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HomeMy WebLinkAboutMiscellaneous - 88 FARRWOOD AVENUE 4/30/20181 cc C v r Date c TOWN OF NORTH ANDOVER PERMIT FOR WIRING 'Vr This certifies that .... ......: ��.`� '`..c /� `° '. v °/-c v. has permission to perform wiring in the building of ....................... at ... .. f.? .✓ts ! �, ... 4 /. � , rth Andover, Mass. bo Fee . `.3 7. . Lic. No... ELECTRICAL INSPECTOR Check # 36)L/( ) 136-0 , mID m� 1p .O i O +O•- N ci o o p, � •ci a w d p' a, O td a) N N N � cd a� D b O A> U ti d y p .� N FL a� '�j cqo �. o ai 0 bio � D ��A pU � �'� �.� vii N p•a.-O. bA U O ° � r••i U � iG ttt O ORO 4 +� � N � • p � ti N V a a.w sy C> m ° � Id o o .° o � � 'o q I�y o aw wbIN ca v ��yy � o vj o t .a U N M b ..D � O a (32 °� cy ani m q •� °� .''� l A, o wyyw '00 aan'�,.� 43, 4. w c� v o Z +3 a� . ti4-f 0 0 dao v rW p 0 ro �b °' q o o •�;� °� °' �+ w yy ,q R, y � •y � U U w .a '�' cct •S�-n p� N �+ p, o• b N .*., N i. w U �c N� W'� c�C m .4 '�•' O � y 'O a� U 4 N c o o a c� wom�, F�9a' 0 N 0 • �oom2oredveai Official use Only . . Permit No. Occupancy and Pee Checked BOARS} OF FIRE PREVENTION REGULATIONS ev. I/071eave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in ac<:mrdance with the Massachusetts Electrical Code (MEQ, 527 CMR 12.00 {PMSE PMT.flV.W ojz TTE � -&FO TZOM Date: . City or Town of %�%/'� Andover To the Inspector of fires: By this application rhe undersigned gives notice of his her mbentivn t o perlorrn 1heelectrical wockdescnWbelaw. Location (Street � N.�.ht,a�� ��' �iI ri^L!)n/l� �1/P,l'J UP .. •� laZ Owner or Tenant , Owner's Address Is this permit in conjunction with a building permit? Yes F1 No Telephone (Check Appropriate Bog) Purpose of Building D 1.(3 �, in A Utility Authorimflon No. Existing Service Amps T Volts Overhead El Uadgrd-o New Service Amps I Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Overhead a Undgrd ❑ NM of Meters No. of Motors _ (A91P5' — of tl,c ,r u.ir,o Inhtn may hp waived by the Insmctor of i'l imt No. of Recessed Luminaires No. of Cell:-Susp. (Paddle) Fans No. of Tot*t Transformers KVA No. of Luminaire-Outtets No. of Hot Tubs Generators KVA a of Luminaires Swimming Pool AbZruove e 0 g d.. No. o Emergency B tte Ufflts y No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners 0.0 8n Initiating Devices No. of flanges oiril No. of Air Cond. Tons Na: of Alerting Devices _ NO. of Waste Disposers Heat ump , um er ons Totals: o. o Self -Contain DeteMion/Alertin Devices No, of Dishwashers I Space/Area Beating KW Local E❑ Municipal Q Other. Connection N`oi of Dryers Heatin .A lienees KW g pp Security Systems: No. of Devices or Equivalent No. of Water No. of O. of Data Wiring: KW Ballasts No. of Devices or E uivalent S.. s _ Heaters c►mmunkmons No. Hydromassage Bathtubs No. of Motors Total 11P No. of Devices or Equivalent V 111L1a. --- Attach itdditional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal p0li0y:) We rk to Start: Inspections to be requested in accordance with NEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the Ikensee provides, proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CIIECK ONE: INSURANCE Do BOND - ❑ OTHER .11 (Specify-) I cert fy, 4nder the pains and penalties of perjury, that the information on this application is true trod cornptete- ctrrt� ��. t SPr�i'(;QS zirYti LIC.NO.: F Ri1'1 NAME: tea.. d�a tc�-.►� Licensee: L��nt�P �. YC51 Signature LIC. NO. (I, f applicable enter "exempt" in the license nbber 1tne-) Bus. Tel. No.:6YAZ Address `�D .. Ali. Tet. No.1�L)iS-tit y.?a *Per M.G.L. 0.147, s. 57-51, security work requires of Public Safety `°S" License Lim. No. _ -- OWNER'S INSURANCE WAIVER I ant 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 Mnt owner/Agent Telephone No. j'EldhglT SEE: 5 d� Sigp29tu1e The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Ledbly Name (Business/Organization/Individual): �'L Fc ZR l C AC f1 U!L'FS /N C Address: City/State/Zip:iti/G t/A„ Are you an employer? Check the appr 1. g I am a employer with employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t S N-0/0/ Phone #: riate bog: 4. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' -_. comp. insurance.: 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' coma. insurance required.l a Y - x'66'- 7y6 7 Type of project (required): 6. ❑ New construction 7. Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.9 Electrical repairs or additions I LE] Plumbing repairs or additions 12. ❑ Roof repairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ? 6i A A Al C Policy # or Self -ins. Lic. #: No V C 3 / 3 G 62 Expiration Date: zg1. Job Site Address& F4,wOD &aw,, � ' City/State/Zip-ffdr4h trr&g ;NlA lVY-4�_ Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerci !2 a pains an al ' o _ erDury that the information provided above is true and correct. n e _ _ _ J T-% �+s - 6i� - 7y6 Offlciul 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 #: Date .. e �/.? � �...... 3� TOWN OF NORTH ANDOVER ° .... A • - PERMIT FOR GAS INSTALLATION �9SSACHUSEtt This certifies that .... �. � ......................... . has permission for gas installation . �� ................... in the buildings of .. /� f r ! .! �? ! ... ..�.'` ............... at ... .d ..�1? �� °..`..`� .......... , North Andover, Mass. Fee. Lic. No.'9 C .j ... .. p:._ .. ............ . GAS INSPECTOR Check # G 3 J 7U6 MASSACHUSETTS UNIFORM ,PPLICATION FOR PERMIT TO DO GA5 FII l INN CitylTown: • A�, CoQ VcPerrnit# " MA. Date: �� 0°1 Building Location: �q`r'W Aye Owners Name.kr1k01q�. Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: ❑ Alteration: ❑ Renovation: ❑ Replacement: X] Plans Submitted: Yes ❑ No FIXTURES -- 0 UJ W D w m °v cn l'- O= W w f m= � 0U' � >- z W 0 0 H W rn w 4m m 1- Q (L Q W = LL > N V W N W O tr = W O W Z_ W W W > W W Z N J Q Q Q mQ W 0 Z 0 y ~ > Z ~ 2 p D Q W w J O a W tW— >>> ~O L) D O LL (7 t9 S 2 SUB BSMT. BASEMENT 1 FLOOR 2 Nu FLOOR 3 FLOOR 4 FLOOR 5 FLOOR 6 FLOOR 7 FLOOR 8 FLOOR Check One Only Certificate # Installing Company Name v t ��D Corporation Address3 �M+�f►C�'1�R CitylTown•�ac.3"�� State ❑ Partnership Business Tel: ti{ \X0`3°1 t"��t"�� Fax: E]Firm/Company Name of Licensed Plumber/Gas Fitter: C rt`Q,T�C� INSURANCE COVERAGE: I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. Other t ❑ A liability insurance policy 9 type of indemnity ❑ Bond OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives thisCheck One Only Owner ❑ Agent ❑ Si nature of Owner or Owner's A entue and By checking this box ❑; 1 hereby certify that all of the details and information I have submitted (Or entered) regarding this applicaticat on w II be in compliancetw th alltPertinent p olvisgon of the Massachusetts State Plumb ng Code and Chapter 42 of the Gelneral Lawsr this app Type of License: By ® Plumber ❑ Gas Fitter Signature o Licensed Plumber/Gas Fitter Title Master p� Journeyman License Number: G-4% City/Town ❑ LP Installer r `n m z rA m z C trf rn a b b r n Y � �. °z r o � o o o cn O r a O r 6129 Date/0.-./'-.C'k.S . ....... ....... . ...... .... ..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....................... .......................................... has permission to perform / ...... wiring in the building of. ...............(......�=!. North Andover Mass. 0 ........... -4••....<< .......... .... ....... ....... Lic. NoQW-.9. ELECTRICAL INSPECTOR Check # J 10/ / 1,; 4N,:1aWII,T&I APPUCATTONFOR PE] All. WORK To BE PEIMRMBD IN ACCON (PLEASE PRDff IN INK OR TYPE ALL VMRM, Town of North Andover The undersigned applies for a permit to perform the Location (Street & Number) PA Owner or Tenon S �G. Owner's Address el M -f Ls this permit in conjunction with a building permit: Purpose of Building Permit Na �� I OMUPm" & Fen Checked IL WORK 12:00 Date l l� S' = O (Check Appropriate Bog) 1�-2 S [ -e ry,� t o\. � Utility Authorization No. Existing Service Amps ...L.Volts OverheadUnderground New Service AmPr� Volt Overhead Underground C3 Number of Fades and Ampacity Location and Nature of Proposed Electrical Work No. of Metes No. of Metes Na of Lighting Oadit Nm of Hot Tube No. of Transh mere TOW KVA Na of Lighting RiUm 3whwing Pod Above 9001W M Below Oeaerata KVA Na of Receptacle OudW No. of On Burner pound No. of Emeraeaep Lighting Battery Units Na of Switch Oudeu No. of On Barron FIRE ALARMS Na of Zones No. of Rsngae S 9 Na of Air Cond. Toud 1 Toga Na of Demcdoe and No. of Dispoasb Na Of Had TOW TOW TOM KW hddadng Dwica Na of 3oimdhq DeAca No. of Dishwashers Space Ara Heeling KW Na of SeK CenthrW t epi Muwcipd Ober No. of Dryers , Hoeft Devices KW Comtecdons No. of Water Nesters KW Na of Na of SIAN Baitaeis Na Hydro Manage Tale Na of Motor Told HP Inst wwCm=W Piatat Ddxw item*dN esda>tQemllarta IhneandIWdv&F dofsmerolleOffiZ dradct>gtleb�c N15URANO B{14D E] Orin 1:3 rmseSp * WoikbStat 4;1 t"` ispectintDteRa}ded -WudarFbnftofpe*. � s EEMNAME 6 i ;=tee Td �k ^, ()? YM m NO ❑ F)ouhnedlededYFi4,pkaiidcseftetYpedoo�m�bi► r 'y V1,N_ q� dV*edElmftWhk S PZ* >o UC=Na e 3-)d 5- Lioen M Bt lk=TldNa IIV9t1RAi�WAMnondudzLizw341theiraanae AtT>iNa oWr,WS �� w�e�earihaib�l«liivalmtasaz}a�edbyMeeaad�dhc�ae�liaat ardthe rM9*tseonUspmrk�wa'nmf loph ms ❑ (Please check one) Owner � Agent Telephone No, pgwr FEE 31palure ol Owner or Agent I�i "0 1. yr. ;Ih,I7 TTITTW PennI.t No. Occupancy 3 Fees Checked APPUCA19ON FOR PERMIT TO PERFORM ELECTRICAL WORK ALL WORK To et: tr1RPORM® IN ACCORDANCE rvrrit THE MAssACHussrs eLECrRR:AL cope, 527 CMtt 12:00 (PLEASE PRIIVT IN INK OR TYPE ALL 1NPORMATION) Date°I Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street 3 Number) Owner or Tenant �'z Co � 4 �, t V\ To the Inspector of Wires: Owner's Address Is this permit in conjunction with a building permit: Yes® No (Check Appropride Boit) Purpose of Building f S ( Cie Utility Authorization No. Existing Service Amps�.V alts OverheadUnderground TOW New Secvica ,��� Amp /Volts Overhead Underground Number of Feeders and Ampecity Location and Nature of Proposed Electrical Worst No. of Meters No. of Meters Na of Li&M outku Na of Hot Tubs No. ofTronshatagn TOW KVA Na of U{hting Pit tsms Swimmb* Pod Above Mound 11 Bekm , OatpaWu KVA Na of Receptacl Outlets No. of of Bu noes No. of Emergency Uehtwg Battery Units No. of Switch Outten No. of Ow Bumen FIRE ALARMS NO. of Taros No. of Rn ps S No. of Air Cool Tu a d NDetsedm and J No. of Disposal Na of HadTotal TOW POEM Tons KW So No, a Sounding Dovlosa No. of Dishwashers Space Ara Hwiq KW No. of SeK CaMahne Mwddo Othw No. of Dryen Hoeft Devices KW Connections No. of Wow Heaton Kw Na Of Na of S 131110018No. Hydra Mwsp labs Na of Moron Total HP iWM=CMMV Paaa�ntb�leQieott�iofMs■schs�CiQmlLants Ihmsuhtr>rbdvefdpaoddst:neoh�a dreddl�itae bar. WSURAN�'s BM C3 WodcbStst�i'►1 i"` . t in�e�timDreRa�lobd WundarPhPtnarbcfpefty '> 1 FMMNA11E i;�me �y 6� •� (c%'t S �A orhsrtltktitic &dw Yin Lj NO LJ r)euhtedtededYE%Pistsidcrr 9xgped An4so ''f 1-\ JD r- VLA dValxdElaW Wc& s itouYh - RW U=Nn 3 d S LioMM haTdNa MC% �t3 .�-� �� o vv� o i 1� �� s i. e ✓I /Vl G . AXTel, No, oJwi>WSMRAIMWAM3 ;Iamswaedsti rLic wdmr,d iheira=meaom*arirtt2r6im*gxvabtasaapmdbyMombasCa=WL e ardihtrrp�s�zondispmraiappic:�wtiKsfireq�t ❑ (Please check one) Owner C3 Agent Telephone No. 17� � �. FEE � �._VM Date/7- ��,r •''i' ................... ,,09TH pf t�.�o , 1ti0 TOWWOF-NORTH ANDOVER PERMIT FOR GAS INSTALLATION i This certifies that ,F .. _ '.....1?........... ............... has permission for gas in the buildings of ...... ` `. .� : /............. at . ?.... �P. ...-.-z ..:. . , North Andover, Mass, Fee'�7n...... Lic. No:.......... �;� ............ GAS INISPE&OR Check # v`�� z -z- 6 9/ '1 69/'1 MASSACHUSETTS UNIFORiv1 APPLICATION FOR PERMIT TO DO GAS FITTING MA. Date: ea o Permit# - City/Town Building Locatioi Owners Name; Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: ❑ Alteration: ❑ Renovation: ® Replacement: ® Plans Submitted: Yes ❑ No Lj nt��2 FIXTURES W Z LU Y 2 W Q W W 0 U) _ W m= CW7 J v ~ to 0 W W z Z z Q W LU W OO Q F=- O W N W m O Q o. I- l7 w W x > cn U w (7 = w w H W Q C7 J W Z N H z w �- Q Q m w O z 0 y > zUJ Q SUB BSMT. BASEMENT —TsTFLOOR 2 FLOOR -3'FLOOR 4'r -FLOOR 5 FLOOR 6 FLOOR 7 FLOOR 8 FLOOR Check One Only Certificate # Name Installing Company �::Mb �� � [� Corporation ,z Address: City/Town-7-`� IEc-'S- *n State: -4' ❑ Partnership ' Business Tel: %-4i3Fax: ❑ Firm/Company Name of Licensed Plumber/Gas Fitter: INSURANCE COVERAGE: I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes No El If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy 9 Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and fhat my signature on this permit application waives this Check One Only Owner ❑ Agent ❑ Si nature of Owner or Owner's Agent By checking this box LJ; 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 the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Title City/Town APPROVED (OFFICE USE ONL Type of License:�``� ® Plumber -- ❑ Gas Fitter Signature of Lic1trised Plumber/Gas Fitter ER Master �n e�1 ❑Journeyman License Number: ❑ LP Installer s " NORTH ANDOVER BUILDING DEPARTMENT 400 Osgood Street Tel: 978-688-9545 Fax: 978-688-9542 BUSINESS FORM FOR TOWN CLERK / Z/z 5 M - DATE: I511 OW5 NAME: � t-\ C -VtC e I L--1- \/ I h ADDRESS: NO CA Ljh4 ILI 8 s Fcivo-v,,�' /div? Uk-lf � ZONING DISTRICT: 1` TYPE OF BUSINESS: S BUILDING LAYOUT DC) ct�(AA AVAILABLE PARKING SPACES:v ZONING BY LAW USAGE:YES NO BUILDING INSPECTOR SIGNATURE —(, � �,-L, Or-�e Uc�� Revised I1.5.04 BUSMS FORM FOR MWN CLERK P, Date.?.:.!� :1�o TOWN OF NORTH ANDOVER i:.� •..`. °c PERMIT FOR PLUMBING./- This LUMBING., -This certifies that ...TL0 !P ........ f........... . has permission to perform .... ))a �z f -" .................... plumbing in the buildings of ................ at .... . rl?A0.« ............ . North Andover, Mass. 4L Fee. Lic. No. �? 3 3.3 .. ....... q,j— . -..... ..... . PLUWING INSPECTOR Check # l- I (' ` , 6538 G MASSACHUSETTS UNIFORM APPLICATION FOR, PERMIT TO 00 GASFITTING TA pe) ,Mass rp J^3 O, � Date 2p Permi J BuildinVLqcati on owners me n. // ?,Jim New❑ Renovation ❑ Replacement 0/ r PlansSubmitted: Yes ❑ No p Installing Company Name Address Business Telephone Name ofLlcensed Plumber. or Cas Fitter Check one: Certificate ❑ Corporation ❑ Partnership o. i have a Curren tlf b)Ilty Insurance policy or Its substantial equivalent, which meets the requirements Yes a.— No n of MGL Ch 142. If you have checked yes, please indicate the type of coverage by checking the appropriate box. A liability insurance policy 0/ Other type of indemnity ❑ Bond OWNERS INSURNAtrE 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 ons perm application valves this requirement Signature o Owner or Owners Agen Check one: Owner ❑ Agent ❑ hereby certify that all of the details and Information 1 have submitted for entered) In above application are true and accurate to the best of ty knowledge and that all plumbing work and Installations performed under the permit Is e r this application be in compliance with II pertinent provisions of the Massachusetts State Cas Code and Chapter 142 of the Zgn IreO Type of License: 13y ❑ Plumber Title fL tensed Plu ber or Cas Fltter ❑ Gasfitter City/Town APPROVED (OFFICE USE ONLY) &Matter License Number [)Journeyman a a W. g 01 Y Date ....... d ...... �. 01 <".ORT" 14, TOWN OF NORTH ANDOVER o PERMIT FOR PLUMBING SSAMUS� This certifies that... !...:!' .'.'..'.'�� . " ................. . has permission to perform .... 2?. t .......................... plumbing in the buildings of ...1. .............. at ...�Sj .. �/~� 9.,r, A A.': U.,;.Z ......... , North Andover, Mass. Fee. �.1.....Lic. No. .IR?—!.�). ....... :.: 1,..�.`-'�?`----.... LUMBING INSPECTOR Check # " G5 -3i i (Print or [ViAbbACHUSETTS UNIFORM APPLICATION FOR -PERMIT TO DO PLUMBING e) ass. Date Zg--Permit I K d "?d Building Lpcati New ❑ Renovation ❑ B.P. # SUB-BSMT BASEMENT 1ST, FLOOR 2ND FLOOR 3RDL OF 0 R 4TH FLOOR STH FLOOR 6THOLF OR 7TH FLOOR Installing Company Name 4dd_ress 3usiness Telephone -- =foc= vwne Typecy Replacement/ FIXTURES SEWER # to LO } i- Z o U Uto = z = LU Y ¢ tn. O o U W z to Z -T- W O § LO g W 0in w v=i lame of Licensed Plumber or Gas Fitter ', - ///�-�j-T r .�� eice' Submitted: 0 M_ Plans ■ No ■ .SEPTIC # z z } i- Z o U Uto = z = LU Y ¢ tn. O z OLO LL LO cQll h- 0 z W D t, z w a of WO z a z 0 a LL �LaoLu 0 2 ¢ o i=- ¢ m01 0 :W� Check one: Certificate ❑ Corporation ---------------- ❑ Partnership tr Firm/Co. INSURANCE COVERAGE: 1 have a current liability insurance policy or Its substantial equivalent, which meets the requirements of MGL Ch. 142. Yes s-� No ❑ If you have checked es le �, pleas indicate the type of coverage by checking the appropriate box. A liability insurance policy lrl*, Other type of Indemnity ❑ Bond ❑ OWNER'S INSURNACE 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. Signature of Owner or Owner's Agent Check one: Owner ❑ Agent ❑ ereby certify that all of the details and information I have submitted (or entered) In above-appllcation are true and accurate to the best of knowledge and that all plumbing work and installations performed u r the permit Issued for thiaplication will be in compliance with pertinent provisions of the Massachusetts State Plumbing Code and h to 42 of e G oral Law . By Title Sign re of Licensed Plum er City/Town APPROVED(OFFICEUSEONLY) Type of Licenser fLNtfster OJourneyma:n License Number__ 1c 3 t O s O Aw 6 Location // No. ,- ��.��� Date TOWN OF NORTH ANDOVER 7- •• 7Q p Certificate of Occupancy $ Building/Frame Permit Fee $ Check #23. 3 / Foundation Permit Fee $ Other Permit Fee TOTAL vBuilding Inspector6/ 1.1 Property Address: 1.2 Assessors Map and Parcel Map Number Number: Parcel Number 1.3 Zoning Information: Zonis Distrid Proposed Use 1.4 Property Dimensions: Lot Area Fronts ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard ReqWred Provide RegWred Provided ReqWred Provided 1.7 water Supply M.CLL.C.40. 54) 1.5. Public ❑ Prate ❑ Zone Flood Zone Information: Outside Flood Zone ❑ 1.8 Municipal Sewerage Disposal System: ❑ On Site Disposal System ❑ SEL,TION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT I Historic District: Yes No 2.1 Owner of Record MFS god $�n N' Name (Print) Telephone Address for Service: 2.2 Owner of Record: Name Print Address for Service: SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Pt G HA r t-) \lam PoesON Licensed Construction Supervisor: IYDISaol Ad mgnature Telephone Home Name S --323C 0 3 0z"T.? License Number /?— ;;�l—.-;)aoi Expiration Date Not / X 6 —�� 5 Registration Wumwr Expiration Date T M X 3 z O v rn O z M O an r v rn r- r z a SECTION 4 - WORKERS COMPENSATION (M.G.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 .......0 No ....... ❑ SECTION 5 Description of Proposed Work check all a ucable New Construction ❑ 1 Existing Building ❑ 1 Repair(s) ❑ Alterations(s) ❑ 1 Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: I SECTION 6 - ESTIMATED CONSTRUCTION COSTS 1 Item Estimated Cost (Dollar) to be Completed by permit applicant {iFCIA.0 Q!ILY 1. Building 30r) • c/'T� (a) Building Permit Fee Multiplier 2 Electrical C% Y� (b) Estimated Total Cost of Construction 3 Plumbing Cliy) Building Permit fee (a) X (b) �j 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5) CC) Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name of Owner/ Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TMERS Isr2 No 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHEVINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 1 E w O 0FFmq 0 0 �o O H C _v C.3 A O m C ;Z O m Ea D C O ts V CL H Ec C cm fn• �C_ W ' O O o • �' 3 .m N t0 mo r aC.3 y O O C O ,CC OIL N -30.0f ciz �a o �o Z O COL p F-0 a m � W C .no o am •too dtLcc O C = t� ED m COD CL •� �_� Z gto o 0 � � C_ Fl- = �0.. 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I.;'t: suol�ein9aa 3u�plln8 3o paaoll _ --- il��l � e C<'oWI10NO111t41avrl111 1`. /lrsJiif�Xusef BOARD OF BUILDING REGULATIONS sense: CONSTRUCTION SUPERVISOR lumber: CS 030000 rthdate:07/21/1948 expires: 07/21/2007 Tr. no: 3742.0 Restricted: 00 RICHARD J MADISON 3 MADISON AVE GROVELAND, MA 01834 Commissioner The Commonwealth of Massachusetts c 1 Department of Industrial Accidents Office of Investigations 1 It•.1 600 Washington Street Nll 11 ` Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information 9 Please Print Legibly Name (Business/Organization/Individual): Address: _7 %�%�JS «N (1 City/State/Zip: ICU V4�— L -G d11'0 Phone #: %-? jd Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I e oyees (full and/or part-time).* have hired the sub -contractors 2. L&I am a sole proprietor or partner- listed on the attached sheet. + ship and have no employees These sub -contractors have 3. ❑ working for me in any capacity. [No workers' comp. insurance required.] I am a homeowner doing all work myself. [No workers' comp. insurance required.] t workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Q pt9-[) . Expiration Date: 7 _n/-07 Job Site Address: & •— C rEfvr L,&ov 13 AUC" City/State/Zip: 0/g Y 5 r Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi"nder the paiys and penalties q f perjury that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # -- 4, --aS- Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. . Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia DETAIL°'STARTS HERE FAX PURCHASE ORDERS Date: 10/05/2005 Page: 2 FROM: THE HOME DEPOT FAX: (781) 942-8614 STORE 2614: READING,MA PHONE: (781) 944-6423 Ext. 381 60 WALKERS BROOK DRIVE READING, MA 01867 ________====(Use this number to invoice The Home Depot) P.O. Nbr 14405222=====__ For customer: DAYTON, JAMES=====__ 240-265 KITCHEN POINT (NATIONAL) FROM MEASURE: 020661M0l MEASURE PO#: 14404724 INSTALLATION SITE: DAYTON, JAMES PHONE: (978) 725-4916 Ext. 88-11 FARRWOOD AVE NORTH ANDOVER, MA 01845 TRIP CHARGE: $0.00 CUSTOMER NAME: JAMES DAYTON PHONE: (978) 725-4916 WORK Ext ORDER: 020660 REF #: I01 No merchandise selected. MERCHANDISE WILL ARRIVE AT SITE VIA THE FOLLOWING: KITCHEN POINT (NATIONAL) OPTIONAL LABOR PURCHASED: 01 ...Kitchen cabinets worksheet points for demolition, debris removal, electrical, plumbing, cabinets and appliance (UTILIZE THE KITCHEN POINT WORKSHEET TO OBTAIN TOTAL NUMBER OF POINTS) Quantity: 15.75 UM: EA Price Ea.: $27.00 Extension: $425.25 02 ...Permits Quantity: 450.00 UM: EA Price Ea.: $1.00 Extension: $450.00 CUSTOM WORK: O1 HAUL AWAY CABINETS Quantity: 25.00 UM: EA Price Ea.: $27.00 Extension: $675.00 02 HAUL AWAY CARDBOARD Quantity: 3.00 UM: EA Price Ea.: $27.00 Extension: $81.00 FAX PURCHASE ORDERS Date: 10/05/2005 Page: 3 ________====(Use this number to invoice The Home Depot) P.O. Nbr 14405222=====__ For customer: DAYTON, JAMES=====__ 03 INSTALL 4 NEW OUTLETS AND GFCI Quantity: 35.00 UM: EA Price Ea.: $27.00 Extension: $945.00 04 INSTALL/HOOKUP TEMP SINK, FAUCET Quantity: 15.00 UM: EA Price Ea.: $27.00 Extension: $405.00 05 INSTALL DOUBLE/SINGLE BOWL TOPMOUNT SINK W/FAUCET, DISPOSAL Quantity: 13.00 UM: EA Price Ea.: $27.00 Extension: $351.00 06 SHEETROCK DOWN AFTER NEW PLUMBING UNDER SINK AND NEW GAS STOVE Quantity: 20.00 UM: EA Price Ea.: $27.00 Extension: $540.00 07 INSTALL WALL CABINET Quantity: 28.00 UM: EA Price Ea.: $27.00 Extension: $756.00 08 INSTALL BASE CABINETS Quantity: 14.40 UM: EA Price Ea.: $27.00 Extension: $388.80 FAX PURCHASE ORDERS Date: 10/05/2005 Page: 4 ________====(Use this number to invoice The Home Depot) P.O. Nbr 14405222=====__ For customer: DAYTON, JAMES=====__ 09 BASE OR WALL SINK OR PANEL INSTALLATION Quantity: 3.00 UM: EA Price Ea.: $27.00 Extension: $81.00 10 INSTALL FREE STANDING RANGE Quantity: 3.50 UM: EA Price Ea.: $27.00 Extension: $94.50 11 INSTALL MICRO -HOOD COMBO INTO EXISTING VENT INTO DEDICATED CIRCUIT Quantity: 4.50 UM: EA Price Ea.: $27.00 Extension: $121.50 12 INSTALL REFRIGERATOR Quantity: 2.00 UM: EA Price Ea.: $27.00 Extension: $54.00 13 INSTALL DISHWASHER WITH FITTINGS AND AIR GAP Quantity: 5.00 UM: EA Price Ea.: $27.00 Extension: $135.00 14 REMOVE TILE AND SHEETROCK REPLACE SHEETROCK TAPE AND COMPOUND READY FOR TILE Quantity: 25.00 UM: EA Price Ea.: $27.00 Extension: $675.00 FAX PURCHASE ORDERS Date: 10/05/2005 Page: 5 ________====(Use this number to invoice The Home Depot) P.O. Nbr 14405222=====__ For customer: DAYTON, JAMES=====__ 15 INSTALL TILE BACK SPLASH OWNER SUPPLY TILE AND GROUT Quantity: 30.00 UM: EA Price Ea.: $27.00 Extension: $810.00 16 HIGH RISE CHARGE Quantity: 5.00 UM: EA Price Ea.': $27.00 Extension: $135.00 INSTALLATION LABOR SUB -TOTAL: $7,123.05 INSTALLATION LABOR TOTAL: $7,123.05 00546660 P.O. Nbr 14405222=====__ r -------------------------i V I of N i I I M I I I N� I �I I I r I �I z N I ■ I I 0. I W I z I I I I I M� I I I I I O I _o Ln I C? 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