
No, of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ElIn- ❑
rnd. rnd.
o. o mergency Lighting
Batte 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
g
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Dis posers
p
Heat Pump
Totals:
Number
Tons
KW
..... ....
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
S ace/Area Heating KW
P g
Local ❑ Municipal ❑ Other
Connection
of Dryers
y
Heating Appliances KW
Security
SystemNo.
No. of Devices or Euivalent
Devices
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, or as required by the Inspector of Wres.
Estimated Value of Fr ectrical Work: (When required by municipal policy.)
Work to Start: S 1ZJ1 Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE CO 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 co age is in force, and has exhibited proof of sa t the p it issuing office.
CHECK ONE: INSURANC BOND ❑ OTHER ❑ (Specify:)
Icertify, underthepa' penalties 7&11
erg , tltat the ' format' on this app tcaf�on is true and complete. C
FIRM NAME: _ �t C . C LIC. NO.: �i
Licensee: S k (f Signature LTC. NO.:
(If applicable, ente exem ' jn the ce se number line. /. Bus. Tel. No. --
Address: 4 U/l -29i1A &I,'J � � Alt. Tel. No.:
*Per M.G.L c. 147, s. 57-61, security work re4uires Department of Pu 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 PERMIT FEE:
Signature Telephone No.
. �I
❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3L.
Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence' during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012.
❑ Rule R — Permit/Date Closed: *** Note: Reapply for new permit ❑
❑ Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass F?1
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass 0
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments: "
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass IN
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass n
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
FINAL INSPECTION:
Pass 0
Failed M
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com
4�
The Commonwealth of Massachusetts
Ln Department of IndustrialAccidints
Office of Investigations
600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): �/ w�l CC
Address: �� / �i /&�, 4 , -
City/State/Zip: Phone #:
A e yan employer? Check the appropriate box:
Type of project (required):
1: I am a employer with �a
4. ❑ I am a general contractor and I
have hired the sub -contractors
❑ `
6. Ne construction
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet. #
�• emodeling
ship and'have no employees
These sub -contractors have
8. ❑ Demolition
working for me in any capacity.
workers' comp. insurance.
9• ❑ Building addition
[No workers' comp. insurance
5. ❑ We are a corporation and its
10.❑Electrical repairs or additions
required.]
3111 am a homeowner doing all work
officers have exercised their
right of exemption per MGL
11. ❑ Plumbing repairs or additions
myself. [No workers' comp.
c. 152; §1(4), and we have no
12.❑Roof repairs
insurance required.] t
employees. [No workers'
13. ❑ Other
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
T Homeowners who submit this affidavit indicating they aie 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. �
//vInsurance Company Name:. /
Policy # or Self -ins. Lic. #: C�1 Expiration Date:
Job Site Address: OU /'" � L City/State/Zip: / o t'�
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requiredunder Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the ins n alit s of perjury that the information provided above is i/rlc�e and correct.
.Cio»afiira• nat0. -,' Z
Phone #:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other - -
Contact 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 employeiis 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 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 Go=oawealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston} MA 02111
Tel. # 617-727_4900 ext 406 on 1-877rMASSAFB
Revised 5-26-05 Fax # 617-727-7749
www-mass.govfdia
This certifies that
........ ................. / . . .........
has permission to perform . &k� ... ..........
plumbing in the buildings of . . . ..........................
at ... .......... North Andover, Mass.
Pee Lic. No. /-�� ................ ...
PLUMBING INSPECTOR
Check # 1I
i3e � 10 - 13 � c; W 1-3
s !Q�- -'
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY e _ a _i MA DATE PERMIT #
JOBSITE ADDRESS OWNER'S NAME
P
OWNER ADDRESS TEL—FAX— _ _I
TYPE OR
OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIALip
PRINT
CLEARLY
NEW: 0 RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES 0 N00
FIXTURES'l 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 GAS10ILISAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
__........ 1
DISHWASHER
DRINKING FOUNTAIN
FOODDISPOSER —__► .- 1 .-._-..__ I .._._.._---..._._€ (_..._._. .__._..__ I .__....___€ ..._ € ..__.__! ..._. _.__€ ._I
FLOOR/AREA DRAIN
INTERCEPTOR (INTERIOR)-
INTERIOR
KITCHEN SINK _l _.__.J __..__._.i 4 i -- _—I .._.i __E ._._._._I .._._i __..._. __........_! J __( .-_._......�
KITCHEN
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE / MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION ` _.. ` _ .. _ _i _- - .1 _ _ Jf
WATER HEATER ALL TYPES
WATER PIPING
A JI_-
INSURANCE COVERAGE:
Q have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO M
OF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY` OTHER TYPE OF INDEMNITY 0 BOND ...I
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 0 AGENT 10
SIGNATURE OF OWNER OR AGENT
B 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 y kno ledge
and that all work installations the issued for this application will be in co ith ne sio he
plumbing and performed under permit pli
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME C�/ M LICENSE # y _I SIGNATU E
i y1
IMP JP CORPORATION O# F PARTNERSHIP]=#LLCN # E=
COMPANY NAME _/_ ADDRESS
CITY --------- ___ - I STATE ZIP �� TEL L(70 C)
FAX CELL St 7/O 1! „i EMAIL __.� ____LC%/ tl --- - _.--_.._ S.. .QL_ ... ___...._._ _...._. .....__._ . I c
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
UT www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: T7
City/State/Zip: /�7'�, %I�� MA-::� Phone #: "77 41 76� 6� /' G 9'
A,.reu an employer? Check the appropriate box:
I A 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.
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.] f
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. XRemodeling
8. ❑ Demolition
9. ❑ Building addition
10. F1 Electrical repairs or additions
11.FgPlumbing 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 aie doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. , n
Insurance Company Name:. �l�-`�cG 7"
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' .compensation policy declaration page (showing the policy number and expiration date).
Failure to -secure coverage as requiredunder Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ido hereby certify under thea n / en toof. eryury t the information provided above is true and correct.
Phone #:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other - - -
Contact 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
500 Washington Street
Boston., MA 02111
Tel, # 517-727_4900 ext 405 or 1-877:MASSAFB
Revised 5-26-05 Fax # 517-727-7749
vww.mass,govfdia
,x COMMONWEALTH OF MASSACHUSETTS, 1
} PLUMBERS 'ANDGASFITTERS
LICENSED Al A MASTER PLUMBER ..
ISSUESTHE ABOVE LIGENSSE TO µ
EDWARD ''A 'KELLEY c .
57 MARICYN RD
> ANDOVER MA O181D-293
9.429 05/01/14 .183146
j
l g
:�
Date:...�.............................
TOWN OF NORTH ANDOVER
10
PERMIT FOR WIRING
This certifies that r-
has permission to performer d : n�:;.;.;=......�.........................................
wiring in the building of..
at ...6F0..... "�'' ?^"''...:............... . North Andover., Mass.
ig
Fee ..A...f .:..... .. Lic. No./7lj ............. .
__1` ELECTRICAL SP U...
R
j
Check Nom®
8309
4
' x
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
� Official Use Only
Permit No.
Occupancy and Fee Checked
[Rev. 11/991 leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: /� a / y gegJ.,
City or Town of: �A/®`t i // /�/yD�1y�� 2 To the Inspector of Wires:
By this application the undersigned givesnotice of his or her intention to perform the electrical work described below.
Location (Street & Number) r d /-)/I T%iY L' /V _
Owner or Tenant j%%1, /Za- Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box)
Purpose of Building r l"u� t' C�/ice/ Utility Authorization No.
/ Volts Overhead ❑ Undgrd ❑ No. of Meters
Existing Service Amps
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: `e ? r..zn�7 lv
fa SSU /h.Sri�l/ �,K 7`�✓�IC'S' .moi<�r6J %sl�Gr� %vim iy �rrnr��17`c2
r,,tho f„ tt,,,,,,,o tnhle mm, he waived by the Inspector of Wires.
Attach additional detail if desired, or as required by the Inspector of Wires.
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
undersiomd certifies that such coverage is in force, and has exhibited proof of sa a to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
(Expiration Date)
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
I eertify,' under th'e pains.a_nd penalties of perjury, that the information on this application is true and complete.
:CIC. NO.:
14 -(XL NAME: CIC. NO /Oil c9�l
Licensee: Signature
�—.
PP
(7f applicable. enter "exempt" in the license number line) Bus. Tel. No.
Address: .0- zz, !SZ
®1� Alt. Tel. No.:
OWNER'S URANCE WAIVER: I am aware that the Li ensee does not have the liability insurance coverage normally
required by law. By my signature below, 1 hereby waive this requirement. I am the (check one) ❑ owner Elowner's agent.
Owner/Agent PERMIT FEE: S Ire, �J
Signature Telephone No.
Sg • Receipt 0 -
No. of Total
No. of Recessed Fixtures
No. of Ceil: Susp. (Paddle) Fans
Transformers KVA
No. of Lighting Outlets
No. of Hot Tubs
Generators KVA
No. of Lighting Fixtures
Above In-
Swimming Pool rnd Elrnd. ❑
o. u mergency tg tng
Battery Units
No. of Receptacle Outlets
No. of Oil Barac,s
FTRF ALARMS No. of Zones
No. of Detection and
No. of Switches
No. of Gas Burners
Initiating Devices
No. of Ranges
To`
No. of Air Cond. Tons
No. of Alerting Devices
Heat Pump Number Tons KW
No. of Self -Contained
No. of Waste Disposers
Totals:
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal ❑ Other
Connection
No. of Dryers' `
g
Heating Appliances I{Vy
Security Systems:
No. of Devices or Equivalent
No. of WaterNo.
Heaters KW
of _No. of
SiQ»s Ballasts
Data Wiring:
No. of Devices or Equivalent
Telecommunications Wiring:
No.'Hydromassage Bathtubs. ., t .
No. of Motors Total HP
No. of Devices or Equivalent
//�
nTu�rr• /i`� n.._ -� a'7 -o, % �t T_ �r� dtJT '/S /��%� C.' r -CSL
Attach additional detail if desired, or as required by the Inspector of Wires.
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
undersiomd certifies that such coverage is in force, and has exhibited proof of sa a to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
(Expiration Date)
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
I eertify,' under th'e pains.a_nd penalties of perjury, that the information on this application is true and complete.
:CIC. NO.:
14 -(XL NAME: CIC. NO /Oil c9�l
Licensee: Signature
�—.
PP
(7f applicable. enter "exempt" in the license number line) Bus. Tel. No.
Address: .0- zz, !SZ
®1� Alt. Tel. No.:
OWNER'S URANCE WAIVER: I am aware that the Li ensee does not have the liability insurance coverage normally
required by law. By my signature below, 1 hereby waive this requirement. I am the (check one) ❑ owner Elowner's agent.
Owner/Agent PERMIT FEE: S Ire, �J
Signature Telephone No.
Sg • Receipt 0 -
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TOWN
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TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that .. .. ...... .
has permission to perform f' ......... ...............
plumbing in -the buildings of �'`"" a'� �.....................
at .fi.a "' ...... -:.. , North Andover, Mass.
Fee Lic. No.97 %..%C: ..... ti .... ... .
W GING IN P CTOR
Check # AV,? 7y
7811
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING 8po
(Print or Type) °
rrwas 3 Rd
/`1�� ' A��a�E� � , Mass. Date _� 19; Permit#
Building Location 86 ?A-foN Owner's Name
Type of Occupancy
New ❑ Renovation Eg) Replacement ❑ Plans Submitted Yes ❑ No ❑
FEATURES.
.Installing Company Name /F-rran K GouVei'b . P C60J- S1Check one:
Address f� I� ~�' �C �' v L 460rporation
❑ Partnership
Business Telephone — V ❑ Firm/Co.
Name of Licensed Plumber ' �r-,rA n k-- G ou V e f zk--
Certificate
o2 7d ,
INSURANC/COV RAGE:
I have a cuility insurance policy or its substantial equivalent which meets the requirements of MGL Ch 142.
YesNo ❑
If you have checked yes, please in ' ate the type of coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity ❑ Bond ❑
OWNERS INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws and that my signature on this permit application waives this requirement.
Check one:
Owner ❑ Agent ❑
I hereby certify that all of the details and informatio have submitted (or en ered) in above application are true and accurate to
the best of my knowledge and that all plum ' or and installations p o ed under the permit issued for this application will
be in compliance with all pertinent provisions of th Massachusetts Sta umbing Code and Chapter 142 of the General Laws.
i
By
Signature Licensed 1-15 er Gl��e--•
Title Type of License: Master [Journeyman ❑
City/Town License Number M j16.2 -C9- o
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installing Company Name Fr -411K �Oul/P�/�... PL.Ae-r (1 tJi` xfW—iCheckone:
eI Address , Pr' n@ e- "D 0 S,� ❑'/'Corporation
No C 41m ,Turd
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING 8jo
(Print or Type) r% °
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Mass. Date IV Permit#
Building Location gV PA-rrOJ I-AiJ F Owner's Name PAL
Type of Occupancy
New ❑ Renovation Cts Replacement ❑ Plans Submitted Yes ❑ No ❑
FEATURES
Business Telephone i `113 ) 0115 1— 19 O 0 ❑ Firm/Co.
Name of Licensed Plumber ', rG n k.. 6,ouye;A•...
Certificate ,
INSURANCE CO/V�ERAGE:
I have a curren ;liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch 142.
Yes P No ❑
If you have checked yes, please in ate the type of coverage by checking the appropriate box.
A liability insurance policy Q Other type of indemnity ❑ Bond ❑
OWNERS INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws and that my signature on this permit application waives this requirement.
;- Check one:
_ Owner ❑ Agent ❑
I hereby certify that all of the details and information -1, have submitted (or entered) in above application are true and accurate to
the best of my knowledge and that all plumbing-wor�/and installations perfo med under the permit issued for this application will
be in compliance with all pertinent provisions of the M'aYssaacchusetts Stat umbing Code and Chapter 142 of the General Laws.
t�. /10 'e, 44 --
Signature o icense um err
Title Type of License: Master E Journeyman ❑
City/Town License Number0
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Certificate ,
INSURANCE CO/V�ERAGE:
I have a curren ;liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch 142.
Yes P No ❑
If you have checked yes, please in ate the type of coverage by checking the appropriate box.
A liability insurance policy Q Other type of indemnity ❑ Bond ❑
OWNERS INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws and that my signature on this permit application waives this requirement.
;- Check one:
_ Owner ❑ Agent ❑
I hereby certify that all of the details and information -1, have submitted (or entered) in above application are true and accurate to
the best of my knowledge and that all plumbing-wor�/and installations perfo med under the permit issued for this application will
be in compliance with all pertinent provisions of the M'aYssaacchusetts Stat umbing Code and Chapter 142 of the General Laws.
t�. /10 'e, 44 --
Signature o icense um err
Title Type of License: Master E Journeyman ❑
City/Town License Number0
APPROVED OFFICE USE ONLY)
Date .../ .' ...... .
2 TOWN OF NORTH ANDOVER
• PERMIT FOR GAS INSTALLATION
�9SSACMUSC�-
Et
This certifies that .......................................
has permission for gas- installation
in the, buildi"s of ... ............................... .
at
/ .tet. F .... North Andover, Mass.
Fee. w Lic. N0't t �R�a �. `=-hy'�....... .
GAS INSPESft /
Check #
6492
4'913-, d6
MASSACHUSETTS UNIFORM A'PPUICATION FOR PERMIT TO DO GASFITTING
(Print or Type) a
IQ . A N�6VIF k, , Mass. Date 6 ^'5 20 o8 Permit#
Building Location 80 ?A—I rO4 to M F— Owner's Name4 -//—"P'�MF�31�
ram` l y Type of Occupancy
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INSURANCE COVERAGE:
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Yes kY No ❑
If you have checked yes, .p:71:0ther
the type of coverage by checking the appropriate box.
A liability insurance policy type of indemnity ❑ Bond ❑
OWNERS INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws and that my signature on this permit application waives this requirement.
Check one:
Owner ❑ Agent ❑
I hereby certify that all of the details and information i have submitted (or entered) In above appttcanon are true ana aaaurate to
the best of my 1 and that all plumbing work and installations performed under the permit issued for this ap�icatwn wiN
be in compliance with a 1 pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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Title ❑er Signature of Licensed Plumber or Gas Fitter
❑ Journeyman License Number A% %61--6
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Date.. . / -.3-11--e.. 7 ...
1 F p TOWN OF NORT A VER
PERMIT FOR GAS INSTALLATION
This certifies that ?!` �' " �' ....
has permission for gas installation .... ......
in the buildings -of .............................
at ..� ...�-�.. 2! ..�? . , North Andover, Mass.
Fee? .y. Lic. No.... .7/ .`�! ......... .
�i GAS SP�EGTOR
Check #
MASSACHUSETTS UNIMIRM APPUCATON FOR PERMIT TO DO GAS FITTING
(Type or print) Date �v alb%
NORTH ANDOVER, MASSACHUSETTS
Building Locations 1Z14 N�' Permit # � // / _
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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 Massachusetts State Co a and%iapter 142 of the General Laws.
Title
City/Town
PROVED (OFFICE USE ONLY)
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Master
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Plans Submitted \ qA
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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 Massachusetts State Co a and%iapter 142 of the General Laws.
Title
City/Town
PROVED (OFFICE USE ONLY)
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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 Massachusetts State Co a and%iapter 142 of the General Laws.
Title
City/Town
PROVED (OFFICE USE ONLY)
sled PhIfnber Or Gas Fitter
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Signature of
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Gas Fitter
Master
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sled PhIfnber Or Gas Fitter
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License Number
Page 1 of 2
Date: May 12, 2003
Case No.: 03-01-0632A
LOMA
� MSN
Federal Emergency Management Agency
Washington, D.C. 20472
dy O O
LETTER OF MAP AMENDMENT
DETERMINATION DOCUMENT (REMOVAL)
COMMUNITY AND MAP PANEL INFORMATION
LEGAL PROPERTY DESCRIPTION
TOWN OF NORTH ANDOVER, ESSEX
A parcel of land, as described in Deed, Document No. 39344, recorded in
COMMUNITY
COUNTY, MASSACHUSETTS
Book 3915, Pages 168 and 169, filed on December 1, 1993, in the North
District Registry of Deeds, Essex County, Massachusetts
COMMUNITY NO.: 250098
NUMBER: 2500980009C
AFFECTED
NAME: TOWN OF NORTH ANDOVER,
MAP PANEL
ESSEX COUNTY,
MASSACHUSETTS
DATE: 0610211993
FLOODING SOURCE: BOSTON BROOK
APPROXIMATE LATITUDE & LONGITUDE OF PROPERTY: 42.651,-71.066
SOURCE OF LAT & LONG: PRECISION MAPPING STREETS 4.0 DATUM: NAD 83
DETERMINATION
OUTCOME
1% ANNUAL
LOWEST
LOWEST
WHAT IS
CHANCE
ADJACENT
LOT
LOT
BLOCK/
SUBDIVISION
STREET
REMOVED
FLOOD
FLOOD
GRADE
ELEVATION
SECTION
FROM THE
ZONE
ELEVATION
ELEVATION
(NGVD 29)
SFHA
(NGVD 29)
(NGVD 29)
80`Patton Lane
Residential
6-C
_
_
Structure
X unshaded
X(unshaded)
102.6 feet
103.5 feet
_
Special Flood Hazard Area (SFHA) - The SFHA is an area that would be inundated by the flood having a 1 -percent chance of being equaled or
exceeded in any given year (base flood).
ADDITIONAL CONSIDERATIONS (Please refer to the appropriate section on Attachment 1 for the additional considerations listed below.)
PORTIONS REMAIN IN THE FLOODWAY
This document provides the Federal Emergency Management Agency's determination regarding a request for a Letter of Map Amendment for the property
described above. Using the information submitted and the effective National Flood Insurance Program (NFIP) map, we have determined that the
structure(s) on the property(ies) is/are not located in the SFHA, an area inundated by the flood having a 1 -percent chance of being equaled or exceeded in
any given year (base flood). This document amends the effective NFIP map to remove the subject property from the SFHA located on the effective NFIP
map; therefore, the Federal mandatory flood insurance requirement does not apply. However, the lender has the option to continue the flood insurance
requirement to protect its financial risk on the loan. A Preferred Risk Policy (PRP) is available for buildings located outside the SFHA. Information about
the PRP and how one can apply is enclosed.
This determination is based on the flood data presently available. The enclosed documents provide additional information regarding this determination. If
you have any questions about this document, please contact the FEMA Map Assistance Center toll free at (877) 336-2627 (877 -FEMA MAP) or by letter
addressed to the Federal Emergency Management Agency, P.O. Box 2210, Merrifield, VA 22116-2210. Additional information about the NFIP is available
on our web site at http://www.fema.gov/nfip/.
Mary Jean k M., Acting Chief
Hazard Study Branch Version 1.3.4
Federal Insurance and Mitigation Administration MX173014003V3204LOMAV3204SPF2
Page 2 of .2
Date: May 12, 2003
Case No.: 03-01-0632A
LOMA
• f� MA�y�
Federal Emergency Management Agency
.�4
a� Washington, D.C. 20472
Jay o O
LETTER OF MAP AMENDMENT
DETERMINATION DOCUMENT (REMOVAL)
ATTACHMENT 1 (ADDITIONAL CONSIDERATIONS)
PORTIONS OF THE PROPERTY REMAIN IN THE FLOODWAY (This Additional Consideration applies to the
preceding 1 Property.)
A portion of this property is located within the Special Flood Hazard Area and the National Flood Insurance Program (NFIP)
regulatory floodway for the flooding source indicated on the Determination/Comment Document while the subject of this
determination is not. The NFIP regulatory floodway is the area that must remain unobstructed in order to prevent
unacceptable increases in base flood elevations. Therefore, no construction may take place in an NFIP regulatory floodway
that may cause an increase in the base flood elevation, and any future construction or substantial improvement on the
property remains subject to Federal, State/Commonwealth, and local regulations for floodplain management. The NFIP
regulatory floodway is provided to the community as a tool to regulate floodplain development. Modifications to the NFIP
regulatory floodway must be accepted by both the Federal Emergency Management Agency (FEMA) and the community
involved. Appropriate community actions are defined in Paragraph 60.3(d) of the NFIP regulations. Any proposed revision
to the NFIP regulatory floodway must be submitted to FEMA by community officials. The community should contact either
the Regional Director (for those communities in Regions I-IV, and VI-X), or the Regional Engineer (for those communities in
Region V) for guidance on the data which must be submitted for a revision to the NFIP regulatory floodway. Contact
information for each regional office can be obtained by calling the FEMA Map Assistance Center toll free at (877) 336-2627
(877-FEMA MAP) or from our web site at http://www.fema.gov/nfip/reg.htm.
This attachment provides additional information regarding this request. If you have any questions about this attachment, please contact the FEMA Map
Assistance Center toll free at (877) 336-2627 (877-FEMA MAP) or by letter addressed to the Federal Emergency Management Agency, P.O. Box 2210,
Merrifield, VA 22116-2210. Additional information about the NFIP is available on our web site at http://www.fema.gov/nfip/.
Mary Jean k�C.F.M., Acting Chief
Hazard Study Branch Version 1.3.4
Federal Insurance and Mitigation Administration MX173014003V3204LOMAV3204SPF2
�A
Community Map Repository
Federal Emergency Management Agency
Washington, D.C. 20472
Dear Community Official:
Enclosed are copies of recent Letters of Map Amendment (LOMAs) and/or Letters of Map
Revision based on Fill (1.0�4R-Fs) issued to amend or revise the National Flood Insurance
Program (NFIP) map for your community.
As you know, the map repository is a local resource for information regarding the risks of
flooding in your community. A priority of the Federal Emergency Management Agency (FEMA)
is to ensure that changes to the flood -risk information, such as those resulting from the issuance
of a map amendment or map revision, are sent to the repository for the benefit of the public.
Please note that NFIP regulations require that the local map repository attach the enclosed copy
of the LOMA and/or LOMR-F to the appropriate NFIP map on file.
We appreciate your cooperation in maintaining this valuable community resource. If you have
any questions about any of the enclosures, or if the address of the repository for your community
has changed, please contact the FEMA Map Assistance Center toll free at (877) 336-2627 (877 -
FEMA MAP).
Sincerely,,,
Michael M. Grimm, Acting Chief
Hazard Study Branch
Federal Insurance and Mitigation Administration
Enclosures
Federal Emergency Management Agency
MS. ERICA LOLLI
FIRST FINANCIAUSIB MORTGAGE CORP
110 CEDAR STREET
WELLESLEY, MA 02481
DEAR MS. LOLLI:
Washington, D.C. 20472
May 12, 2003
CASE NO.: 03-01-0632A
COMMUNITY: TOWN OF NORTH ANDOVER, ESSEX COUNTY,
MASSACHUSETTS
COMMUNITY NO.: 250098
This is in reference to a request that the Federal Emergency Management Agency (FEMA) determine if the
property described in the enclosed document is located within an identified Special Flood Hazard Area, the
area that would be inundated by the flood having a 1 -percent chance of being equaled or exceeded in any
given year (base flood), on the effective National Flood Insurance Program (NFIP) map. Using the
information submitted and the effective NFIP map, our determination is shown on the attached Letter of Map
Amendment (LOMA) Determination Document. This determination document provides additional
information regarding the effective NFIP map, the legal description of the property and our determination.
Additional documents are enclosed which provide information regarding the subject property and LOMAs.
Please see the List of Enclosures below to determine which documents are enclosed. Other attachments
specific to this request may be included as referenced in the Determination/Comment document. If you have
any questions about this letter or any of the enclosures, please contact the FEMA Map Assistance Center toll
free at (877) 336-2627 (877 -FEMA MAP) or by letter addressed to the Federal Emergency Management
Agency, P.O. Box 2210, Merrifield, VA 22116-2210. Additional information about the NFIP is available on
our web site at http://www.fema.gov/nfip/.
Sincerely,
Mary Maj.,,C.F.M., Acting Chief
Hazard Study Branch
Federal Insurance and Mitigation Administration
LIST OF ENCLOSURES:
LOMA DETERMINATION DOCUMENT (REMOVAL)
cc: State/Commonwealth NFIP Coordinator
Community Map Repository
Region
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