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HomeMy WebLinkAboutMiscellaneous - 88 HILLSIDE ROAD 4/30/2018 (2)IN O O ao CO 00 0o = 0 O cn o m 0 0 O D 0 0 0 v This certifies that. ' �5 has permission to perform OfAejc.r�) U� rt �� �-wL dj�,,,�„r�,,.. Po ca', wiring in the building of ... ��' �...[.#� S. ................ . . N rth Andover, Mass. cA�1 Fee . �a..... Lic. No ' . �.. M�..... . ELECTRICAL INSPECTOR Check # '10918 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance-with the Provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall-be limited as to the time of ongoing construction activity, and may be.deemed.by. the-Inspector-of _Wires abandoned.and.invalid iflie—_ .. _ or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this puipose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, and extending"through August 15, 2012. le 8 - Permit/Date Closed: �' ***Note: Reapply for new perm' ❑ 0 Permit Extension Act — Permit/Date Closed: Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. l o g /9 Occupancy and Fee Checked [Rev. 1/071 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 4,2 7 A2 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) W W lh j ap- rd Owner or Tenant P Q be r � Ot-- Pe—Sal Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ®' No ❑ (Check Appropriate Box) Purpose of Building k -6 ► G1 n i1 a L IJN f Ill n of Utility Authorization No. Existing Service , Amps / Volts Overhead ©' Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: to lff- .S&'1 M M 111 9 pod I ®UM P, Y� ,cl-es ofnd t, 5�T_ Comnletion ofthe followine table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans s Total of Trsformers KVA Tran No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires ' Swimming Pool Above ❑ In rnd. grnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets 3 No. of Oil Burners FIRE ALARMS I No. of Zones No. of Detection and No. of Switches No. of Gas Burners Initiating Devices No. of Ranges No. of Air Cond. Tons Tot No. of Alerting Devices Heat Pump Number Tons No. of Self -Contained No. of Waste Dis osers p Totals: J.KW Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW P g Local ❑ Municipal F1 Other Connection No. of Dryers Heating Appliances KW Systems:* SecNo. of or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wtres. Estimated Value of Ele trical Work: (When required by municipal policy.) Work to Start: 0710 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE K BOND ❑ OTHER ❑ (Specify:) I certify, under thepains andpenalties of perjury, that the information on this application is true and complete. FIRM NAME: UCC 1' 6 f6f"(- -T-A G LIC. NO.: 26 7 Licensee: eu fry 1-iArt vnS Signature Q LIC. NO.;�1 (If applicable, ent "exem t" in the license numbe line.) Bus. Tel. No.: �%S' (o C i- OUR Address: ` C{ L �%/ t tin */) 6 � Alt. Tel. NoA79- 96'- qL'1 *Per M.G.L c. 147, s. 57-61, security work requiresepartment of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent FPERMITFEE.- $ Signature Telephone No. r •.ti'rJu�til,l..Cid.�%+J.�i��-��-�jt [�Q�iJ�Y%1iRJJ�I,�i�l�®•.� �.1�t �j: ��yfL,�lu�.sr..R�A`l Jt�a.t��®��: r�O�i3'tJ.Cf=eCJ. OJ.Yf '�sset� [ +'a3IeQ-�[ j e-iuspset oxt xegruregs:50.00) [ h8pectore coriune�afs: ® (Icagec#oxeftVatuxe -m knitiais) Date �.ns�ieetaJrS' com�nenfis: (fiispadoxs' Ognatuze -m Wilals) date 3, DMAR GRODND )WRACTION. I'nspectors' comments. (juspectozs' fflgnaiuxe-•idflals) ]ate � assert--[ I tspectaxs' eo�nr�teRfs. hylerl-- (bspactors, ftuatuXe-io;hMals) :-7�ZSpeCtlon�"eC(iiiYe{� (c�; Data rsec��-[ � �`azied�-[ )_ '?te xnspecizottxequu'ed ($50.00} �[ � pectors' cornanents: _ . �lnspeetoxs'szgnatue-noxuitials) Date_ . 31 OR TAGS AM TO BY, FATED PUT AM MFT ON SITE IF TM ARM TO 3E MSTECTED XS.'OT The Commonwealth of Massachusetts • Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA. 02111 UT www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/individual):®(I Lj C Gi Gei *1 Address: P, 0, go X qY City/State/Zip: (/J 11M M i Y) 6P 94h Phone #: c/ 7 8' 37 " Are you an employer? Check the appropriate box: 1. [g I am a employer with 3 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. # ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10:❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.E4 --Other F40 *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. 1 Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company ',ona I -461Sv('U11C Policy # or Self -ins. Lic.#: �, � 2" / O( Expiration Date: AR h .3 ^ lTlS� I< G' Job Site Address: �S If i'4City/State/Zip: V o X 71 A J,0Ver Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). 1b Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine `V up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. day /3 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom . of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The 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:MASSAFB Revised 5-26-05 Fax # 617-727-7749 wwwmass,govfdia AMERICAN CLAIMS SERVICE MULTI -LINE ADJUSTERS BUILDING INSPECTOR/COMMISSIONER, BOARD OF HEALTH AND/OR BOARD OF SELECTMAN Building Inspector Town of North Andover 1600 Osgood Street Building 20, Suite 2035 North Andover, MA 01845 INSURED: Depesa ADDRESS: 88 Hillside Road North Andover POLICY: PHO0100881881 LOSS DATE: 02/1112015 LOSS TYPE; Ice Dam ACS FILE: 31394 PD Claim has been made involving loss, damage or destruction of the above -captioned property, 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 and claim file number. Ned Grady Claims Representative 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. Unless we hear from you within the next 10 days, we will not be obligated to pay any portion of this claim to you. Date 03/12/2015 7 KIMBALL LANE, BUILDING C, LYNNFIELD, MASSACHUSETTS 01940 TELEPHONE (781) 245-9516 / FAX (781) 245-1077 E-MAIL — claims.acs@verizon.net Date���l�^.. 9502 :6 TOWN OF NORTH ANDOVER .'� .. Ooc PERMIT FOR PLUMBING v This certifies that ......... has permission to perform .� .. �Q plumbing in the buildings of .. ................... . at ...!./. ....CU `s... ...C.. 2.......•... , N h An over, Mass. Fee..`//.....Lic. No.). IQ.M� , ....... PL MBING INSPECTOR Check ." �� w "Tip MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK �. iii RMIT # CITY t� I MA DATE#ia; JOBSITE ADDRESS � — / _ S_� P lGG � OWNER S NAME II POWNER y ADDRESS _ I TEL ______IIFAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0! EDUCATIONAL Q RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: 0 PLANS SUBMITTED: YES J NO© FIXTURES 7"FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM I _..-,___,_ i .-.__-, ► .__._.___-.I .._ J _ __[ -._ _-__._ _.__ _____( ___._ _[ ___ . k [ _ .. 1 f DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINKLAVATORY ROOF ROOF DRAIN._l .------ j SHOWER STALL SERVICE / MOP SINK TOILET 9 .__...___{ .-_ .._ ! .-__. i _.._ _ URINAL -J ----i .--_..___[ .___._.._[ WASHING MACHINE CONNECTION WATER HEATER ALL TYPES _I -J __. ! WATER PIPING OTHER_----- _----- -' - - - INSURANCE COVERAGE: B have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES [ NO Ell BF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY Q BOND Ml OWNER'S INSURANCE WAIVER: Jar a 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 D AGENT 10 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be ' i iance with all Pertinent pris' of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME , r•.,� ��y�.,•7-.- (LICENSE # SIGNATURE JP CORPORATION D# j PARTNERSHIP 01 #= C PANY NAME (/�/�-,� �,y �-� !ADDRESS w j CITY v j STATE �, ZIP-�� `� TEL FAX CELL EMAIL W CL to iu w I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 UV. www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/OrganizatiorAndividual):_ Address: "5 1c, City/State/Zip Print or C..- r` Phone #: L7�61— !�;00 02 Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2.1 ZNt am a sole proprietor or partner- listed on the attached sheet. $ ( ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] i employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. El 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. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: -44< /8., e City/State/Zip:_ dv��� ✓f-�a✓ov�' Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby 5gMfyer the pains n penalties of perjury that the information pro videdW bove is true and correct. Signature: Date: Pf,/ C, Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #• Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 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 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION -In C' This certifies that > ../- P --.I ..e, ........ Ho . .......j .............. I P- I has permission for gas installation C! ......... in the buildings of . . . - --0 C' ................................ at....... NorthAndover, Mass. F2. �. Lic. No. 0.0. �( GNSPECTOR Check# 190� )v •` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY r�A Ctvi(�I MA DATE v ERMIT# -- JOBSITE ADDRESS OWNER'S NAME OWNER ADDRESS TElf_ FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL ( EDUCATIONAL Ej RESIDENTIARY+ k'' CLEARLY NEW:.- RENOVATION: -©-J REPLACEMENT: FJ PLANS SUBMITTED: YESO N0[] APPLIANCES Z FLOORS- BSM 1 2 3' 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE �- FRYOLATOR FURNACE -.-.. _. -_:. - -- GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES JXNO[j_I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY © BOND El OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER DI AGENT 0 SIGNATURE OF OWNER OR AGENT 1 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 om with all P inent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME i h,,� LICENSE # /!Q_� SIGNATURE MP MGF( JP Ell JGF nLP-GI CORPORATION PARTNERSHIP 0#= LLC [-3 COMPANY NAME: L CITY FAX CELL �V� EMAI ADDRESS STATE ZIPTEL C W H °z z 0 H U a w . ° } Off' w � W � [°- a ° U w : z a 1_- W w 5 Go aco o a LU LU W N W a o a I -- CL a IL a w = w F-- LL H ° z z ° H U W C7 x c� a ,.i 1 The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation ]Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): Address: City/State/Zip:. Phone #: 6 /- <T!�6(—!gca C5 Are you an employer? Check the appropriate box: L ❑ I am a employer with 4. ❑ I am a general contractor and I mployees (full and/or part-time).* have hired the sub -contractors 2. I am a sole proprietor or partner- listed on the attached sheet. ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roof repairs 13. FJ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they a're 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 Policy # or Self -ins. Lie.#: Expiration Date: Job Site Address:/ //�7id� /�G/ City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Xdo hereby er azeAaIns andpenalties ofperjury that the information provided cove is true and correct. Signature: Date:il Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone r 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 -contractors) 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 Mossaclhusetts ]Department of Industrial Accidents Office ofhavestigations 604 Washington Street Boston, MA. 02111 Tel, # 617-727-4900 at 406 or 1-877, MASSAFB Revised 5-26-05 Fax # 617-727-7749 www-mass,gov1dza Date TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that & -5 y ........... has permission to perform ......... wiring in the building of . . . . . . . at . .. .... X .. ...... ..... .. North Andover, Mass. Fee. 3� .... Lic. No.. H74. EL7Check # 1CAL INSPECTOR 11093 aG • DD// (fommonweahk o f Vamac"etb Official Use Only c� c7 Permit No. /J o Z3 eUePartmerti o�._tire �ervices _ Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL 1NF0RAJATION) Date: % J 2 q l z,D 1 L 1 City or Town of: N 0 V� Ah 4OVe, Y- To the Inspector of Wires: By this application the undersigned gives notice of hir her intention to perform the electrical work described below. Location (Street & Number) I ( v r!^ Owner or Tenant A leG(Oj Telephone No 111 q ZD$ - 520Z- Owner's Address q 9 a! 15fer Vd, NOYth A VJOV>✓�— , MA D Q S .Jl Is this permit in conjunction with a building permit? Purpose of Building Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Yes ❑ No ® (Check Appropriate Box) Utility Authorization No. Overhead ❑ Overhead ❑ Undgrd ❑ Undgrd ❑ No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: 1f5T0J jJ&g770h Of 411 Iph(- V01 JVJ!rZ , yV rel e5S 6wtn Icy r 01 bot tln 5H6te-rn. 4 Completion of the fol/owing table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans r o Tota Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above ❑ In- El. Swimming Pool rnd. rnd. o Emergency Lighting Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. of Detection an Initiating Devices No. of Ranges Total No. of Air Cond. Tons No. of Alerting Devices No. of Waste Disposers eat um • Totals ......um.. er „ons o. o Self -Contained Detection/AlertingDevices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal atio ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems: No. of Devices or Equivalent No. o aterKW Heaters o. of o. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP a ecommumcations %Viring: No. of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 0 BOND ❑ OTHER ❑ (Specify:) I certify, under an thepairis and penalties of perjury, that the information on this a fi on is true and complete _ FIRM NAME: V 't" iri ''. LIC. NO.: 14-71 G Licensee: .�,��C��1if,'p GoPP0 jg Signature LIC. NO.: )41 [ G (1f applicable, enter "exenpi t� " in N e license nu nber line.) BUS. Tel. No. 4"1"I � Address: 4`31 fV • P1'13VD, IST g 4 (P 6 q" Alt. Tel. NoIROJ 2310232 *Per M.G.L. c. 147, s. 57-61, securi y work requires Department of Public Safety "S" License: Lic. No. SSGO 00 1351 OWNER'S INSURANCE WA R: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my sig below, l hereby waive this requirement. l am the (check one) ❑ owner ❑ owner's agent.. ©gn Signature nt. PERMIT FEE: S `I l7 0(? Signature � � Telephone No. Client#: 15008 AC.ORU. CERTIFICATE OF LIABILITY INSURANCED TE(MMDDrr ) 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: If the certificate holder is an ADDITIONAL INSURED, the policy(les) 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 endorsement(s). PRODUCER MJ Insurance, Inc. 2730 E. Camelback Road, Suite 250 Phoenix, AZ 85016 CONTACT NAME: Kimberly Shedd PHONE 602-772-3304 F4C 602-772-3349 AIC No Ext): AIC, No ADDRESS: kimberly_shedd@mjinsurance.com GENERAL LIABILITY 602 772-3300 CUSTOMER ID #: PHPK787771 11/01/2011 INSURER(S) AFFORDING COVERAGE NAIC # INSURED APX Group, Inc.; APX Alarm Security Solutions, Inc.; ARM Security, Inc. Vivint, Inc.; 4931 N 300 W INSURER A: Philadelphia Insurance Company 23850 INSURER 6: Travelers Property Casualty Co. 25674 INSURER C: Provo, UT 84604-5614 INSURER D: DAMAGE TO RENTE PREMISES (Ea occcur enc $100,000 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER! 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 REQUIREMENT, 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. INSRDDL LTR TYPE OF INSURANCE NSR UBR POLICY NUMBER POLICY EFF MWDDr%W POLICY EXP MMIDD LIMITS A GENERAL LIABILITY PHPK787771 11/01/2011 11/01/2012 EACH OCCURRENCE $1,000000 V X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE F1 OCCUR DAMAGE TO RENTE PREMISES (Ea occcur enc $100,000 MED EXP (Any one person) $EXCLUDED PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $2,000,000 POLICY JECTPRO-LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ SCHEDULED AUTOS HIRED AUTOS PROPERTY DAMAGE $ (Per accident) NON -OWNED AUTOS $ A UMBRELLA LIAB OCCUR PHUB362903 11/01/2011 11/01/201 EACH OCCURRENCE $10000000 EXCESS LIAB CLAIMS -MADE AGGREGATE $10,000,0 0 DEDUCTIBLE $ X RETENTION $ 10,000 $ B WORKERS COMPENSATIONWTRJU6277M717511 AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVEE.L. OFFICER/MEMBER EXCLUDED' [N NIA 11/01/2011 11/01/201 WCSTATU- X OTH- ER EACH ACCIDENT $1,000,000 E.L. DISEASE - EA EMPLOYEE $1,000,000 (Mandatory in NH) If yes, describe under E.L. DISEASE - POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Named Insured Cont. Vivint Servicing, LLC and Vivint Funding, LLC. Town of North Andover 1600 Osgood Street, Suite 2-36 North Andover, MA 01845 ACORD 25 (2009/09) 1 Of 1 #S346883/M338315 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 m 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CLASS19078 Q� �epartment • uific Safety One Ashburton Place, Rm 1301 Boston,02108-1618 License: S -License Number: SS CO 001351 Vivant NC - STEPHEN BCOPPOLA 4931 N 300 W PROVO, UT 84604 Expires: 07/22/2013 DPS -CAI 0 40h1-09/10-PC-DBSLICENSESPAPERFYII Jlze -r°o.,vm�ueu(11 � /%/fcze�,�zuaelt _ DEPARTMENT OF PUBLIC SAFETY S - License Number: SS CO 001351 Expires: 07/22/2013 Tr. no: 396.0 S -License: VIVINT INC STEPHEN B COPPOLA 4931 N 300 W PROVO, UT 84604 Commissloner Restricted To: 00 Tr. no: 396.0 Keep top for receipt and change of address notification. DIG SAFE CALL CENTER: (888) 344-7233 COK8K0ONVVEALTHOFKA4SSACHUSETT5 BO4RD CONTRACTOR FA *"E"'~'^''-- - oousure�^ouvcucF�vsano� 7YPE JkPX ALARM SECURITY SOLUTIU� itL STEPHEN D COPpOLA -� 31 0ENJAI-1.I14 ST � GROVELuND MA 0I8I4-l0i,^ , Vi7l C O7/31/13 u3l5/� ! |'KB /mm -IVA' ` - COMMONWEALTH {)FK8ASSACHUSE?7� ' BOARD --------�c�cin� FA AREGISTERED SYSTEM TECHNICIAN ISSUES IxsABOVE LICENSE TO: TYPE STEPHEN B [0PP0LA � -D 31 BEMJAMIN ST � CROVELAND MA 01034'I0 4 831567 22l9 u 07/31/l3 /�� ��� 9338 Dateg.'q:.%" . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that �.G �.h. � e�... ..............� has permission to perform. plumbing in the buildings ofY►.'1..".......... ° at. &1- ..A. l ( . '5.-1.......... , North Andover, Mass. Fee g2 -.S -.V. Lic. No... ....... PLUMBING INSPECTOR Check #a/v lZ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIt TO PERFORM PLUMBING WORK �`• � r TYPE-Ok PRINT CLEARLY 'CITY i !,VORm >2 MA DATE 1 /.2. 1 PERMIT #i` j $ g %'�t ►TS•'�G rC�c�. �—i 'PLS JOBSITEADDRESS I I OWNERSNAMEj �4(m OWNERADDRE$S TEL IFAXI . OCCUPANCY TYPE COMMERCIAL EDUCATIONAL i RESIDENTIAL Jkr NEW: RENOVATIQN:I r'! REPLACEMENT; f ( PLANS SUBMITTED: 'SES 1 I NQ( I FIXTURES 1 FLOOR- 6SM 1 2 3 4 5 6 7 a 9. 10' 11 12 13 14 I: I_ pEVICE { DEDICKI-Eb SPECIALINASTE'SY$TEbl • --. DEDICATED GASlOIUSAND SYSTEM ' • --• I - • - � - - �..........I DEDICATED GREASE SYSTEM , I ....: ........: ....._ ;.... .. �._ __.I ..._.._I --_ DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOORIAREADRAIN INTERCEPTOR (INTERIOR) ..yl - ( { KITCHEN SINK . • • •- � ! ...._.I . ... I _. i .... ' LAVATORY ROOF DRAIN 6HOWER STALL ... SERMOEIMOP SINK TOILET URINAL t WASHING MACI-IINE CONNECTION — — WATER. HEATER ALL TYPES. % WATERPIPING .OTHER 1 INSURANCE COVERAGE: 1 have a ctirrent iabilit hsiirs[ice poliliy.or its sulistaoflal pquiValent which meets the regi[irenients of MGL Ch. 142. YES )Af NO j IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVFRAGE BY CHECKING THE APPROPRIATEBOX BELOW LIABILITY INSURANCE POLICY ( OTHER TYPE OF INDEMNITY (j BOND [• (� OWNER'S INSURANCE WAIVER: I ant aware that the licensee aloes not have ihe'insurance coverage required by Cliapt6142 of the Massachusetts General •Laws, and that my signature on this permit epplicatipny+aives this regtliretiten't. 30 _ eHECK-ONEONLY:. OWNER AG . - SIGNATURE OFOWNEIRDR AGENT I hereby certify lhal 811 of the details and irifonnalion 1 have8ubditted of dnlered recgarding'this applicaliori ate true and accutale to the best of my knowlddye and that all plumbing work and lnslallalions peifonned under [fie permit issued for this application twill be in em liance e'11 If Pe pr visio of the Massachusells Stale -Plumbing Code and Chaptgr 1412 of the General Laws. PLUMBER'S NAME[ I l t c �av�c� 4C t/' LICENSE it >' 24 1 Z1 SIGNATURE — MP(W' ,1P1 COj2PORATION1 1111 1PARTNERSHIP1 fill' ILLCI 1##1 % � 47 7 COMPANY NAME { I ADDRESS I 1 CITY1 0,1111r-V;CGc' JSTATEImA Izipl. oiq� ( TEL FAX I ] CELL EMAIL I (IV -4 0 ;4 no on 0 -- - I - I - I .- - I - - I- I-- .. LL) LU tst 0 LU -- - I - I - I .- - I - - I- I-- .. fXtltTitsr o.-W41es 61fl- 11,011., Wr S -n w ieelfc,kli OnEdrds LI -11.1c It 1,nsttraucc.eantifan},�Tlivir��; .. Ig , 0110iito.--t 2 Old Aff"att " It Milk PrOolro"thdrs" Wt WRY Cte0111:01,O)f pige (sytol'Nig dfo;jiQM-,y I ((1I1It)pr.btqd. requ I o. fum lip tos:060.doalld� [IIII I DS LOS. I I d )Ixlorllsl trio vroblor. 110 Ildvi-scif Oli�t �Copy bFiluk, slatem alit to ffice of Wes coyet-o'go Vey., ficttf xi—f—me'- D.1_/ C) "P / / 07014(wi,be. po um rorb!" ltk fills aree, to fh, CoOlt" f 6111 it Pplefol OhIrdefor-aliel I 114vo-firred 11mS16--colif-iaclol-a EM4 P tuld:11ollo CIIII)TOyco Baro w4e IR' ODIllp- fit s it ral ft, boo XV9 0.9 reep 111pol I i I I Mil a 0- 00110wPol,116111111URT �Dftl 110 ieelfc,kli OnEdrds LI -11.1c It 1,nsttraucc.eantifan},�Tlivir��; .. Ig , 0110iito.--t 2 Old Aff"att " It Milk PrOolro"thdrs" Wt WRY Cte0111:01,O)f pige (sytol'Nig dfo;jiQM-,y I ((1I1It)pr.btqd. requ I o. fum lip tos:060.doalld� [IIII I DS LOS. I I d )Ixlorllsl trio vroblor. 110 Ildvi-scif Oli�t �Copy bFiluk, slatem alit to ffice of Wes coyet-o'go Vey., ficttf xi—f—me'- D.1_/ C) "P / / 07014(wi,be. po um rorb!" ltk fills aree, to fh, CoOlt" 11"brma" Wad ludy'afto 130ce oteilotiic'r etu orhApMedijind ok umttcji.A� pst t'ejlellfkbtsq. 1.1c6JI56 pe-rillif to -off e.j.-:ito -,I bj"sJjlcss-or- f& tojjsrJ!ij ef tee hist Ad'di6ofta.11j, MOE; tjjpjor-j e� idillop Myerhge requlrea?� .5% §25 CM 8 If ates "'JN 0 1 t I I Or t he! C 01110 1011 w Ual t i i i or a iiy- 0 f ifs p W It t6af's' ub'd FVT's 10 n � 6, if! filto ally. colitiact tor forn)(IfIto o f it ( It -11 gcccPln�To eviddi lcf,- orF o mpj ra n cv 1,11 ff, tifc, m''su ri�i`n'c.'e 60il prgr;qfitecfto fliocciiih6tEnj aqj lori Pie a s D Q11 .110" W v -0j) (tim ANA O�Ipkfdlv I MWW. jib w9_61M* 'JI I i CT-Plal to I I I I IIAP qtt) al 0119 xv! th I h ir ce it Mi o at (s) (if in -V A. 11milm, jV11,11 110 clilployq 0 1 oi7LLP does linvo lit Acddonfsfbr colirtmintidl, of j, le of .1silt-alice,covefage. AYsb ba sit ve. to s1gli qlld (late flib p rf t(jaylt .Tho Fifticlavifshoul_ci bare-Itivileffro the Ulf license Isba, � reque'sted, not Ill-'Departmicult of .in a, "IIw*p'ucsli'Qjjs rp-gal-Aig,1110-1,11v 6r:•ifyku are requived to -obfiq.hia utorkers' lfsco -e6Ies*jkpkitdqiterdielr City or ToAll OhiclaTs te(T 10.01bi 'Y. f0t fLfd ll: mr.h"k�fffldavif yo ly bIfUfhQ4vdIItthoomcW )Please -bei stird to fill io -j1puban f�fidcfjj�Loll, all, lie, is qj)p allt pbliqy In formation (ifne-ce's5ky)paid widet "To'b irc:Address7l the jjppljcajjt*.Shojff(j wrl(e Italf loc-flfioll.s ibilier dal Vdjltuke- all .4 noti (i:E a ciag,license or.'perntitia burn Laves eta) sant persottis NQ�'rzquiracl to cpl,iplereftus aEJ"idtt�df, qV Vic pip dono.t WS11afe to-givixis it crgll' i01 Boston, Aman Tdj. 01617-727-4POD eXtq Aig Vt 6i 1,121'-774 9 V111VAhass.koddfa x r (100 (-0-- Date...-...l.Z. �. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...........'....................................... . /� ... has permission to perform .... �!��...l.�........A ...... ��- k s wiring in the building of ......... ... ..... : ............. .................... ................................ at ..... .91- 4�.`a..Co� ...... D ...................... . North Andover, S. Fee. ............ Lic. No...: 74 .................��.:. ,. ..... EL f ICALINSPECTO`� / Check # 1070.6 `s Commonwealth of Massachusettts offioiat use only Department of Fire Services INA) INA) _ BOARD OF FIRE PREVENTION REGULATIONS[Rel/07) ccyandFeeChecked (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT.IN INK OR TYPE ALL INFORMATION) Date: 3 — !�— I Z City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 2" F 4 t `I sl'a-c Owner or Tenant 12 V dlv e n.} 6ke/k 1-16C— Telephone No. Owner's Address i" �1 YAto^ o U•h°.1 -) v— , 71, - ` _ 7F I Is this permit in conjunction with a building permit? Yes '9 No ❑ (Check Appropriate Box) Purpose ofBuilding sic � ( 64'6 t l t \ I Utility Authorization No. Existing Service��,y Amps (26/ &t , olts Overhead Undgrd❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Lcation and Nature of Proposed Electrical Work: Q© eutw No. of Recessed Luminaires No. of Luminaire Outlets No. of Luminaires No. of Receptacle Outlets No. of Switches No. of Ranges No. of Waste Disposers No. of Dishwashers No. of Dryers No. of Water KW s Heaters No. Hydromassage Bathtubs OTHER: No. of Cell: Susp. (Paddle) Fans No. of Hot Tubs Swimming Pool Inde ❑ gr; No. of Oil Burners No. of Gas Burners No. of Air Cond. Total Space/Area Heating KW Heating Appliances ],y No, of No. of Signs Ballasts No. of Motors Total HP ollowing table may be waived Generators KVA Au. o Emergency Lighting ❑ Batter Units FIRE ALARMS N:oo:fZ:o nes No. of Detection and Initiating Devices No. of Alerting Devices No. of Self -Contained Detection/Alertin Devices Local❑Municipal Connection ❑Other Security—systems.—W—_ No. of Devices or Equivalent Data Wiring: .4ttach additional detail if desired or as required by the Inspector of wires. Estimated Value of Electrical Work: ®t,v 6u (When required by municipal policy.) Work to Start: 3 -' —) Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE; Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof'of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that"such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE J�J, BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penaltie ofperjllry, that the information on this application is true and corpleic FIRM NAME: 5 C� ., LIC. NO.: Licensee; 5;t- �,,, Signature LIC. NO.: (Ifapplicable, ente�r,`� empt" in the license nitmb ling•) Address: �: 1,'c- . �j Bus. Tel. No.: 9 @7 S % i J Alt. Tel. No.: *.pe M.G.L c. 147, s. 57-61, security work requires D rtment of Public Safety "S" License: Lie. No. OWNER'S INSURANCE WAIVER: I an aware tha 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/Agent El owner's agent. Signature Telephone No. - 'PERMIT FEE: $ _ NGECWC.AL PERMIT EEECMCAL INSPECTOR -_ . �'�ssec�---• � � S+'ailed--[ 7 �e-fnspectiort xequ�.recs($50.00) ~ [ ] �Tnspectozs' commeJafs: ' glinectore signature -• xco sni-iials) pate 72asse$ Failed--[ ]e xuseetzo� xec�uixeci ($50.00) - [ j Tnspectars' c ettfs: (Xnspectors' ,hzgnafare •-.ao initials) Jute 3. U MUR GROUM 731 R CTZON' - Passed •— [ 1 S+azIecl-- [ ?ze-inspection. required ($50.00) [ inspectors' coxnxaents: C=pectoxsSignature•-n.o infiials) Date 4. DI'SPFCWON--SWVICE: - �r.�,?uC`�sr1�T�'inl�3 ��+0 Aw;fa ii ; NA1lr1Ii:. I'assecl—[ Z Failed—[ � hie-inspectionxe �'nspectoxs' eoxnn�.e�tis: (Cuspectoxs' Signature •• Sao initials) r 5. WS'ECTkON -• OAR:' Date �'assed--[ � p+'ailed-,[ )- "�texnspectioxtxeciuired($50.00)•-[ � � - -- - Cnspectoxs' corhments: (L�speetoxs' i9zgnaEuxe uo initials) plate - - -- DOOR TAGS :ARE TO BE MIND OUT AND BEFT OST SATE IF TM AREA. TO BEINSPECTED IS NOT .ACCESSIBLE ANDA. RE WSPECTZON OI` X50.00 INTO BY, CHARGED. - The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations 600 Washington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): Address: City/State/Zip; U ,L7 ", YAc k_ 0 Lei §?_hisrie #: 017 S `4? 9 5-0 O Are you an employer? Check the appropriate box: 1. ® I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. I ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ 1 am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.R[Electrical repairs or additions 11. El 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. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lie. 6-14 Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as 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 thPIA for insurance coverage verification. I do hereby cert0Jn er the rr_1ns anrfpenalties of perjury that the information provided above is true and correct. Phone #: 7 1? q ? 1� 15--000 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # 1 2-1 1 L 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 #' S 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 n 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 repres¢ntatives 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 -contractors) 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 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 re arding 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 affidavii'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, # 617-72.7-4900 oxt. 406 or 1-877:MASSAF& Revised 5-26-05 Fax # 617-727-7749 i wwwanass,govfdia 6089 A6 - Date.................................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....... ........ .. ...... ........... ............................ has permission to perform,.... ................... ........................ njring in the building of. .......................................................... at ........................................... ........ ... . ............... ,North Andover, Mass. Fee ... ............ Lic. No. ............. ......................... ......... ....44 ..... ----------- ...... .... .... ELECTRICAL INSPECTOR Check # 34, DERUMWENTOMBEWSWRY permit No. !f WARDOFFMPMFNIXa MGVAA77Od 527 6912 op. & Fees Checked a; i 5" APPLICATTONFOR PERMITTO PERF _ ELECTRICAL WORK All. WORK TO BE PERFORMED Ri ACCORDANCE WITH THE MASSACHU ELECTRICAL CODE, 527 CMA 12:00 (PLEASE PRINT 1N INK OR TYPE ALL 0MRMATION) Date 1� 2 21 Town of North Andover" The undersigned applies for a permit to perform the electrical work describe! below. Location (Street d Owner or Tenant Owner's Address To the Inspector of Wires: Is this permit in conjunction with a building permit Yes [n No (Check Appropriate Box) Purpose of Building A 6z Utility Authorization No. Existing Service Amps /.Volts Overhead © Underground a No. of Meters New Service Amps..L.V olts Overhead En Underground C No. of Meters Number of Feeders and Ampacity *L, 1' 74X '4 i c 6-�-- g '1�11 Location and Nature of Proposed Electrical Work Na of Lighting Outlets No. of Hot Tubs No. of Tanabnnrs Told KVA Na of Lighting FlItures Swimming pool- Above World Below, at"Ind amerat rs KVA No. of Receptacle Outlets No. Of on Butner No. of Emergency Lighting Battery Units Na of switch Outlet No. of Om Bumers FIRE ALARMS No. of Zones No. of Ranges Na of Air Cond. Told Tan No. of Ddwdm and. No. of Dispaede Na of Hest Total Total Pony@ Toes KW No. � �� Devices No. of Dishwashers ta Space AHaving KW Na of Self Centsbwd Detectirn�Sowtding Device Local Muddpd Otter No. of Dryer Heating Dorioee KW Connection E3 No. of Water Heuer KW Na of Na of S Baihuds !%. Hydra Massage Tubs No. of Motors Total HP hasartaeQNWF PMWlDlheJq=1rabafINaesdsraet�Ge®1Ladw lhateact=ttLit *hiuii ceihk,Yindudr;Uo 0! r cribsuYES NO Ih%wsu6rri1ladveidpt0af(fS=lDth0ffian YM 1r)rohm Phichtftle4pecif aympby d ET MI AN M BOND OM Spa BOEtDAe EWM*dVaileefEkcticalWhk $ } WakIDSM DiaRm Rc* Rim SigledundkrFbvMmofp4W.. VONNAME S 1^/��e�� r UD=Na Lic� D v I -C span 4 IlorsleeNo Bu*=TdNn /- c at�ea 0W?I It'SMRANCEWAIVF 1= we d9dleLcaited",gg1l�agtkine ALTdNa arddretrrp�sgcetaemais�ritappi�i cmwai�esil:tequi�t`or�a�"°°ie�`�s�004"1Dd�MaceletalL�va (Please check one) Owner Agent Telephone No. aiisnawm of Owner Of Agm' FEE SE`S Date.. �� /..G.:.�"i..`...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ... e.. trsas permission to perform .....�r� .e ....................... Vring in the building of ....... ............................... Qi at ................... ` �, North Andover, Mass. Fee./,�y...... Lic. No7-....a!,r��..'' ... �/�?w....... CLECTRICAL INSPBCOR 1. Check !I ��.�__ t/ d��•//{"� 5774 1liL' ll'u1 viulY rlr.ALJn yr tr�.�rta�,ntv.wi 1 u DEPAW NW OFPUNKSAFE TY BOARD OF FIRE PREVE MON RDGUL47TONS 527 ag APPLICATIONFOR PERMITTO PERFO. ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MAWACHUSSTS (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Town of North Andover The undersigned applies for a permit to perform the electrical, work describ6d below. Location (Street & Number) Owner or Tenant C/ 7 le Uv Owner's Address ^--A / mow% S7. Is this permit in conjunction with a building permit: Purpose of Building c Existing Service •� AmpsVolts New Service Amps olts Number of Feeders and Ampacity Yeas/ No LPermitNo.ncy &Fees Checked S ` -TICAL WORK 527 cMR 12:00 Date To the Inspector of Wires: (Check Appropriate Box) Overhead Underground Overhead Underground Location and Nature of Proposed Electrical Work iry 6 w 4 — i le,V-6 _ Utility Authorization No. No. of Meters C3No. of Meters No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA ground around No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting BhtinB 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 Total Total Pumps . Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers 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 OTHER• ks==CoveiagePutsuentbdieregimerrta>�afMa Gai�alLaws T.heaa.natLd- tYlr==FbLyitdii vCW1*le absul�rrialegtivalai Yf NO Ihar 9kniWdva5dpa0afafS=lDthe0ff= YI?S ryouhwch%iWYFi'S,pkaseirtdraled etypeofaorervrby BCND O'II11~R y) Pxpirr�lDtale Estin*dVakreofE bcftEd Wak $ WadcbStait h>SpeMmDAeRgxskd Roi>gtr Final SignedPei b%cfpajuy►. FIRMNAM6 << /�" v ! /�� `� /✓ / LitmreeNa _ �%� CZE .. _ 1 Tr1No. OWMUS MJRAN(EWA1VVfR-IxmmndrtdzLwwdoasuo�Im� stdthatmystgtvMcndispmTitappkabmwawadiisregtim= (Please check one) Owner M Agent a Signature Owner pl7" AIL TdNo. ��1ec�n�alentasrac}iredbyMG�iaaLanvs Telephone No, PERMIT FEE $ �"- /)zot� /� oc, �- © 4�-- 6- 2 -2 o �—) p4z 6�6-65-- . P✓� . »y'--.:�+�'..`►-.�f"��.-r--�..i�/.-r/•R�"---``*'"/.��7'lr:a�-.-�3e'TFif'_.`::n�,,,.��+?ti-.�-s^�^'Y``.. .. Location No. Date „°RTM TOWN OF NORTH ANDOVER I •,h�o� 0?o�t•`1O F „ Certificate of Occupancy $ • .°, ,,* Building/Frame Permit Fee $ --'" 67;----Fb-Lfhdation Permit Fe $ Other Permit ee $ n Sewer Connection Fee $ ` Connection Fee $ QUO 9 ��Wgqaaqt��er �9°O'iAL $ 1 00 6256 ` �Building'lns ector Div. Public Works iv,pB,6%iliT NO. o APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. V/ PAGE 1 MAP 4-40. LOT NO. I 2 RECORD OF OWNERSHIP IDATE BOOK ;PAGE ZONE SUB DIV. LOT NO. �I i LOCATION /CCLC�CCC77�� PURPOSE OF BUILDING 14 v V Gi OWNER'S NAME NO. OF STORIES f/S17F OWNER'S ADDRESS �j�p _ BASEMENT OR SLAB ARCHITECT'S NAME BUILDER'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES - SIDES REAR " GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES EST. BLDG. COST PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT. ( PAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER ROOM f SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED��� BOARD OF HEALTH ATURE OFOW OR A ORIZED AGENT FEE c) C) OWNER TEL. # PLANNING BOARD PERMIT GRANTED CONTR. TEL. iq 19 CONTR. LIC. # BOARD OF SELECTMEN 0/7 BUILDING INSPECTOR j 4 BUILDING RECORD 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 . I RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. f h 0 CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH 3 1 2 13 PINE HARDW D— PLASTER CONCRETE CONCRETE BL'K. BRICK OR STONE PIERS _ DRY WALL UNFIN. 3 BASEMENT AREA FULL FIN. B'M'TAREA _ '/. '/r l/. FIN. ATTIC AREA N_O B M HEAD ROOM FIRE PLACES MODERN KITCHEN _ _ 4 WALLS I 9 FLOORS CLAPBOARDS B _ 1 2 �_ 3 _ _ _ DROP SIDING WOOD SHINGLES ASPHALT SIDING ASBESTOS SIDING CONCRETE EARTH HARMU D COMMCN VERT. SIDING _ ASPH. TILE STUCCO ON MASONRY STUCCO ON FRAME lll� BRICK ON MASONRY BRICK ON FRAME ATTIC STRS. 8 FLOOR _ ' CONC. OR CINDER BLK. WIRING STONE ON MASONRY _ STONE ON FRAME SUPERIOR I� POOR _ ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE GAMBRELMANSARD I I HIP BATH (3 FIX.) TOILET RM. 12 FIX.) FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY _ _ WOOD SHINGES KITCHEN SINK SLATE _ NO. PLUMBING _ TAR 8 GRAVEL STALL SHOWER ROLL ROOFING MODERN FIXTURES _ _ TILE FLOOR TILE DADO 6 FRAMING 11 HEATING WOOD JOIST 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 7 NO. OF ROOMS GAS OI l ELECTRIC B'M'T 2nd _ 10 13rd NO HEATING f h 0 Cil 0 z x a O c v O w e , v cn O z A 10- w O w U C w pp v w pu a4 w w c� yG cn w" p U w :7 � O w G ii w x aw co zvo cn ' 40`vAm Op cn 1 o as c c � ' o � C N C2 c a� Q• c ev a� c ,� ev o N � o a C r•+ N `. C m v`mc E CL= L N CV 0 L O N y N m 3 cm ® N m t _ '0 N N C C A o . - y +' mCD 0 W Q C.c. m N m O = O 01 ��coG acr m m O� V H Z O c Cs c a Q G i m =3: •O = m m 0 N m cc m t W CO 'O ��C_...U. •� •N aZ A C Z .,, m •- oc •E CO .2 N o ui C3 CD CL g Im ca m '� o = W cc �iy•� O F— = * a ZZ m CD O CD O Z O O CO) y .co L - CL O s C O Co v _m CL CO) O O 0 .Q CO2 C O C.3 O i O V CL COD C C3 CM C 0.— =:m CC:m m m Location , f �t. No.Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check #� f *17818 Building inspe6,tor TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER:Jd DATE ISSUED: / r d -a SIGNATURE: Building Co—i-,ioneWnEeEtor of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number M /1 N jj n y6, ' / 1.3 Zoning Informations Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide R red Provided Required Provided 1.5. Flood Zone Information: . 1.7Water lyM.G.L.C.4054) Public Private ❑ Zone Outside Flood Zone 1.8 Sew a Disposal System: Municipal On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSIUVAUTHORIZED AGENT Historic istrict: Yes No 2. O er of Resor / ✓� / On ;A)36 o���o��� Nat}1 Print) Address for Service : "Signature Telephone �y ' 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: ress Signature Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Si nature Telephone V M z M go 0 r M r r a zA Q W 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 .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building Repair(s) ❑ Alterations(s) Addition 0 _, r-%- i 1 $ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: P("'q) o .� G J'4)1 ,- /l L I SECTION 6 - RSTTMATFn r0NCTR1rrTTn1V rncTQ 1 Item Estimated Cost (Dollar) to be OCIAI TJSE Oily Completed by permit applicant i z 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number �,iivi� ,4 1V 112.' q_UMrEhJ[ D W1M1N OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on, My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION Date 1, 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 M aik Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TEVMERS 1ST 2 ND 3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING x MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE t+ 0 z s? x a w a a a a a o LE V)w° •r d v U w a a°4 w a w .� oG pG w" C7 w a w w' o z v cn c 0 O � C ti � C V V •dam d C A ea Cl :Z C O O • y m Ea o jao o o SL GO E� m v$ 3 c O� m � C 0CM �3 y C_ � _Cm i � r CO, NJ O y CLC -3 mos o > 1 = O �O C c a T a 0 'y O v Z m0 c R 0 O N nc til aEo � o •• 0" D $ m CO) O yw�Z c +r CL I E f3� OSI C O '� .0 z no m E MoZ y y C O ro 7 CO Co m 0 CD C �C N • 0 Z 0 cm 5 FE - I I O E L O Z Ci CL OCD y Q � I ccm O•— CD Q� O M O •i m m CD CD a ♦.. .0 O � O �CD O Q O O a aCo v�Q o *-� c to CL 0 CDcoV c Z CD C. y � C • c cc M. _y Q 0 LLI y LLI 99 W W ca Ic D. Robert Nicetta, Building Commissioner 978-688-9545 978-688-9542 Fax NORTH of •d ^ y'4 � s s i TOWN OF NORTH ANDOVER ;s D �t�# s,C BUILDING DEPARTMENT 400 OSGOOD STREET NORTH ANDOVER MA 01845 HOMEOWNER LICENSE EXEMPTION Please print DATE I r X u JOB LOCATION 0 /�i 4j, c� e Number Street Name PRESENT MAILING ADDRESS 4 ��� 1 S C c► 11 Map/Lot -yaj<— Ty-�? 7a/ Y7�-off Phone Work Phone N�rjf�c� z�ei MP- DiZyl City/Town State Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings of two 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 108.3.5.1.) 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, one or two family dwelling, attached or detached structures attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. 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 comply with said procedures and requirements. 4"", 1 HOMEWOWNER'S SIGNA APROVAL OF BUILDING OFFICIAL Cr North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: SC/0 /M AS (Location of Facility) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector a Town of North Andover Building Department. The following is a list of the required forms to be filled out for the appropriate permit to be obtained. FOR ROOFING, SIDING, INTERIOR REHABILITATION PERMITS 1) BUILDING PERMIT APPLICATION 2) DEBRI REMOVAL FORM 3) WORKERS COMP AFFIDAVIT 4) PHOTO COPY OF H.I.C. AND/OR C.S.L. LICENSES 5) COPY OF CONTRACT 6) FLOOR PLAN OF PROPOSED INTERIOR WORK FOR ADDITIONS / DECKS 1) BUILDING PERMIT APPLICATION 2) FORM U 3) MORTGAGE PLOT PLAN (MINIMUM) 4) DEBRI REMOVAL FORM 5) WORKERS COMP AFFIDAVIT 6) PHOTO COPY OF H.I.C. AND C.S.L. LICENSES 7) COPY OF CONTRACT 8) FLOOR/CROSSSECTION/ELEVATION PLAN OF PROPOSED WORK WITH SPRINKLER PLAN AND HYDRAULIC CALCULATIONS (if applicable) 9) MASCHECK ENERGY COMPLIANCE REPORT (if applicable) FOR NEW CONSTRUCTION (SINGLE AND TWO FAMILY) 1) BUILDING PERMIT APPLICATION_ 2) FORM U 3), GROWTH MANAGEMENT BYLAW 4) CERTIFIED PROPOSED PLOT PLAN 5) PHOTO COPY,OF H.I.C. AND C.S.L. LICENSES 6) WORKERS COMP AFFIDAVIT 7) TWO SETS OF BUILDING PLANS (one to INCLUDE SPRINKLER PLAN AND CALCULATIONS (if applicable) 8) COPY OF CONTRACT (if applicable) 9) MASCHECK ENERGY COMPLIANCE REPORT be returned) TO HYDRAULIC In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the board of appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One'copy and proof of recording must be submitted with application. f Location -' / rx- � No: ` 4 Date 7 '� Check # 1$151 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $� —Building I spt?`ctor 1 - TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING See#i"00640 1iB BUILDING PERMIT NUMBER:' 6 q DATE ISSUED: 41—c-�-As SIGNATURE: Building Commissioner/Inspector of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: S(7, , &- are— 0 6 -- Map Number Parcel Number 1.3 zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area Fronts ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Pmvided Re red Provided 1 1.7 Water Supply M.G.L.C.40. 34) 1.3. Flood Zone Information: Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Sita Disposal System ❑ Public ❑ Private ❑ SECTION 2 - PROPERTY OWNERSHW/AUTHORIZED AGENT N,17i.�7,; �icti t: �! �.17 2.1 Owner of Record /yo,�� sore (Pri t) Address for Service w -/()) 'sib Signature Telephone t 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ t Licensed Construction Supervisor: License Number ss gignatuire Expiration Date Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone P SECTION 4 - WORKERS COMPENSATION t'M_G_i_ r 152 .a 7c, rai Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit wilN result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......0 No ....... 0 SECTION 5 Description of Proposed Work check ao a cable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify n rt Brief Description of Proposed Work: SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed bpermit applicant OFFICIAL USE ONLY . 1. Building J (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) 26, 4 Mechanical(HVAC)�v 5 Fire Protection 6 Total 1+2+3+4+5 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 ?rebyauthorizeto act on h. ; ' t all matters r9ia e to work authorized by this building permit application. Si ure of Owner�� �lJ 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 Lrue and accurate, to the best of my knowledge and belief Print Name Signature of Owner/.Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIIVIBERS 1' 2 3 KV SPAN DIMENSIONS OF SILLS DRVIENSIONS OF POSTS DB ENSIGNS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHEV NEY 1S BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE �,/�a-aaizc�ivaella REGULATIONS, SUPERVISOR 5 1 i Tr. no: 11003 1 .a { missioneP t' • e �,/�a-aaizc�ivaella REGULATIONS, SUPERVISOR 5 1 i Tr. no: 11003 1 .a { missioneP f NORT►1 TOWN OF NORTH ANDOVER ° •• "� OFFICE OF p BUILDING DEPARTMENT 400 Osgood Street North Andover, Massachusetts 01845 D. Robert Nicetta, Building Commissioner Please print DATE: Y/, ?? A JOB LOCATION: HOMEOWNER HOMEOWNER LICENSE EXEMPTION ?Y Number �( )), �, JJ Street Address OnSJALJ-4-A1UA0 b)j Name Home Phone PRESENT MAILING ADDRESS �'A0,C Telephone (978) 688-95454 Fax (978)688-9542 M f� 7, A,1L, c, o lyy- 94? C //6 Map/Lot '81-Y''65 -_Sy? ) ??l �/�?- 65-5 "Ir Work Phone City Town State Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings to two 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 108.3.5.1) 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 or two family structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned "homeowner" assumes responsibility for compliances 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 comply with said procedures and requirements. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL I.I(MRD OF AITEALS 698-9541 COINS[.RV TION 698-95.30 IIT ALTI I 68X0540 PLANNING (.)M0535 M North Andover Building Department; Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: (Location of Facility) Signature of Permit Applicant Date ,. . NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector I y. M North Andover Building Department; Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: (Location of Facility) Signature of Permit Applicant Date ,. . NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector I The Commonwealth of Massachusetts Department of Industrial Accidents Ofte of Invesdlgadons Boston, Mass. 02111 ' Workers' Compensation Insurarm Affda* Name Pleass Print Name: �ocaMon: City Phone I am a homwwrw performing all work myself. 0 I am a sole proprietor and have no one working in arty c apadhr I am an employer MvAdng workers' compensation for my employees working on this job. 01 v Pg&w s w c), -- 3(S -- -73? / zo --ol r FaUs to secrre coverape ar rewired under Secd n 25A ar MOL 152 can lead to the knposbm d olminal Pw al m d.a Ana up to $1,300.00 andlar one Yuri' imprk0 W l ant_s.rd_as.chd.paoaOW ID M IDM dA ST1r1P VAOM DRI]ER..i4et.a.Aaa d.01Ln.0q-ag* apalod ma 1 undenitand that a copy d this statemerd may be forwarded to the Cffm of Invesdgsd M d ft DIA for covenpe variticatlorr. I do hereby certh under die palms and pmuff a d perjury drat NO krtbrnrad m provided *bow b true and correct Signature Date Print name Phow # offcw use only do not write In this area to be completed by city or town afAdar CRY or Town pin �..,.►�. ❑ BuildirlA DW []Check M Immedale response Is requiad ❑ Lkwkft Board ❑ SGMChnert's Olflt=e Contact person: Phone * ❑ Hea3/th Department ❑ Other O z h rA ui CL �cm O•— 'C c c a M FS m c 03 a O� a a O R Q O L O d O y � ca o C w ev �v _ C3 0 CD iTa L w cn cn a ., m G w O r� v x U is G w" CLy w G w OG a: w 0 c� r�. O cn EO cn ui CL E Ir t FA y C m C7 c c 73m O cp c s m O Z O 5 0 f u O I y �cm O•— 'C c c Q M FS m c 03 Z �3 O� o O R Q O L O d O y ca o C ev �v _ C3 0 CD C C2 C..) CL y c C CL C c 1p A CLy O Ea :c m.2o `z w a o y o vCD mc C36-- 0 o �` fA 3 cm m� C C � m a :r c y W 112 y :o aL,3 ` m O r ovi yZOac NSO �y LTJ CO cc «C+ 'O Z C +�+ W •r .y V E f0.1'C Q C4 d to •� O� a y� �Zaa4 m E Ir t FA y C m C7 c c 73m O cp c s m O Z O 5 0 f u O I y �cm O•— 'C CD Q M FS m m 03 Z �3 O� O O R Q O L O d ca o c ev �v CL 0 CD C C2 C..) CL y c C C c CLy LLI U) LLI U) 19 W UA 19 W N Date. E ",� �T" N, TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SSACHUS� i This certifies that .......lit/ .` ..L .............. has permission to perform ..... ...... . r plumbing in the buildings of-,�!}.�.. t \ at ..9. 9. !�,!c! .�?�L_.%....:..{, North Andover„Mass; .. Fee/// 7.•01-ic. No./.��'� ... .,$��'/� PLUMBING INSPECTOR Cheek d -% 6442 MASSACHUSETTS UNIFORM APPLI (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location Owners Name of FOR PERMIT TO DO PLUMBING y h ul2y'y3; S Date -5-19167 r _ Permit # Amount 1.67 New Renovation ©� Replacement Plans Submitted Yes No ❑ (Print or type)r Check one: Certificate Installing Company Name pao F I0 Izi°S ❑ Corp. Address < L1164 Partner. torn s S C�i9 o Business Te ep one g -2 r 7 y4, irm/Co. n Name of Licensed Plumber: p/a v/ r 1,p k'�S Insurance Coverage: Indicate the type f insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity 13 Bond Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance .Signature Owner 1:1 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 Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plung Code d Chapter 142 of the General Laws. P? - By: Signature o icense um er Type of Plumbing License Title 1,�7QS- CityiTown Eicense Numoer MasterJourneyman APPROVED (OSCE USE ONLY El r r NOWz G) TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVAT& OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUMDING PERMIT NUMBER: 6b DATE ISSUED: �1 7' C;) - SIGNATURE: Building Commissioner1I or of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: Ao r A � A j zj er 0 1.2 Assessors Map and Parcel Number. Map Number Parcel Number 1.3 Zoning information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area Fronts R 1.6 BURDING SETBACKS ft Front Yard Side Yard Rear Yard RegWred Provide Required Provided RecjWmd Provided 1.7 water Supply M.G.L.C.Q. § 54) public ❑ Private 0 1.3. Flood Zone Fafmmstioo: Zone Outside Flood Zone 0 1.8 Sewcup Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record zp2t)' �G �U�ji-S ( \\ Q _ n U y 17 � ` G c'c / V �.. � nr -,came Address for Service: -,y. Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: j 1, 3'J A r ss 2-4 2 7 ignature Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone r r NOWz G) 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 of in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......0 No ....... 0 SECTION S Description of Proposed Work check a9 a bl New Construction ❑ Existing Building 0 Repair(s) 0 Alterations(s) ❑ Addition 0 Accessory Bldg. 0 Demolition 0 Other 0 Specify Brief Description of Proposed Work: TIZiP ive, R3 I gw.rTION 6 - F.RTTMATF.'n rnNC7v1[TVT1rnYd rncme will result Item Estimated Cost (Dollar) to be OFFICIAL USE ONLY Completed by permit applicant 1. Building (a) Building Permit Fee Mulier ti l(b) 2 Electrical Estimated Total Cost of Construction 3 Plumbing Building Permit fee til x tbl t, v 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number ow. l-T7/1➢r 7. r%1WWw1M A iT rKYt MM • mt�v ... OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT erebyauthorize 11KOS C -0J as Owner/Authorized Agent of subject property to act on �l matters r a ' e to work authorized by this building permit application. Sigidure of OwnerDate SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION ,, ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Signature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1' 3RD SPAN DIMENSIONS OF SELLS D11VIENSIONS OF POSTS DIIbIENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CH11VINEY 1S BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE