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HomeMy WebLinkAboutMiscellaneous - 835 SALEM STREET 4/30/20181 • Union Mutual of Vermont Companies 1874 Union Mutual Fire Insurance Company New England Guaranty Insurance Company, Inc. Eastern Mutual Insurance Company UNION MUTUAL Community Mutual Insurance Company OF VERMONT P.O. Box 158 • Montpelier, VT 05601-0158 • www.unionmittual.com February 12, 2016 North Andover Building Inspector & Health Department 1600 Osgood Street Building 20; Unit 2035 North Andover, MA o1845 RE: insured: Matthew Levis & Pamela Levis Loss Location: 835 Salem Street Policy Number: HOP71707 Date of Loss: 1/3/2013 Type of Loss: Dwelling repair Claim #: CLM23324 To Whom It May Concern: A claim has been made involving loss, damage or destruction of the property captioned above, which may either exceed $1,000.00 or cause Massachusetts General laws, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss, cause of loss and claim number On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail. Sincerely, Brice Bianchi Claims Adjuster 1-800-671-8550 Ext. 604 BBianchi@unionmutual.com 139 State Street • Montpelier, VT 05602 0 Telephone: 802-223-5261 a - This certifies that . f has permission to perform Date ..... 411.� .................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING wi ng in the building of ....... !!LD. 0 1-, 'D 'e at �v (�k ......................... A ....... Fee ... R5�7 ........... Lic. No. Check # �—Im�-L R.7 ....................................................................... A1,140A'SS, -Tu" ............... t ............................................ e \JI,5 ............................................................... ?Aj!fT .................. ^,, North Andover, Mass. ............ n e 0 1-1 12 > I I - Ae 67�p-)C? oN V-11111 M Print Form ,_-1 (.;onluioneslen�lr o� /rl�as+a�alrlls --<)fticial Ilse Unly I'cnnit No. Z + «U�iarinrnnl oP.}irr,�ieweNr.Ra 0c alta I-ce Checked . ' BOARD OF FIRE PREVENTION REGULATIONS Rcv_1/07) (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK %11 walk to tic lice fomied in mcoulance with the Ninmachuscnc I icchical ('adc (MEC). 527 CMR 11.410 WL EASE 1 /It AY IN INK OR TYPE ALL INFC)RAIA'1'10M) Date: / Z 4 /'y City or Town of: /UpT+h _ (4R' mip r To the In pertai• of l irvs: By ill ls applicauun the undcrrq.ncd gives- notice chis or her intention to perforin the electrical wart: described hdow. � � Location (Street & Number) J �.�.{ m '�- , Owner or'i'enant Owner's Address Telephone No.Q�g=9f�/-� Is this permit in conjunction with a building permit? Ycx [] Ni► L (Check Appropriate Box) Purpose of Ruildinl; wt Solar - PV Wilily Authorization No., ala Existing Service Amps / Volts Overhead L] Undgrd ❑ No. or Meters New Service Amps / Volts Ov rhead El lhfdgrd f] No. of Meters Number of Feeders and Anipacify Locution and Nature of Proposed Electrical Work: Install Solar Electric - Photovoltaic (PV) system [ 3D panels) rated 7, 6S kW -DC @ S.T.C. Grid Tied. in cot> action with a Building Permit. CanmkWon it/ the /idlat+4ne luhlr nen• 1H, ituimed he- 11te lnsberiepr id'14 ow -w_ No. of Ikecessed luminaires No. of Cer A%usp. (Paddle) Funs r n anal '1'rensfarnserx KVA No. off mininaire Outlets - No. of Ital Tots Generators KVA No. of luminaires SwimmingPool a n- rad. rad. 0 o. o g ` , 9 BaHery.mnit enry I a 1414V :41.A 14 Ot s JlVsi. of Zone% +'te c6os+r1 aria— [flitialiug h2ier� fist. rid Alerting lief ict-. No. of Receptacle Outlets No. of Oil Burners No. of Switches No. of Gas Burners No. of Ranges `ataons No. of Air Cond. Tons _ 1 \u. ofV4atic Disposers Cutsio umlirr I ntfr Ue�t+ni liE n1 1Is unic t • _ ` Local t ogneclton (�j other u . ys�tems: No. of vices or t'.guh alt-nl No, of Dishvrashers , p S acclAres liextin + KW Ideating Applinncc�s KW No. of Dryers --� No. of W1 ater — KW Heaters o, n —^No. -o Ballast% 111812 %'Iring: No. of Devices or I• uivalcut No. Ilydromassage Rathtuhs No. of Motors 'rotas I IP Telecommunication! rr ng: Na of Devices at uitalent It1nc !1 ntlditinnn! drluil !/ tk'SirrYl. n1' n3 irgl ivd l ►r thi• iuxpcc-1111, n/ I F101%. lislilnalul Value cif Electrical Work: X00 ._.__ (When required by Inunicipal policy.) Woit to &art: A.S.A.P. Inspections to tic requeslell in accordance with MCC Ride 10. .11111 upon Completeoll INSU'RANC'E C (WERAGE: l)nles% aan•rd by the owner, no permit far the perfarmancc of ciccideal work sn.iy ixsur uudcss the licensee piuvidrs, pruul tit lialiibly ius+ulassre inchsaling "c:umpictixl apclafinn" coverage or its sulsslantial cqui%alcul. 'I lic untlemigned cellil-lcs that Such coverage is in farce, Sold has exhibitt:al proul'ol'sank to the pennil issuing of ke. CHECK ON'I : INSURANCE E✓ 110ND ® OTIIER 0 (Specifv:1 1 certify, under /lie pains and penalties njperjury. that the injarinadon an tleia application is true and complete, rlkM NAME.:. SOLARCITY CORPORATION_ LIC'. NO.: 1136 MR I,icenrcc: Matthew T. MarktiafnSignature_�! . _ ,'¢;.cc'- ,._ __ LIE'. NO.: 1136 MR (!/ alytlk•nlsk" 000• "1•arml/1 " in I&I lirrnae 1111018100' film.) Bur. 'l'd, No,. 774-25"180 Address: 24 St. Martin Drive (Building 2 / Unit 11). Marlborough, MA, 81752 All. Tel. No.: 774-2513-ti505 •I'cr M.Ci.I.. e. 147, s. 57-61. security work requires Ikpartlnent of Public Safety "i" License: Lie. No. OWNER'S INSt IRANCF. WAIVER: I am aware that the Licens ec docs nut have the liability insurance coverage ricinnally required by late. fly my signature below, I hereby waive this requirement. 1 am the (check one) 0owner Q owner's agent. Ownr/Agcnt PfsRAfIT FF, E- S Signature '1'elophane No. t t4. r « rw .., , , 14 , It'. , c. N q )Mee of E:onaamer Aftaim d Rarinea Regulation �F �t ME 'IMPROVEMENT CONTRACTOR ouistretiim. 168572 Type Cx0flitlat' 302015 Supplement SOLARCITY CORPOR4TION MATTHEW MARKHAM 24 ST MARTIN STREET BI_0 2UN1 FAMI-80ROU0H. MA 01752 iladenccrelary E'L.ECTRICIANS ISSUES THE FOLLOWING LICENSE AS Ao\i REGISTERED MASTER ELECTRICIAN SOLARCITY CORPORATION MATTHEW T MARKIiAM � -,4 SAINT MARTIN OR BLDG 2 UNIT II MARLBOROUGH MA 01752-3o6o :�4." r www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Allglieant Info Mation Please Print Legibly Name (BusinesslE)rganixation/lndividaal):_SOLARCITY CORP � Address: 3055 CLEARVIEW WAY Cit /Statc/Lii : 0""v WV% t cu, U"' uff4UG Ynone #: 000-. i L -9 - The Commonwealth of Massachusetts Type of project (required): Department of Industrial Accidents 4. ❑ I am a general contractor and Office of Investigations t 1 Congress Street, Su11e 100 ' Y Boston, MA 02114-2017 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Allglieant Info Mation Please Print Legibly Name (BusinesslE)rganixation/lndividaal):_SOLARCITY CORP � Address: 3055 CLEARVIEW WAY Cit /Statc/Lii : 0""v WV% t cu, U"' uff4UG Ynone #: 000-. i L -9 - Are you an employer? Check the appropriate box: Type of project (required): I. ❑ 1 am a employer with 5000 `– 4. ❑ I am a general contractor and 6. ®New construction employees (fop t -tithe and/or 2.0 1 am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub -contractors have g, 0 Demolition working for me in any cepacitY. employees and have workers' 9. []Building addition [No workers' comp. insurance required) camp. insurance; 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.0 1 am a homeowner doing all work officers have exercised their I I.[] Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGI. 12.0 Roof repairs insurance required.] t c. 152, § 1(4), and we have no SOLAR / PV 13.Q Other_ employees. [No workers' comp. insurance required.] *Any applicant that checks box # t must also rdl out the section below showing their workers' compensation policy inrormation. t I lomeownen who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check; this box trust attached an additional sheet showing the name of the sub•contraetots and state whether or not those entities have employees. Irthe sub•cantrnctors have uanptoycm they must provide their workers' comp. policy number. I am au employer that is providhng workers' connpensallon insurance for my employees. Below is rhe policy and job site informatfon. Insurance Company Name: LIBERTY MUTUAL INSURANCE COMPANY Policy # or Self -ins. Lic. H .WA7-66D-066265-024 _ Expiration Datc _09/01/2015 Job Sitc Address: 0 � s CitylState/7..ip:,_� f GTf'U2f " 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 Ofiicc of Investigations of the DIA for insurance coverage verification. ` l do hereby certify trader the pains and penalder of perjarp Nrol lite tnr formalon provided above is true and correct. a 4 -9 (( n /} / sienaturc: -� % il_iIi to_ � I ale �2-� � Ql)7cial use only. Do not write In this area, to be connpleted by city or town official City or Town: — Permit/License #. Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6, Other Contact Person: Phone #: AC aD CERTIFICATE OF LIABILITY INSURANCE ATE (MMID DDIVYYY) !879:,7014 ; CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS_. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: It the certificate holder Is an ADDITIONAL INSURED, the pollcy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsemen s . PRODUCER MARSH RISK & INSURANCE SERVICES CONTACT NAME:.IFAX 345 CALII'ORNIA STREET, SUITE 1300 Mj EM: _ _ .. _ _ (AIC, Ne): CALIFORNIA LICENSE NO. 0437153 ADDRESS: SAN FRANCISCO, CA 94104 I _ INSIIRER(S) AFFORDING COVfRAOE NAIC • 998301-STND-GAWUE-14.15INSURER A : UbeMid Fire Insuraloe Company 16586 INSURED INSURER e : L" Insurance Corporation 42404 (650) 963 5100 _ NIA NIA SolarCily Caution INSURER C : 3055 C*wAew Way INSURER D: San Mateo. CA 94402 I i INSURER E : _ I INSURER : envcDAr_Gc C90T19ICA1rC AIIIRRRER• SFA.nn2!4n2A'G•(12 REVISION NUMBIER:4 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REOUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS_. "Alb- BR*' -- 'POLICY NUMBER ILICY EFF MPO�CY E7lP LIMITS IL SR - - _ TYPE OF INSURANCE A GENERAL LIABILITY i T82-66ia6265A14 0910112014 091010015 EACH OCCURRENCE E 1,000000 X I COMMERCIAL GENERAL LIABILITY I DAMAGE TO RENIED 100,000 PREMISES (Ea ocpWrenre) S i I CLAIMS -MADE X OCCUR I i MED EXP (Any.Tv parson) 5 10,000 f I i 1 1,000.0110 PERSONAL d AOV INJURY � S l GENERAL AGGREGATE f 2,000.000 I GEN'L AGGREGATE IJMIT APPLIES PER. I I PRODUCTS • COMPIOP AGG i S 2,000,000 Y25,000 X POLICY X PRO LOC I DedUL'6ble S A AUTOMOBILE LIASILITY I AS2.661.066265-044 09.10112014 09!0112015 ao") LE LIMIT 5 1000,000 I I X ANY AUTO � � ( BODILY INJURY (Per Person) IS /LLLOVIMFD SCHEDULEU, X AUTOSNON O t jBODILYINJURY (PW aced")IS 4 J X VMED ' HIREOAUTOS AUTOS I I{ ( PROPERTY DAMAGE s (Per -Can) X Ph Dam Ys. a� ! I COWICOLL DED. f $1.000151,000 UMBRELLA LIAS I OCCUR EACH OCCURRENCE. S EXCESS UAB I CLAIMS-MAOV ! AGGREGATE. 5 DED RETENTION I S B SATION I AND EMPLOYERS` LIABILITY YNN WAT660066265-0Z4 [WCIG61-066265034(W1) 09.9112014 0910112014 10910112015 0910112015 i X } WTAT I- j JOT"' 1 TWLIbllT$ : ER i 1,000,000 ANYPROPRIETOR/PARTNEPJEXECutIVE OFFICERIM:EMBER EXCLUDED'+ IIIA, EL•EACHACCIDENT S B (Myaensdatory in NH) I 'WC DEDUCTIBLE: 5350,000' E L DISEASE . EA EMPLOYEE S 1.000,000 DESCRIPTION OAF OPE RATIONS .aw ° E L DISEASE • POLICY LIMIT - S 1'� i DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES IAN+UI ACORD 101, Additional Rerlunu Schedule, It mare apace Is required) 4 vdeam of Insurance t� Solarcity Caporaw 3055 Cloanliew way San Mateo, CA 94402 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Of Manh Risk A Insurance Services Charles Marmolejo C —;;'.` ®1980.2010 ACORD CORPORATION. All rights reserved. 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TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING kThis certifies th .................. ... .......................... .................. has permission to perform.:A:e.0.--.1A ..................................... plumbingin the buildings of ............................................................................................. ,:;?)() 3 n� -15� .... ................ at ........ ......................... North Andover, Mass. Fee..'.�35 Lic.Ni­o.- 1.10W ..... . . ............................................................ C3 4;�36�Lj PLUMBING INSPECTOR Ched, IM �< MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' CITY dZ0 'FA I MA DATE lY!3T1 Z0/ PERMIT# JOBSITE ADDRESS 1 30 EAR CS kw — $ OWNER'S NAME � N POWNER ADDRESS TEL *&AX TYPE OR OCCUPANCYTYPE COMMERCIAL EDUCATIONAL Q RESIDENTIAL PRINT CLEARLY NEW: � RENOVATION: REPLACEMENT: Q PLANS SUBMITTED: YES ® NOQ FIXTURES'l FLOOR--> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB E __. CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/ AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING INSURANCE COVERAGE: hasp a current liability insurance po'licy or its substantial equivalent which meets the requirements of MGL Ch. 142. YE i NO Pj IF YOU CHECKED YES, PLEASE INDICATZTH TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLIC OTHER TYPE OF INDEMNITY BOND Qi OWNER'S INSURANCE WAIVER: I m 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 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 compliance with all Pertinent provision of Massachusetts State Plumbing Code and Chapter 142 of the General Laws. � /,'���, PLUMBER'S NAME 11- L �LS'7C� /L / LICENSE #IGNATURE M4— JP D 4 CORPORATION PARTNERSHIP ®# _ LLC a E COMPANY NAMEV2i, ,Val rC..!'T A, FI ADDRESS ] / �/ /A AR ,a Z" 'YJ - CITY STATE ZIP Q/ ��-1 TEL FAX E CELL V1 H U W a 1 � t w � , .. a oz Fl N W � W � w O C w0 a w co Ix W o a w � >co W a p z J D. 4. �3 � L11 S W F- LL W �i H H U a e •Y •f A i • " The Commonwealth ofMassachuseils ` Department of Indusirigl Acciclents Office of Investigations 600 Washington. Street Boston, .NIA 02111 www.mass govMa Workers' Compensation Intsurance Affidavit: BuifciersIContracforsIElect iciansIPliimbers Applicant Information Please Print Legibly Name (Bus"mess/Oxganizaiion&dividuai): '3u J y f( 7� "V C_ Address: City/State-01): 14All dzl4holie #: Are you an employer? Check the appropriate box: Type of project (required): I am a employer with 4. ❑ I am a general contractor and I 6, ❑ New construction employees (M and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. '1• [1 Remodeling ship and`have no.employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance, g• Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required..] officers have exercised.their 3. [l I am a horn eowner doing all work right of exemption per MGL 11. [] Plumbing. repairs or additions myself. [No workers' comp. c, 152, §1(4), and we have no 12.❑ Roofrepairs insurancere ed. i employees. [No workers' �' a 1311 Other comp. insurance required.] xAny applicant that checks box Of must also fill out the section bel6w showing their workers' componsationpolicy information. t'Homeowners who submit this affidavit indicating they 9e doing all.worY and then hire outside contractors must submit a new affidavit indicating such. tContractors that checkthis box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. X am an employer that isproviding workers' compensation insurance fornzy employees Below is thepolicy and joh site information. insurance Company Name% Policy # or golf ins.Lic. #: Expiration Date: rob 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 ofMGL o. 152 can lead to the imposition of criminal penalties of a fine up to $1,50 0,00 and/or one=year imprisonment, as well.as civil penalties in the form of a STOP WORK ORDER and a ane 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 fInvestigations of the DTA. for insurance coverage verification. I do liereby, cert jy under t� tiains amUenalties ofperjury tl�q the information provided above is true and correct, official use oply. Do not write in this area, to he 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 0: r� Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an ernployee is defined as "...every person in the service of another under any contract of hire, - express orimplied, oral orw.ritten." An employes is defined as "an individual, partnership, association, corporation or other legal entity, or any two ormore of the foregoing engaged in a joint enterprise, and including the legal representatives of a• deceased employex, 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 apartn.ents'and who resides.therein, or the occupant of the dwelling house of another vvho employs persons to'do maintenance, constrae'ti ii 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 employes." MGL chaptex 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 comm%oinwealth 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 beenpresented to the contracting authority." Applicants Please till out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone numbers) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partuerships (LLP) with no employees other than the members or partners, are notrequired to carry workers' compensation insurance. If au LLC or LLP does have employees,apolicyisrequired. Be advised that this affidavit maybe 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 fll inthe ponnit/Ucense number whichwill. be used as a reference number. In addition, an applicant thatmust submitmultiple 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 of idavitia on rile 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 crpermit 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 youhave any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: j Tho GQoweaM oYasarhuSPite Depaximent Qf].du .ia.1.A,ccldonl `.. ome ofJAVeNtigat ions 60 gton Stogt Boston, UA 0.21.11 TQI, # 61`1-7-2'x,49.00 e 406 ox 1•-877 MASSA I Revised 5-26-05 Fax# 617-727-7749 WWW.Mass,gov dia 'Om ONWEALTH OF MASSMHtjsFTT-q. 'e" S-"�5 a , 61�' "U4 ��ej I) olll� ABBREVIATIONS ELECTRICAL NOTES JURISDICTION NOTES A AMPERE 1. THIS SYSTEM IS GRID-INTERTIED NA A AC ALTERNATING CURRENT UL-USTED POWER -CONDITIONING INVERTER. - BLDG BUILDING 2. THIS $YS1QA HAS NO BATTERIES NO UPS CONC CONCRETE 3. A NATIONALLY -RECOGNIZED TESTING DC DIRECT CURRENT LABORATORY SHALL UST ALL EQUIPMENT IN EGC EQUIPMENT GROUNDING CONDUCTOR CDMPUANCE WITH ART. 110.3. (E) EXISTING 4. WHERE ALL TERMINALS OF THE DISCONNECTING EMT ELECTRICAL METALLIC TUBING MEANS MAY BE ENERGIZED IN THE OPEN POSITION, ESB FIRE SET -BACK A SIGN WILL BE PROVIDED WARNING OF THE GALV GALVANIZED HAZARDS PER ART. 690.17. GEC GROUNDING ELECTRODE CONDUCTOR 5. EACH UNGROUNDED CONDUCTOR OF THE GND GROUND MUL71YARE BRANCH CIRCUIT WILL BE IDENTIFIED BY HDC HOT DIPPED GALVANIZED PHASE AND SYSTEM PER ART. 210.5. I CURRENT 6. CIRCUITS OVER 250V TO GROUND SHALL Imp CURRENT AT MAX POWER COMPLY WITH ART. 250.97, 250.92(8). Isc SHORT CIRCUIT CURRENT 7. DC CONDUCTORS EITHER DO NOT ENTER kVA KILOVOLT AMPERE BUILDING OR ARE RUN IN METALUC RACEWAYS OR kW KILOWATT ENCLOSURES TO THE FIRST ACCESSIBLE DC LBW LOAD BEARING WALL DISCONNECTING MEANS PER ART. 690.31(E). MIN MINIMUM B. ALL WIRES SHALL BE PROVIDED WITH STRAIN (N) NEW RELIEF AT ALL ENTRY INTO BOXES AS REQUIRED BY NEUT NEUTRAL UL LISTING. NTS NOT TO SCALE 9. MODULE FRAMES SHALL BE GROUNDED AT THE OC ON CENTER UL-USTED LOCATION PROVIDED BY THE PL PROPERTY LINE MANUFACTURER USING UL LISTED GROUNDING _ POI POINT OF INTERCONNECTION HARDWARE PV PHOTOVOLTAIC 10. MODULE FRAMES RAIL, AND POSTS SHALL BE SCH SCHEDULE BONDED WITH EQUIPMENT GROUND CONDUCTORS - S STAINLESS STEEL - STC STANDARD TESTING CONDITIONS TIP TYPICAL UPS UNINTERRUPTIBLE POWER SUPPLY V VOLT VICINITY MAP INDEX Vmp VOLTAGE AT MAX POWER Voc VOLTAGE AT OPEN CIRCUIT W WATT PVI COVER SHEET 3R NEMA 3R, RAINTIGHT PV2 SITE PLAN PV3 STRUCTURAL VIEWS PV4 THREE UNE DIAGRAM ' Cutsheets Attached A LICENSE GENERAL NOTES 1. ALL WORK TO BE DONE TO THE 8TH EDITION GEN /168572 ELEC 1136 MR OF THE MA STATE BUILDING CODE 2. ALL ELECTRICAL WORK SHALL COMPLY WITH THE 2014 NATIONAL ELECTRIC CODE INCLUDING MASSACHUSETTS AMENDMENTS EV BY DATE COMMENTS MODULE GROUNDING METHOD: ZEP SOLAR AH,t North Andover R) rsw.,,ano� UTILITY: Nationol Grid USA (Massachusetts Electric) °sem°` MATTHEW DENCE Tom Conlon °k-Kwvw,wMu mauaN NaTeem mm JB -0181367 00 °'°k LEMS, N11f116 SISta! Com Mount Type C 835 SALEM eamr 6 MY" DWI swwmm oc. m suu n eE o�®a .mc m N ST V ARRAY` �7.65' P'Ai001ER50V1�"`�OPO"� ANDOVER, MA 01845 IONs 30 CANADIAN SOLAR CS6P-255PX NORTH aeGN!)AwM E N fA/XEL'll0n MIN M s ero ua ai ns ecsfcmc H a P'"' 01^ ;'"" ° $gARp1Y EQWNn, �1lellt THE ■dllnl� `°°�O10P� - COVER SHEET PV 1 O 1/73/2015 Mult' le Inverters 9789946059 30 FA-�Js PITCH: 40 ARRAY PITCH: 40 - MPI AZIMUTH: 204 ARRAY AZIMUTH: 204 MATERIAL, Comp Shingle STORY: 2 Stories PITCH: 23 ARRAY PIT04:23 MP2 AZIMUTH: 204 ARRAY AZIMUTH: 204 MATERIAL, Comp Shingle STORY: 2 Stories (E) DRIVEWAY - Front Of House AC �© O _- Inv;j(LC)I ' Inv; LEGEND Q (E) UTILITY METER & WARNING LABEL O INVERTER W/ INTEGRATED OC DISCO & WARNING LABELS DC DISCONNECT & WARNING LABELS B � AC DISCONNECT & WARNING LABELS Q DC JUNCTION/COMBINER BOX & LABELS O S MP2 a MPI Q DISTRIBUTION PANEL &LABELS A 6 tcQ LOAD CENTER & WARNING LABELS O DEDICATED PV SYSTEM METER STANDOFF LOCATIONS CONDUIT RUN ON EXTERIOR CONDUIT RUN ON INTERIOR GATE/FENCE 0 HEAT PRODUCING VENTS ARE RED INTERIOR EQUIPMENT IS DASHED SITE PLAN Style: = � 1' 81 01' 8' 16' � tQ°pFN°a- THE 16°"A7°"M a"� JB-0181367 0�MATTHEW$ Torn Conlon oanu.0 sxau xm a TW rm ME ax'rr v azar suaarc"' RESIDENCE ��qa } SolarCity. Yanw s sma Cum Mount Type C "° 9"Lnff°a'®""°E°" ff m 835 SALEM ST 7.65 KW PV ARRAY ' 'To, m m mmpm asR XKaxon"tlaaHu9Rltort torus NORTH ANDOVER, MA 01845 30 CANADIAN SOLAR CSBP-255PX r a u.a arty au,gy ua n nc sac uo usE or n[ arsccmc ""�°� MuIC le Inverters s>wmr aax�a[ ■man � ran[x �OXary xc 9789946059 rt¢ aue SITE PLAN sacra ar ate PV 2 0 1/13/2015 r. (awl mo-YVOvi°am�` W� a>'rtom (�-sol-am Os,-aaerl ...mmy� %Z SIDE VIEW OF MPl N1s n MPS NdPACING NSANn!£Vpl Y -SPACING Y{ANOIEVER NOIR IiNOSGPf 6q' 29" STILGERED POa70 q6' 211' RRFI£R 216 @ 16. OC MPAROOY PL F RZI 330909 PR PIt01 Os 90 STOa1B: 2 b U. 2x6 @l6' OC Ca 5hi k PV MODULE X -SPACING X -CANTILEVER Y -SPACING Y - CANTILEVER 5/16' BOLT WITH LOCK LANDSCAPE 64" 24" INSTALLATION ORDER & FENDER WASHERS PORTRATf 48" 16" RAFTER 2X10 @ 16" OC ROOF AZI 204 PITCH 23 STORIES: 2 LOCATE RAFTER, MARK HOLE ZEP LEVELING FOOT (1) LOCATION, AND DRILL PILOT ZEP ARRAY SKIRT (6) HOLE. (4) (2) ILOT HOLE WITH PRETHANE ZEP COMP MOUNT C PGLYUL SEALANT. ZEP FLASHING C 3 (3) INSERT FLASHING. (E) COMP. SHINGLE (1) (4) PLACE MOUNT. (E) ROOF DECKING (2) (5) INSTALL LAG BOLT WITH 5/16" DIA STAINLESS . (5) STEEL LAG BOLT LOWEST MODULE SUBSEWENT MODULES INSTALL LEVELING WITH SEALING WASHER (6) FOOT WITH (2-1/2' EMBED, MIN) BOLT & WASHERS (E) RAFTER 1 STANDOFF SScale: 1 1/2" = r (E) 2x4 SIDE VIEW OF MP2 NTs D MP2 X -SPACING X -CANTILEVER Y -SPACING Y - CANTILEVER I NOTES LANDSCAPE 64" 24" STAGGERED PORTRATf 48" 16" RAFTER 2X10 @ 16" OC ROOF AZI 204 PITCH 23 STORIES: 2 ARRAY AZI 204 PITCH 23 Comp Shingle �u—vluwuY vv LEVIS, MATTHEW LEMS RESIDENCE Tom Conlon Mount Type C 835 SALEM ST 7.65 KW PV ARRAY - CANADIAN SOLAR I CS6P-255Px NORTH ANDOVER, MA 01845 9789946059 s�Er PV a M GROUND SPECS MAIN PANEL SPECS GENERAL NOTES INVERTER SPECS MODULESPECS LICENSE BOND (N 08 GEC TO TWO (N GROUND an N.LLller-Hammer In I: ngroun ed INV 1 -(1) A-(10)CANADIAN SOLAR 1 CS6P-255PX CFN X6&572 ` S AT PANEL VATH IRREVERSIBLE CRIMP Melm Number•. 12 853 465 Inv 2. OC Ungrounded m.,m .>�. ell. . ak mm". PV Module; 255TA 231.3W PTC, 401nm, Mo Blk Frame, H4, 7fP, fi00V EIEC 1136 MR Ore Ina d SmA Entrance INV 2 -0) I = . mR . e� Vor. 37.4 Vprnm 30.2 �w INV 3 ( 200A MAIN SERMFE PANEL ( 20OA/7P MAIN CIRCUIT BREAKER Inverter 1 (E) V,WNG W7LER-HAMMER BRYANT (N) 125A load Cenler 2WA/2P DISCGIMLH ] s SOLAREDGE SE38DOA-USOOMZ (0 lOAOS g C 20A/2P SdarLlly u x 3 A L 40A/2P �a' -------------------------- _E __ W W MP 1: 1x18 e I I WI, uvi __ r9a__------------- -___________ _ _�_____ _ &�___ __________ 1 44 f __J Inverter --` 1 e SOWIEDGE SE30WA-USOWSNR2 O OA/2P I u TO 120/243/ SINGLE PHASE I I L_ a' 2,MP 1: 1x12 UtE11T SANfE I I w I I [ac __________ rJ I y� - - Pxoro wLrucSYSTEM EQUIPPED VATH RAPIDSHUTDOWN Va' = MAX VOC AT MIN TEMP OI ('>; "��w PveAaa®8RJOR g ('I :d A: eaRBAASR AC A w itauEt DC d� e¢0°ma4N Ge N 4M (DOPV m 200 2xA+A25 . 303{ H4. M b C4 NP C E1 A I (6 AMG R SaM Bae 0> ILFIp� g,@>onp�Y, -(2I lm-H2w 8 f pDNS® -ro Rao 5/d a B, ca (N) ARRAY GROUND PER 690.47(D). NOTE PER EXCEPTION NO. 2, ADDITIONAL ELECTRODE MAY NOT BE REWIRED DEPENDING ON LOCATION OF (E) ETEC rj''�� I AMC CIRF; fld OSI-(I)AMG 0%T-2, Ree I AIIC 014 iNAII-2, Bad O ffII jAMG 010. Nnl-2. net [� 1 Alla 014 nAU-2. Buk Va• = 500 VDC w =15 ADC OP.:Y(IIAMC 01063 F2, Red ftp =350 VOC ImP=1291 AOC =AMG 014 PV MRC BVA Va' =500 VOC [u =15 AOC OG7-(I)AMG 01i,SdMB-ct EGO Vmy =550 vOC Imp=1281 AOC ® l (I)AMCE4 2.M MOjl RALVmD=240VAC Imp=28.33MC ......-(1JAMC F.RAN-2 Q.sl..[2/iZt-(Ij fl.I.IIk.JIr�EYf.......... (I)AMC A147HIN-2 Nhlle RBIIR/1 V.p =240 VAC Imv=15e.TMC ...... -f1))A4C R.THNF�. A?e!.. Et?/TEC.-S1jfaMA,. I.Ok. JIC EYf.......... .....43..1 ANC,01.4M(N-?.hen..AN....-(,jCaMo,A. q4.J/C F,Y,f.......... [[��IAlIC 010.INMFR Bad Va•=5pp VDC Ix=15 ADC k(I)A1m vmp =350 VDC Mp=e. ADC ... ..... ... . ff[''T'j2)A11GI14%MRC.-- ..Ya•=50G VOCLu=15 AUC Oj$H(1)AWASoDd m cipDs• EGC VmD =3511 VIM [mp=BW AOC (I)AMG 341004-2. llr ©if(I)AMC P0. MM1-L RW 010. 1NM=-2.RW. ® ..... �F'1...I1jAAG 010,AIW- Grm...GOP.....-(1j E. X04.3/ Aq.......... ®® ..................................... • .......................... (I )NAC /10, mrl-4 w. UmnRAL VmP =240 VAC hP=125 RAC ...... -11)AN 9.11W& 4!!1 .. EGC/tEP-(1IC,arddl. lop. 3/(.NUT.Imm ......... BFM1R 6 AMCME EYCTPf SWIAIY IVC, I11DM JB -0181367 00 LEMS MATTHEW LEMS RESIDENCE Aft oma Tom Conlon ��6 {e�! {.r SriRI! Com Mount Type ( HaR RmEmN SALEM ST 7.65 KW PV ARRAY TDG3RSOm PAu ro onus 'n tG "U"B115 N @RQ o , MmM@ NO NORTH ANDOVER, MA 01845 u a au w n THE SNE AND USE or m rasPEcmc 30 CANADIAN SOLAR CS6P-255PX aue mm PV 4 a 1/13/2015 o� (eee� m �: eRi&"... �.'w � OF SOLA TY` � t0 M ' 9789946059 R� THREE LINE DIAGRAM ° Mulls le Inverters ONNEC 690.53 Label Location: WARNING (C)(CB) CT'nyIGOC�—RD Rl:V;NACS Oh OAD SPDES h!AEYEOTE'ZD ERGEO Per Code: _ N POS T10 C NAGE •�S'PF.ESE': .Y;h Jh �OGRP.!C0 -5;RE 'POSED"O Ut:7GHT NEC 690.31.G.3 Label Location: 0 0 0 0 (DC) (INV) • Per Code: NEC 690.14.C.2 ONNEC 690.53 ISUSIG=1111'111111 '_ LGR6 oc Az„RD D FpU"SDIC:.'E7=SY_EDCOS FYBEDED ANO ENERGI<ED LabelLocation: �I' ` • • O (AC) (POI) 0 • Per Code: NEC 690.14.C.2 Label Location: Par Code Per d: NEC 690.54 WARNING Ll RC RO -OUCNyi EfL7jN�ACS ERSy1NA OVBOT'^ N_Af D 0 O SUES A'AVr 2eENERC12E0 N E FENFOSU Label Location: (POI) i Per Code: NEC 690.64.8.7 S AC cO V'O :pZ=.RD F QTiT0 H EiLU'Yva FJ,1yyYY"CS,Ot+ AC+OROADSiOc E�=FGRED WiA-10P' SIaIONOR$ERV�ICE �NEP.Gfi{90T �SObR t:Dht�l?r BREAY.ER ��FLSOI:R ERA fG'CURR Label Location: (POI) Per Code: NEC 690.17.4; NEC 690.54 Label Location: Q (D) (POI) Per Code: NEC 690.64.8.4 CAUTI3YS COAND. F..S- ECONJ50b OTOVOLi 'C �� Label Location: %ORR M1IC1�J (DC) (INV) ��►�� Per Code: _ NEC 690.35(F) TO BE USED WHEN INVERTER IS UNGROUNDED (AC): AC Disconnect (C): Conduit (CB): CombinerBox (D): Distribution Panel (DC): DC Disconnect (IC): Interior Run Conduit (INV): Inverter With Integrated DC Disconnect - (LC): Load Center (M): Utility Meter (POI): Point of Interconnection ��,raat,�TTx�,saD�,re�.,�•,aLn�oa I SC Label SetWXCM� 3�5O�W" w was m d rlat ra orleas omrc resort's owwmnrlox,---'--u s>wx [xwt w nilly[ , wrx nc scot uo us a nrt lasccmc �P (®ei zsm o � r i ll .mm wuaory Tawwrt, wrxan n[ wmtp aw-aon a saumrr xc _ WARNING ' CT'nyIGOC�—RD Rl:V;NACS Oh OAD SPDES h!AEYEOTE'ZD ERGEO _ N POS T10 C NAGE •�S'PF.ESE': .Y;h Jh �OGRP.!C0 -5;RE 'POSED"O Ut:7GHT ISUSIG=1111'111111 '_ LGR6 oc Az„RD D FpU"SDIC:.'E7=SY_EDCOS FYBEDED ANO ENERGI<ED LabelLocation: �I' ` • • O (AC) (POI) 0 • Per Code: NEC 690.14.C.2 Label Location: Par Code Per d: NEC 690.54 WARNING Ll RC RO -OUCNyi EfL7jN�ACS ERSy1NA OVBOT'^ N_Af D 0 O SUES A'AVr 2eENERC12E0 N E FENFOSU Label Location: (POI) i Per Code: NEC 690.64.8.7 S AC cO V'O :pZ=.RD F QTiT0 H EiLU'Yva FJ,1yyYY"CS,Ot+ AC+OROADSiOc E�=FGRED WiA-10P' SIaIONOR$ERV�ICE �NEP.Gfi{90T �SObR t:Dht�l?r BREAY.ER ��FLSOI:R ERA fG'CURR Label Location: (POI) Per Code: NEC 690.17.4; NEC 690.54 Label Location: Q (D) (POI) Per Code: NEC 690.64.8.4 CAUTI3YS COAND. F..S- ECONJ50b OTOVOLi 'C �� Label Location: %ORR M1IC1�J (DC) (INV) ��►�� Per Code: _ NEC 690.35(F) TO BE USED WHEN INVERTER IS UNGROUNDED (AC): AC Disconnect (C): Conduit (CB): CombinerBox (D): Distribution Panel (DC): DC Disconnect (IC): Interior Run Conduit (INV): Inverter With Integrated DC Disconnect - (LC): Load Center (M): Utility Meter (POI): Point of Interconnection ��,raat,�TTx�,saD�,re�.,�•,aLn�oa I SC Label SetWXCM� 3�5O�W" w was m d rlat ra orleas omrc resort's owwmnrlox,---'--u s>wx [xwt w nilly[ , wrx nc scot uo us a nrt lasccmc �P (®ei zsm o � r i ll .mm wuaory Tawwrt, wrxan n[ wmtp aw-aon a saumrr xc _ -- I ZOP system rwfs M 14, dFV-N 59TadoOM mals[a®!R'�a9ls+ee�sveses�mar�`me��4r4 �m�MFaae�ns� lca �ma� ¢anasows.�mserwsos F� Fd2 %Sd-aY I uPsaw Nw&Lmvlpv AM6vTedffaw �seea�s��nY'a�rsy.aer�is� s��iy�ea �'s�44 ��s1 e�+�s+�Y2feaaeclrs�na'��ar�aaO�.e�elc'�a�P�uc�m Pa�kR-va: uanaeso.p9m*aea��bCaf Gee 242 ,A r - ams.�'ara.re� - Sg9p�LLtAC1�AFi�P��RmSge9sES�e2md/n - l9lG�CILBsdbnwea�l6]biS��O®i ®SpBdffcA— E ~..ft - bO&i�2aEbG cslvlP®m�P��lCi1fD 7-0 pp _ft—MKW4 n3 ' 2q u fl�a�EiR6mr6bLLQ do — t ftd.M - 2T,$�mb�igp�OmaLLfe�imLLZR4! 5ft!w— ' Fyja�b�s�b7l�as�a�b2f P�b,l Ift 3r 5e C 6 LbLL8�2bs • �IQm�ulLLls'Yifm�[0im mals[a®!R'�a9ls+ee�sveses�mar�`me��4r4 �m�MFaae�ns� lca �ma� ¢anasows.�mserwsos F� Fd2 %Sd-aY I uPsaw Nw&Lmvlpv AM6vTedffaw �seea�s��nY'a�rsy.aer�is� s��iy�ea �'s�44 ��s1 e�+�s+�Y2feaaeclrs�na'��ar�aaO�.e�elc'�a�P�uc�m Pa�kR-va: uanaeso.p9m*aea��bCaf Gee 242 ,A r f -\ f SdazEdge. Power Qpemizec Module lldd-0rt Far UartlhAmerim P300 t P350 A RtDU solar- a . e �farEdgeQpt¢uisc Date. 0 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING. This certifies that ................... . ....... t?l ........ has permission to perform ........ plumbing in the b,uildings of .................................. at. ......... North Andover, Mass. A F e L i c. N o ...... ................ NSPECTOR PLUMBIN Check # 6 11) 6 8 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Prinht% T ) Mass. Date © Permit 1_ Building Location f(3S 1�3 _ J7 Owner's Name Le" #?v Type of Occupancy New ❑ Renovation ❑ Replacement D' Plans Submitted: Yes O No O� IN FIXTURES Installing Company Business Name of Licensed Plumber Check one:. Certificate O Corporation ❑ Partnership X10 INSURANCE COVERAGE: I have a current liab insurance policy or Its substantial equivalent which meets the requirements of MdL Ch. 142: Yes No O If you have checked yfj, please indicate type coverage by checking the appropriate box. A liability Insurance policy Other type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws. and that my signature on this permit application waives this requirement. Check one: Owner O Agent ❑ 1 hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the�,pernit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code er 142 of the General Laws. By- own Type of Ucense: LUsster �!'� Journeyman � City/s. 10 1SE ONLY)License Number x = m ke _z < ' fA h 09 dl O x P. < W W Y_ ¢ Z W C6 O _W h b W M b ft h V < C W < 'O x= h ¢ W O m O W < W O ¢< h N= W N" "O < ¢ 0O J= 6 O C C a O O 16 W=S I- u> 3 O Z O LL lug W h O N sue—BSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company Business Name of Licensed Plumber Check one:. Certificate O Corporation ❑ Partnership X10 INSURANCE COVERAGE: I have a current liab insurance policy or Its substantial equivalent which meets the requirements of MdL Ch. 142: Yes No O If you have checked yfj, please indicate type coverage by checking the appropriate box. A liability Insurance policy Other type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws. and that my signature on this permit application waives this requirement. Check one: Owner O Agent ❑ 1 hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the�,pernit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code er 142 of the General Laws. By- own Type of Ucense: LUsster �!'� Journeyman � City/s. 10 1SE ONLY)License Number J d Z' H LL N' O O D O I- t F ¢ a O Z Z 6 Q � O LL � Z O LL O a a, V � J � 6 �l{ IL Q � LL Z f v t u Date. "'Ov . '6"� ....... ......... ... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION .............. I ....... This certifies that ............. has permission for gas installation�,�,.,-.. ��. .................. in the,buildings of ........................... at North Andover, Mass. Fec-a2 Lic. No..,� ��V. - �ac; � .......... GA�S� �UNSCTOR Check# J c9 ?/ 5577 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFI I t ING (Print or /Type) ' Date 5,23 _ Peir # e ` - Building Location s )13Gi S7 Owner's'Name �G% 4 Type of Occupancy /ZM/6�low %/eG C New ❑ Renovation ❑ Replacement Plans Submitted: Yes❑ No p --l" Installing Company Name \ ° " Ariciress y 1 :; _1vz K,) Z — 96 Business Telephone v1 Name of Licensed Plumber or Gas Fitter ii Check one: Certificate ❑ Corporation ❑ . Partnership 4-Firm/C�.o: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes Zig - No ❑ If you have checked yes. please indicate the type coverage by checking the appropriate box. A liability insurance policy � Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner❑ Agent ❑ Signature of Owner or Owners Agent I.hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this applicati A will be in compliance with all pertinent provisions of the Massachusetts State .Gas Code and Chapter 142 01 the General taw _ BYT of license: - - Plumber Signature of Licensed Plumber or Gas fitter Title Gast' as license Plumber 1 Ct, r oas. a. H H W L^ N N Y V Z ¢ U; N ¢ W N ¢ It O O u N S h W cS (A. ¢ FW- t>= T O f f d z o 0 #Atl u W M. 6 C F- ¢ N d V W = y' z O C> W , W W W -� Z _ ¢ W ¢ W<¢ G7 ¢ W > ~ L W F- V _ J (A ¢ W Z t W d , am S >¢ O �7 W = O 4. Z. 3 CC C t O i J O U O C W > G O d Q, N O SUB—BSMT, BASEMENT 1 ST FLOOR 2ND FLOOR At r 3RD FLOOR / 4TH FLOOR r *. 5TH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR. Installing Company Name \ ° " Ariciress y 1 :; _1vz K,) Z — 96 Business Telephone v1 Name of Licensed Plumber or Gas Fitter ii Check one: Certificate ❑ Corporation ❑ . Partnership 4-Firm/C�.o: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes Zig - No ❑ If you have checked yes. please indicate the type coverage by checking the appropriate box. A liability insurance policy � Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner❑ Agent ❑ Signature of Owner or Owners Agent I.hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this applicati A will be in compliance with all pertinent provisions of the Massachusetts State .Gas Code and Chapter 142 01 the General taw _ BYT of license: - - Plumber Signature of Licensed Plumber or Gas fitter Title Gast' as license Plumber 1 Ct, r oas. a. of vlki 0. 4n aw 4m LL 0 4 ul LL A16 oIL U. Im ku IL IL 4n 96 Location 8 3,5- 's 91 Date No. ) 11 In TOWN OF NORTH ANDOVER 6 6 Certificate of Occupancy $ 41 41' Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL 08 t A tlplow Building Inspector 2M.0-0 PAID 120/ 69 02,16/9912:21 b:l'V-. Public Works PERMIT NO. APPLICATION FOR PERMIT TO BUILD** *****NORTH ANDOVER, MA NI%PNO. I / �� LO' 1.NO.11f' V V �% V Z. RlCORDOFowNERSIIiI' DATE PIIRPOSE(IF B011DING BOOK PAGE- ZOM1E SIIBDIV..LO'I'No. 1.0CAI)ON �'%%� � 0(M_. 54— ()\VNER'SNAME L 1 1 NO. 01:SFORIES �_ z� $'ZFe— (AVNER'S ADDRESS C> G C 1 t BASEMEN( OR SI -AB S �ND RD ARCI III E( -I'S NAME SIZE OF Fl f" TIMBERS -� �� 5 �� 2 3 RI 111 DL•R'S NAME � .moi... ' SPAN DISTANCETONEARESTBUILDING t U 1 Li DIMENSIONS(USILLS _ DIS TANCE FROM Sl REE I' 13 ) DIMENSIONS (A: POS I S DIS I'ANCE FROI`1 I OT LINES -SIDES .(..(S -/REAR DIMENSIONS OF GIRDERS ��� Z �Aw_5 AREAOFLOT 2 �aC FRONTAGE .) ��! NEIGIIT(N:F(AJNDATI(NJ — / THICKNESS i v -X 1 IS BUILDING NEW w -'SIZE OH O(JI ING 1. C X 15 BUILDING ADDI I ION ti C MAIERIAI.OFCIIININEY SLC IS BUILDING ALTERATION N>�� IS BUILDING ON SOLID OKTII.LED LAND 4 WII.I. BUILDING CONFORM TO REOX ItREMENTS OF CODE l�/(�� IS BUIl -DI NG CONNECI ED TO TOWN WATER � S �BOARD OFAPPEALS ACTION, IFANY NV ISBUILDINOCONNECTED TOTOWN SEWER t° (� I 1 IS BUILDING CONNECTED TO NATURAL GAS LINE INSIAICTIONS 3. PROPERTY INFORMATION PAGE I Fit L(llff SECTIONS I-3 EI ECTRIC METERS N ItISf BE ON OxITSIDE OF BUILDING AI-IACIIEDGARA(iLSMUST C(NJFOf(MTOSTATEFIRE REGULATHMS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECT(>f( 1 DA 1 AT lL : / V p� LAND COSI' EST. BLDG. COST l/�! EST. Bi lXi. COS I* PER SQ. FT. ESI. BLIX.i. COS TPERROOM SEPTIC PLRMII* NO. 4: APPROVED By) BUILDING INSPECTOR OWNERSTELa.' C(NJl'R.Tll.fl C(NJI'R.I.1('11 l II.LC.N l V f CJ { f I f r ' N u, JAN 2 9 1998 ' <'R �• IGNA TURIi (A: OWNI-R OR All 1111)RIZI_D Alii .1.p�-7 III. 1'1-RMIT(iRAN'11:1) /�' jj i C, daE /qO n �1� Qs"P` 'r HEREBY CECT/FY T17 7We T/TGE IAISU.COIC AWO RL O T Rz AN 729 TWE BAoVe 741W' T.yE OArECL/.aK /9 LACATEO 47AI T//E LaT .4S -vAv vA-, AND 71am7,/7- OAFS LGGL✓F42e'w /N 1YlrA,l 7'11E tOwN • O NO. An/QWt/t• ZON/N6 ee.0P''ZArA:7 'S ,fL-MA AVYs SETA4COrX 41- . 0 Z044T O /4/ T ETFE aT O�PAI✓IV FOiP SAfaWN O/V %Mq' COAuI!Nt/A//Ty ,JOH1\1 CORT/N ,3'TEP11E.V vo. L+ l f J f 77//S Pe,4A/ .w,P GE _PvE/�+SES -SOT FD.P Bo�.vo.Ps� �TE.PA�sr.�>-iay; • Bo4tvo.oeY �.vFo.C�!- �E.P�P/�11.9Gt' E.V6.WEE.P/.v6 SE.Pr/lES ;4T�0�(/ TA.t'E.y F,�.!!�►�*,�'�Y� i ��Da,CpS - 6G PA�P,(� .S'T.rEET N - 5 04X-, /SETTS O/8/O FORM U - LOT RELEASE 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 or requirements. -- ----•*•**** --***APPLICANT FILLS OUT THIS SECTION* I� APPLICANT -� 4 `^ 1�% CJ r � � PHONE LOCATION: Assessors Map Number fP PARCEL SUBDIVISION LOT (S) STREET ST, NUMBER 1`2 � � � ..r.,..�...,�--..-•--.*....•*..*"'•*"OFFICIAL USE ONLY„....- *`"”" IEREMENDATION F T WN AGENTS: NATION ADMINISTRATOR DATE APPROVED s ` DATE REJECTED COMMENTS 1 .I a 'AA TOWN PLANNER DATE p,PPROVED DATE REJECTED. COMMENTS DATE APPROVED F000 INSPECJ.�R HEALTH DATE REJECTED. TfVNS COMMENTS TOR -HEALTH DATE APPROVED DATE REJECTED. PUBLIC WORKS • SEWER/WATER CONNECTIONS DRJVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE 0 Z o CD O to O UP CL co co CD m O H C 0 a N N ?�o c = re. < m con y O m C O n ymaC ='O y Mw LA -n m CL CL m CD y �„„ y x O-0 G n O O Nt C) : CD: y �0 o���?r.S ` g.� CLm N d y . O. d V Q C GD • ? a CCD G ' y' CD' yz v)_ 7 m. mz �m� �� OF �o. =r CD m O m : I� _= r o.= n� 110, CD a.: C/) El °aha C/) dO �, a -71n z -r, ° 0 r7 O 0-4y cn ^ N o In 0 x a' O O Gt L z 3 )Mq 0 O C tp = 1. +' - 0 0, fV -1 70 N O < N mx ` 7� H zm-N C4 x C -I H O O :Em El L -m EDfm O x O 70 07 Li L l *t n rm zC 70Z �LII_0 to Gl - H D m7::m-.E mD alm v� H mmr C m 1v x r -a OC r 70 m v� -0_ 70 X 70 n - (4l '- D C - amz z -0 70 m Gl Ol -- 70 F- -0 m 70 r vi 00 � - o � n m O 0 70 H O m OD m D 3 m 7l w x r\ H O O 7700 H H � z zr m c- t� cl o 70 O Iz m 70 m ox C --q m m z L N 70 O � D m m C4 x ---I x Ml . m 70 M H Olm m H r O H - Z n ci O O VJ C 3 � H � -0 n s D 70 n 70 O '1 r fzz D m 3 = x H CO v� m -I D H 3 Gl �] m O 70 b m b CD 4- co F- CDH H z m o H o 70 70 m v� m F- D n n 70 m C Po o m 'C1 70 m a m z 70 D F- F- C4 - F - C4 x 0 0 m G-1 r I -� 7 D H 70 `J v1 W b b b F� Fin N O \ 4 - X ii 0 0 m n O F� d N t" N C a a 0 z hf lld� b e b location ,JN o 0 --J Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ I --O�; 11ding/Frame Permit Fee $ ndation Permit Fee $ Other Permit Fee Sew x Connection Fee xt-e-r Connection Fee $ ------------ TOTAL 19 e), IzAt ze, e— A � Building Inspector Div. Public Works s` , yi. 4 . ik4 l� O O FO FO rnrn �rnrn r • r- 6� z z z Q 0 a J A m W z 0 9 > o '-; o "' c` mm r O0 = 1 m a V 3 F r 0 Imq r r 0 m m 0 c q c 3 >I < _n 0 x Z A m z z m m w r 0 r 0 I 0 O Z z A Z �I � i 0 I � mm w r z Q -� m rr { r vM A 0 m 0 ` > > O A 0 Z A z I Z 0 > r > o Oi z m c i 0 r m > i> m 0 I Z v N O A i 0 0 , A r m N A N . O I Iq f O i > I q z -1 0 0 , I m -+ N i LAJ m z W m c ; o a � r I 2 m c v ?_ 0 Z i z i m I O • A I l� O O FO FO rnrn �rnrn r • r- 6� z z z Q 0 a a 0 m 0 W 0 M m Z 0. X 3 0 z mH w to > o m o m n A i 0 a m N mm r O0 = r m a V 3 F r 0 Imq r r 0 m m 0 r q c n1 >I < _n 0 0 Z A m z z m m w r 0 r 0 I 0 Z nl Z z A Z m � i 0 I � - N w r z Q -� m z 0 r vM A z N m 0 m Z fll > O A 0 Z C Z 0 > r > o Oi z m c i 0 r m > i> m 0 I Z N O A a 0 m 0 W 0 M m Z 0. X 3 0 z mH w to > o p o m> O O r N 3 A r c c c> >I >> r= m Z A Z n m m 0 0 m E r 0 r 0 r 0 0 'I Z nl Z z A A fm1 m � 0 I > r z Q Z 0 z 0 r vM A m A m 0 m Z fll > O 0 Z 9 m Z 0 > r > o Oi z m 0 3 0 r m > i> m O m N O A 0 A m N . > I q z -1 0 0 z r m -+ N i (� W o a Z Oww° 2 m c ?_ 0 N -t Z 0 0 A 0 m Z m > T G � a m w m m 9 m m 2 I N m� 3 0 9 0 Z Q Z fit Z Q z O 0 0 m o 0 A w A = 0 A m v Z Z Z m o Z '0 m® -1 r r R n l n1 i [ O � 0 m A m m A lk Q O O 0 A � Z m m \ Z 0 0 0 i H oA A c A z z .r 8� r m > Z 0 m > U, m A m A N N m O E Zx m i p z I I � Q W 0 w A � 0 ID m Zu < It 0 .� , _ fir,, To k, Z32 ell < -j th 0. 0 IL�o 0 a -Ij vs Z,:) U) I O.M w i -n U z w 0 1 E JA W Z 0: u < Z x w W16 W 0 0 (L U A oz. 2 Oz 09 x Www 2� 00 Z tiT z 0 'o u o z �L'5� uwt- w W Z w CL > z U) io� P14 I I I TTT, ou wi TI FT(ITF. oz. 2 Oz 09 o 2� 00 tiT 'o 0 o z �L'5� Z CL > z P14 I I I TTT, ou wi T :'Meo v 0 z w Z o", 0 z 2 u vi 1 - z:Ed>--00-o, V) 0 Z Z ol o w a x V 3 w, z -E Z Z w 2 � , D 0 :Emzg< z 3'-�o TM , x on -- �-Z,W �: 0 Z u < m i 0- o OD z z Z -L o Z z 0 < 0 < -M 0 0 a < < > 3 0 T, t i� < 0 . w 5 w 0 < - 0 62 <0 z v x u < cc z :) 0 u Q< 0 0 z 0 z Z 0 0 < m z 0 u z 0 0 z LL < xi 0 - vi 6 u 0 OZ z 0 Z < 0 < z < < to , a 0 0 u I Z 0 5�1' 0 0 Z < is: Z �qoozz Z Z �z z ZZ N -0 2 0 . 0 0 00000 0 < N u Z 0 v u � (1) < wo o � 0 0 0 u M u D =) v u u li . z z 0 - z 0 1 1) ;- <. Cc, - 0 4 - 4� � w 0 0 Z� 1:20 - 8 N i ;/i < u0i-� u M < I o u , , < Z� < BCK I 3: r - . in FORM U - IAT RELEASE FORM INSTRUCTIONS This form is used to verify.that all necessary approvals/permits from Boards and Departments havin p g-jurisdction 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 fills out this section***************** APPLICANT: Phone g� LOCATION: Assessor's Map Number Parcel Subdivision Lot(s) Street St. Number ************************Official Use Only************************ COMMENDATIONS OF TOWN AGENTS: Date Approved Conservation Administrator,, Date Rejected • Comments Date Approved Town Planner Date'Rejected Comments Health Agent Comments Public Works - sewer/water connections - driveway permit Fire Department Date Approved Date Rejected Received by Building Inspector Date i. 9 Town of North Andover BUILDING DEPARTMENT Homeowner License Exemption (Please print) DATE / ` —3 JOB LOCATION �3 ✓� Number :'HOMEOWNER" Name PRESENT MAILING ADDRESS treet Address Home Phone s�/64C ection of town ork Phone City Town State. Zip code The current exemption for "homeowners" was extended to include owner -occupied dwellings of six units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided .that the owner acts as supervisor. (State Building Code, Section 109.1.1) DEFINITION OF HOMEOWNER: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one to six family dwell- ing, attached or detached structures accessory to such use aid/or farm structures. A person who'constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner" shall submit .to the Building Official, on a form, acceptable to the Bulding Official, that he/she shall be responsible for all such work performed under the -building permit. (Section 109.1.1) The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other.applicable codes, by-laws., rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of .North Andover Building Department minimum inspection procedures and ;'requirements and that he/she will co with said procedures and ,requirements . ,.� % HOMEOWNER'S SIGNATURE .APPROVAL OF BUILDING OFFICIAL Note: Three family dwellings 35,000 cubic feet, or larger, will be required to comply with State Building Code Section 127.0, Construction Control. C-) C) z cn m x D 0 z T Z r _v, CA C O coo CM) CD n Z y CL O 0• r � � o CZ �• CO) 7 O n v CD CD ,c o CL Q CD CD O CD C CD y� Qv y •O CG CD � v CO) O CD Z O O 0, r.« O � • CD O CD O Q y SomO = CD y CD CD C7 o y cj c. C 3 m Z --I CD =rc�a m CD CO COO) CD -� O O y O N =r CD CD = O •� CD 'R ® a O O 0 C2 O� O CDCL�z _ � • �1 'e CD CD y CD roCD a !� n�y 4 1'J CD O y , O °' y y ,CD H �. CD Cn ? H ,z aCD 1 \ / ,dye f CD O C n O O CD O CA CD Z -CD o CACD I m o' CD C•oo. CC n� � o 0 d o G It d 1-0 2L x O y � z m z O O a 0 0 x x tz O ° QM M Fo 6.7 y 0 9 0 c CD 1i' N2-13o5i 6 Date...///19� 1115� TOWN OF NORTH ANDOVER"" PERMIT FOR WIRING I A"y�to c, sriF bg(f,ifts -�tc - .-:: Thiscertifies that ............................................................................................ A" has permission to perform ............................................................................... z C%1 wiring in the building of .... . ........ ........................................................... . at ..... ........ . North Mdover, Mass. Fee ..... 3rdd. Lic. No..(.—.15P5 ............................................................ P C�TIIAT TWQDVf�V C � (+ o � -o,-/ WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Office Use Only �l�e �IIIItIIiIIttlll�ttlj IIftt��tlu>: Permit No. �. Meparttritnt of Public iiiAfettl Occupancy & Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 3190 (leave blank) _ r f' {¢ =APPLICATION FOR PERMIT -TO PERFORM ELECTRICAL` =WOR`K All work to be performed in accordance with the Massachusetts Electrical Code. 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL IN ORMATION) Date City or Town ofTo the Inspector of Wires: The udersigned applies for a permit. to perform the electricalworkdescribed below. / Location (Street & Nu ber) �.,`,,�y� �lJalt_ "3'� 14,�CL Owner or Tenant / Owner's Address Is this permit in conju tion with a building permit: Purpose of Building���V Existing Service Amps _f Volts New Service Amps —J Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work _ Yes ❑ No X (Check Appropriate Box) Utility Authorization: No. Overhead ❑ Undgrnd _ No. of Meters Overhead ❑ Undgrnd _ No. of Meters No. of Lighting Outlets I No. of Hot Tubs i No. of Transformers Total VA No. of Lighting Fixtures Swimming Pool Above In- grnd. ❑ grnd. ❑ I Generators KVA I No. of Emergency Lighting No. of Receptacle Outlets I No. of Oil Burners I Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Air Cond. Total tons No. of Ranges No. of Detection and Initiating Devices No.of Heat Total Total Pumps Tons KW No. of Disposals No. of Sounding Devices No. of Self Contained No. of Dishwashers Space/Area Heating KW Detection/Sounding Devices Heating Devices KW No. of Dryers Local Municipal E Other Connec:;on L. No. of No. of Low Voltage No. of Water Heaters KW Signs Ballasts Wiring No. Hydro Massage Tubs t I No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws 1 have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES - J NO 7— 1 have submitted valid proof of same to the Office. YES n NO C If you have checked YES, please indicate the type of coverage by checking the a propriate box. INSURANCE BOND C OTHER C. (Please Specify) Estimated Value of Electrical Vprk $ Work to Start ��a0 Roug Signed under the Penalties of perju HOME SE FIRM NAME 155 WEST STREET, SUITE (Expitation Date) inal LIC. NO. Licensee i�rtyj� LIC. NO. Address LIC# C-1866 Bus. Tel. No. 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) 35 Telephone No. _ PERMIT FEE $ (Signature of Owner or Agent) x6565 Date .... 0?��z o TOWN OF NORTH ANDOVER PERMIT FOR WIRING �-�47 Y This certifies that .......... ........ .... ........ . .... has permission to perform .... .......... J—Off,v wiringin the building of .................................................. 4 ................................ North Andover, Mass. ................................... �o .............. Lic. N .......... v . ............. ......... Check #7z -P 3 578.4 1 -- — —=� e�� 11W Lulmylulvrrrftun yr Xin67A,vat,KIVOLM I u �•�-- --- �, DEPAR711 WOFPUBIKSWETY Permit No. 5-7 �V BOARDOFf=PREVEM0N NSSl7CZmna Occupancy & Fees Checked A.PPLICATTON FOR PERMIT TO ERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE ASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dat �o D 5 Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical wo described below. Location (Street & Number) kyh S Owner or Tenant 10 1, v1 C , V\ Owner's Address Sr Yrs Is this permit in conjunction with a building permit: Yes 0 No [:3 (Check Appropriate Box) Purpose of Building s n G R y , 1 Utility Authorization No. Existing Service AmpVolts Overhead Underground No. of Meters New Service Amps olts Overhead Underground Q No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work h _'Pk v,� Sh 12 S v-�enZ No. of Lighting Outlets No. of Hot Tubs No. of Transformers TOW KVA No. of Lighting Fixtures Swimming Pool' Above Below Generators KVA ground 11:1 und No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat TOW TOW Pumps . Tons KW Initiating Devices No. of Sounding Devices No. of Dishwasher Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipal Other No. of Dryers Heating Devices KW Connections No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP t •,J i v✓1 t-tk WbikIDSW ktspec6mDeteReqzsWd Sigvdun&r e�Pwwbesafpew RWNAME GGohS �/��S/�► aleft . YES 0 NO 0 1fycu hm dlad®B YES, please nic* ft qpe cf wwvV by F. #atianDate FAn*dVaizdEbcWcd Whk $ Rao I iw LimmNa 1*4 Bu4=TdNa G L/--700 A ,l_`I /� �fCyskOr 10 nQ Na AX Td ICY U OX. ""SPaURANMWAIVFR;lar ammdmtdlelk=dDesmthtnetheinatancew Waits eW!valentasia#wbyM Galn"Lm anti t!ay's aeonthePetTn[app6cA_waivesdisreq�i�rrtat (Please check one) Owner Agent Telephone No. PERMIT FEE $ signature Owner Location No. C), �, I Date C o 0 / TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 7� ?6 145', 4 Building Inspector _ TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING :. ... ME% ib BUILDING PERMIT NUMBER: DATE ISSUED: _ 0 ©� SIGNATURE: /vt� Building Co missionerftEMtor of Buildings Date SECTION 1- SITE INFORMATION Property Address: 1.2 Assessors Map and Parcel Number: /1.1 04 adLb n Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: ` 11 Zoning District Proposed Use Lot Area (so Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided - v 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Zone Outside Flood Zone 1.8 Sewerage Disposal System: Municipal Public Private p On Site Disposal System 0 SECTI 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Nares ( rint) Address for Service: �`-Z3 r7 b Signature Telephone n Owner of Record: ame Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervis r: D53 y 1 {� t, License Number Addre - - ib (/ ' 53 Expiration Date Si nature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number. h(DL ddress Date v--'c'-Expiration Si ture Tele hone a as r rn _r Y) SECTION 4 - WORKERS COMPENSATION (NLG.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will -result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No...... SECTION 5 Description of Proposed Work check all appUcable New Construction ❑ Existing Building A Repair(s) tAlterations(s) Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work:` SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant R OFFICIAL USI'; C?NLYy 1. Building (a) Building Permit Fee Multiplier ` 2 Electrical (b) Estimated Total Cost ofO Construction --- 3 PlumbinE Building Permit fee (a) X (b) t 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 u i 1 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, � , ` ..� j`�l ... hn .. , L",, C.,., (,.� , as Owner/Authorized Agent of subject property Hereby authorize lig, to act on My,Uhal, in all m rs relative work authorz y this building permit application. Si ria' e of Owner Date SEMON 7b OWNER/AUTHORIZED AGENT DECLARATION I, ,� ...� J "��_ 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 Pi nt Na e ) Si afire of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB,,,, SIZE OF FLOOR T VIBERS 1 INI_ ;L 2 ND 3 RD SPAN 1 DIMENSIONS OF SILLS DBAENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS ('0') SIZE OF FOOTING (• X r MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE FORM - U LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that allnecessary approval /permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. ..................................................................:.......... APPLICANT ��`� PHONE Vve' _J 33� ASSESSORS MAP NUMBER v � LOT NUMBER 066 SUBDIVISION LOT NUMBER STREET c1 �^^ STREET NUMBER S ............................................................................ OFFICIAL USE ONLY ..............................'.......t......■•...........................s.■ RECOMMENDATIONS OF TOWN AGENTS DATE APPROVED CONSERVATION ADMINISTRATOR DATE REJECTED COIvAdENT S DATE APPROVED TOWN PLANNER DATE REJECTED COMMENTS DATE APPROVED FOOD INSPECTOR -'HEALTH DATE REJECTED DATE APPROVED SEPTIC INSPECTOR - HEALTH DATE REJECTED r�9e� PUBLIC WORKS - SEWER / WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPARTMENT DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR DATE Town of .North Andover Building Department 27 Charles Street North Andover, Massachusetts 01845 (978) 688-9545 Fax (978) 688-9542 DEBRIS DISPOSAL FORM ti NORTH -,'9 O 0 '�SAC�IUS��Ry In accordance with the provisions of MGL c 40 s 54, and a condition of Building permit # the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, s150a. The debris will be disposed of in /at: locatio r Signature of Applicant � 171 k Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. I IILI l/vIIIII IV I I r r � u i u i vI J i I u w u U0 l UJli l lv Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print v Location Citi �� �� b i �6 Phone am a homeowner performing all work myself. OI am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job- ,S� Comon i name: Address Phone # IG�L '"y 33 lJ (A-1 C City: Phone # __ Insurance Co Policy # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 andtor one years' imprisonment 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 may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby cefift)Vnder the , ' s an `penalties of perjury that the information provided above is true and correct Print Official use only do not write in this area to be completed by city or town official' DCheck if immediate response is required Building Dept Contact person:_ Phone FORM WORKMAN'S COMPENSATION Date \t_�tlt(Y 0 Building Dept 0 Licensing Board 0 Selectman's Office 0 Health Department F1 Other i + L I t I i 14-f t t J -T -�- �- iL + -L-4- T1I I { I I r i 4-4 -4 + +TI '-T -t -s a I R Cl) m m C/) 0 m S. d S. � n Z y CL ?o C1 =• y aC v CD CD o c rM CL cr c ? d CD CCD O CSD C CD H� __.CD n 0 CA O I Cc CD S- CA O CD CD Z� o C CD CD C c?'op = _ 0 �• N C w N np�m in Cl) C Hc'no C2 m CD ? o =r y O G O ErO CD > > m y m O_ C� O ii p L. Cl) CD y :0 co p C=D obCL r m m m y ►� 0 CD co \ J y L Ocro my CL z = N C/) O ,� d CA3:dr mCAd06 So ii. cr CD O O� 0 0 � 0 C)Z o co ,.. r V JA o m a ;Q :dOft COO oI d m� CL n: c CD O M � cn cnx' ^+ G p O O O r -i x p qz O t x O n O O O (� (b O 0 c Location No. Date L TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ *4,vo Foundation Permit Fee $ AC S �Other-Permlt Fee $ Sewer Conne oe $ Water,G%Z*tion Fee $ 0 .01- " $ ,7 QJ0,7t Building Inspector Div. Public Works / �7 , Location No. ,12 0 OFMRTH ANDOVER 4"ro, '%- -",114 *��-/(),�/;,�- Certificate of 8&Q Mcy , $ Building/Frame Permit Fee, $,j. Foundation Permit Fee' Other Permit Fee $ Sewer Connection Fee $ r'l � , , - �, .7 Water Connection Fee $ - j TOTAL $ ' 91 BulIding Inspector Div. Public Works Location SALE111 No. Ditte"4 RT11 0 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fe AENT -W- CHU Foundation Permit $ r Other Permit Fee tallo Sewer Connection Fee $ Water Connection FeINO-Aodovef Collector TOTAL Building Inspector Div. Public Works m r(? G > yo GL�/ 6 D Location No. Date N, I TOWN OF NORTH ANDOVER Certificate of Occ cy $ Building/Frame Perm $ 'rM Nt6 Foundation Perimitfee Other PeA Fee * 41 Sewer Conne% Feed $ j Water Connectio%�q 0 TOTAL Lo' -w. $ B611ding Inspector L-4 0 Div. Public Works ­4� 6 APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. ��% �� V PAGE 1 PER3w 140. ZZ� r IAP 4-40. LOT NO. �+� / l I 2 RECORD OF OWNERSHIP "DATE BOOK "PAGE ZONE SUB DIV. LOT NO. — LOCATION _ '� .� PURPOSE OF BUILDING �"�!/vC / &A? /�J/C�"g 44 /� 7 (SIZE OWNER'S NAME j®� / r / NO. OF STORIES _ 79 v(2 � .. �l /1 OWNER'S ADDRESSBASEMENT OR SLAB SFs>•?��f� ARCHITECT'S NAME �� �e^y SIZE OF FLOOR TIMBERS IST z %p 2ND 0 1 e 3RD ,` !� 3 BUILDER'S NAME 7-6 4y,A / ������ D L SPAN /I`i/aJ,�O DISTANCE TO NEAREST BUILDING � DIMENSIONS OF SILLS __z(� DISTANCE FROM STREET !D'D --_ POSTS DISTANCE FROM LOT LINES - SIDES /'f />/ REAR goo- yC� [JLfJfSO � GIRDERS ` FRONTAGE �' AREA OF LOT 5160 b J HEIGHT OF FOUNDATION nC, 4 THICKNESS r IS BUILDING NE[[Wlli/VVI�J� SIZE OF FOOTING /�Y /i X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION / IS BUILDING ON SOLID OR FILLED LAND U WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY �/� ,V S\ IS BUILDING CONNECTED TO TOWN SEWER IS. BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 PERMITi� FOUNDATION ONLY RMULM BY PARA. 114.8-5. Bt - PAGE 2 FILL OUT SECTIONS 1 - 12 - ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING DATE `� FEE PAID s ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST' BE FILED AND APPROVED BY BUILDING INSPECTOR DATE'FI}.Cp FEE OF AGENT OW)VER TEL. G7 V7 NTR. TEL N CONTR. L!C. G'�--- PERMIT GRAN D 19 r qq,_ rr�; v T1�: VMff FEE I• PLf'I. FOR FRAME/BUILDING 1� 092 ._.,- � �muca s 3 PROPERTY INFORMATION LAND COST ^7 :71,�OQ EST. BLDG. COST[ (l EST. BLDG. COST PER SQ. FT. 7 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. V L 4 APPROVED BY BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN _ ' En $ �.�r DATE : -._.._._EEE PAID: eu MJJ�n�P6GTOR l .. BUILDING RECORD D` 1 OCCUPANCY 12 SINGLE FAMILY STORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA - APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. / 41t0' !. C s CONSTRUCTION 2 FOUNDATION _ 8 INTERIOR FINISH CONCRETE 3 1 2 13 CONCRETE BL'K. _ PINE BRICK OR STONE HARDW D PIERS PLASTER DRY VJALL _ UNFIN. 3 BASEMENT AREA FULL FIN. B'M'TAREA _ V, 11/2 '/, FIN. ATTIC AREA NO B M FIRE PLACES HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS DROP SIDING WOOD SHINGLES B 1 2 �_ _ —{I_ �— 3 _ CONCRETE EARTH ASPHALT SIDING ASBESTOS SIDING VERT. SIDING _ HARDW'D COMMGN ASPH. TILE STUCCO ON MASONRY STUCCO ON FRAME _ BRICK ON MASONRY ATTIC STRS. 8 FLOOR I_ BRICK ON FRAME CONC. OR CINDER.BLK. WIRING STONE ON MASONRY STONE ON FRAME SUPERIORI� POOR ADEQUATE NONE 5 ROOF GABLE ILZI HIP 10 PLUMBING BATH (3 FIX.) _ GAMBREL MANSARD TOILET RM. (2 FIX.) FLAT SHED WATER CLOSET ASPHALT SHINGLES LAVATORY _ WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING TAR 8 GRAVEL STALL SHOWER T ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING It WOOD JOIST 11 HEATING PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. & COLS. STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING _ RADIANT H'T'G UNIT HEATERS GAS 7 NO. OF ROOMS B'M'T_y�l 2nd I _ 10i3rd OIL ELECTRIC NO HEATING / 41t0' !. C s §z 3c 2�w » m2o § § 0 Z § ■ « � 10 t-"@ 2 { co 3 (A o - � % a ° 22M C o 2 02 « 2 o ' r 1 _ z _ - 9 %A �t �»» 1.4 $� oo= - ? „ - -2 wA%" » w ;a o 2 o w z2 . 0% _ 00, E »n ®,|! 2m Aa S� A. 02� or _\, 00 {� ) 00< r we §z 3c 2�w » m2o § o 0 Z § ■ « � 10 t-"@ �k( M ) 3 (A CG 2} � w0 0\ . 101 z �-at�oOIV ° n P%oM f� 22 No �� c Do T �k( z�m 3 70 w0 0\ 22M -2/7 02 « 2 o ' r % _ - mnQ �t �»» 1.4 $� *0m » cm P4r§ (AX »oma m(A »n 2m Aa S� 02� or {� ) 00< r we - 00 00M r- © IIQ z cn 2 § § ` 0: r r \ \ m s * r _ _.(3101 m � n \ § $ 2 n ! o oe I \ M m 5 6 m > z 0 � ? r- _ .� §.\\ § J § 16 (nrn q 'o ( _ f § -0 Co k o ` n -- (rn > § M z C) , (A? a / m \ M n o $ § m / c _ � � FORM U TOWN OF NORTH ANDOVER LOT RELEASE FORM SUBDIVISION ASSESSORS MAP SUBDIVISION LOT(S) PERMANENT ADDRESS ASSIGNED BY D.P.W. STREET V 2 C� ' APPLICANT �G� Ll41 z P110NE �. DATE OF APPLICATION Ll /2 /,�7 PLA I G BOA TOW LANNER CCONSERVATION COMMISSION 7 ;-2, )>- & CONSERVATION ADMIN. TOWN USE BELOW THIS LINE DATE APPROVED DA'Z'E REJECTED DA'T'E AVVP(1VED /L DATE REJECTED DEPARTMENT OF PUBLIC WORKS DRIVEWAY PERMIT WATER CONNECTI01I RECEIVED BY BUILDING INSPECTION DATE l'l: APPROVED UE REJECTED 417 /c �— This form shall be signed by the agents of the Planting incl Health llorirds, the Conservation Commission prior to the issuance of\any building herml.ts for the subject lot. This form stall not releive the applicant from the compliance of any applicable Town requirement or Bylaw. s lo(t5�92 r PAec'E-4 Coo 200. S.F7 n fix` vD ,� • mU' �' °t83� Y r }1 • I Gr."4.fLT l Wp '�-'u E► o F"F' Sr�:.'s'�, +.)� cz. -r- ,. F v t t., => t V.j tea u SFftc=b e S K b kl 4.1 Milt_ iD "G -H Am 'a=, 1-3vl . S.!s E:. l � �t� n., W rr-ri Tkd E X04.1 �6J,G C7f,�-'t" �,2 �t t *..t A` -c` t cs �•.t o � �.,o +.i � �yC�s �,o� 138��. S c5 �'s'�' F-o1M r ray . Es 'i�� f.So�..t Cows t -'o 2�t�(.f7'S/ • GJSi%9� lo(t5�92 Z O r °z o c m fA lw o c V n m _� o c 3 V3 3 44=rel `^ C v fA T A i cc I'D 0) O r °z Flt ou 00 t a 1 C O Z A � w � 0 � z =1 H Z `P'! CZ 3 c° 3 m o c m fA 21 m o c c T m T o c V n m _� o c 3 V3 3 44=rel `^ C Flt ou 00 t a 1 C O Z A � w � 0 � z =1 H Z `P'! CZ 3 c° 3 m o c m fA 21 m o c c T m T o c V n m _� o c 3 V3 3 44=rel `^ fA T A i 0 C•i�3 O ti cl O d ` O O O d � d r 0 y z y y H � d oz rn -n a, b A w r r- tt7 • V1 ON O d s fn rn b rn tZ1 rrn 7C cs. v N I Date. U 3 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that Me C (CA ....... j7C'[— A** has permission to perform .................................... f C Y�- M A h-1 plumbing in the buildings of .................................. 0 3 5 �) F-) I f- W\ 1 - at ....................................... North Andover, Mass. Fee. ql� �X. . Lic. No. �1 .1.3 9 cf .21 -1).' 0 1. Z-1 I M AA. (C.L-l-,� ....... .... .... .. .. ... .. .... PLUMBING INSPECTOR I -P � (. t 9 Check # 5840 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) ` NORTH ANDOVER, MAPSACC�H/USETTS r ; (� priG`l/ _. Date ?C S/� /�Nl 1 �/Permit # Building Location �J Owners Name /� '/ `✓ Amount Type of Occupancy ! ' New 0--- Renovation r Replacement ❑ Plans Submitted Yes 1:1 No (Print or type) Installing Company Name .� Address n,G4 Check one: Certificate M Corp. Partner. ��Fi"rm/Co. Name ofLicensed Plumber: Insurance Coverage: Indicate the insurance coverage by checking the appropriate box: Liability insurance policyEr Other type of indemnity 11 Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner El Agent F1 I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the M chin a lu� e d Chapter k42 of the General Laws. By: Xignature of Licensea Plumber Type 3ofPlumb' 9License Title City/Town License Number Master Journeyman t APPROVED (OFFICE USE ONLY .. _ • •, (Print or type) Installing Company Name .� Address n,G4 Check one: Certificate M Corp. Partner. ��Fi"rm/Co. Name ofLicensed Plumber: Insurance Coverage: Indicate the insurance coverage by checking the appropriate box: Liability insurance policyEr Other type of indemnity 11 Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner El Agent F1 I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the M chin a lu� e d Chapter k42 of the General Laws. By: Xignature of Licensea Plumber Type 3ofPlumb' 9License Title City/Town License Number Master Journeyman t APPROVED (OFFICE USE ONLY O z t 03 W cd it i� a Z H ti W_ ti. 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