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HomeMy WebLinkAboutMiscellaneous - 88 LINDEN AVENUE 4/30/2018I N J Q Q c Nr- r- 60 o0 o m co z 4 c Om o Z M o j jl 'I Date .....q= 3.7./Y ... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ................ vv"'..T....................................U Mt--� .............................. has permission to perform ......... It C7Z/ **'**'*"*"*""* ........... wiring in the building of .... A4 .......... A.41i�+riz ....................................................... at North Andover Mass. Fee L ic. No. 37-17... ECTRICAL &S'PE­CT'*O Check # // 19-703 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Of(ici(tal UseOnly Permit No. I ?,-7 ( 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 (NEC), 527 CMR 12.00 (PLEASE PRINT IN.INK OR TYPE ALL INFORMATION) Date: `� T City or Town of: NORTH ANDOVER To the Insp Noor of Wires: By this application the undersigned gives notice of his r her intention to perform the electrical work described below. Location (Street & Number) �f s f/v = ,01/ e Owner or Tenant Mj Telephone No. Owner's Address S44---e- Is this permit in conjunction with a building permit? Yes V No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion ofthe %IlowinQ table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA 1\ of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. grnd. No. of Emergency Lighting Battery Units No. of Receptacle Outlets No. No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burgers No. of Detection and Initiating Devices No. of Ranges % No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Dis Disposers p I Heat Pump Totals: Number - Tons " KW ..............Detection/AlertingDevices No. of Self -Contained No. of Dishwashers I S ace/Area Heating KW p g Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTkER: % Attach additional detail if desired or as regtdred by the Inspector of Rres. Estimated Value of Electric 1 Work: (When required by municipal policy.) Work to Start: a� Z% 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 'i3surance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cove e is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURA=NCE ff BOND ❑ OTHER ❑ (Specify:) I certify, tinder the pains and penalties of perjury, that the information n this app tion is true and complete. FIRM NAME:. LIC. NO.: Licensee: Signature LIC. NO.: (If applicable, enter "exempt" in the �icenje numbe line.) 1� Bus, Tel. No.: c Address: t /C 4 A,v��� j Alt. Tel. No.: 7 7L .76 *Per M.G.L c. f47 s. 5 -61 security work requires Department 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 PERMIT FEE: $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall -be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass R Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed❑' Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPEC IO : Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors S gnature: Date: M DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com ..� The Commonwealth of Massachusetts - �� Department of Industrigl Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information PIease Print Le ibl Name (Business/Organization/Individual): jJ�j f 6 Address: 4�✓,�Z/1/ �P 1Vl/`P City/State/ZipPhone #: Type of project (required): 6. El New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roofrepairs 13.❑ Other - y dppl►cant that checks box #1 must also fill out the section below showing their workers' compensation policy information. 7 Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam 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. Lie. #: Expiration Date: Job Site Address:City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine Oto $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 Iavesi>gations of the DIA for insurance coverawverification. X do hereby cert r t a ' s an ,(ties of perjury that the information provided above is true and correct. V Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # 7 Z, Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector 6. Other Contact Person: Phone Are you an employer? Check the appropriate box: 1. a employer with 4. ❑ I am a general contractor and I loyees (full and/or part-time).* 71am have hired the sub -contractors 2. a soleproprietor 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 area 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.] employees. [No workers' comp. insurance required.] A- Type of project (required): 6. El New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roofrepairs 13.❑ Other - y dppl►cant that checks box #1 must also fill out the section below showing their workers' compensation policy information. 7 Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam 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. Lie. #: Expiration Date: Job Site Address:City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine Oto $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 Iavesi>gations of the DIA for insurance coverawverification. X do hereby cert r t a ' s an ,(ties of perjury that the information provided above is true and correct. V Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # 7 Z, Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing 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 ti 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 r 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 homeowner 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. t' 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 Connzaa.onwealth, of Mossachusetts Department offadustrial Accidents Office of Investigations 600 Washington Street Boston} MA 02111 Tel # 617-727-4900 ext 406 or 1-8777MASSAFB Revised 5-26-05 Fax # 617-727-7749 c w-mass.govNia Date... 144 Y 10708 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .... A. -H .........O1up.WA.) ...................................................... has permission to perform ...../w ................................................................ plumbingin the buildi f ............................................................................................. F x1r I - at ..... ................................................. IN ort11L Andover, Mass. I ...... ............ 0 ....... ... ........... Fee �/Jt.w .... Lic. No! ............... .... &.1 .... . ...................................... BL6MBING INSPECTOR Check # Date ........ 4?. � .. //. q ............... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ....... ................................................ Chas permission for gas installation ...... .. ................................................ in' the buildings of ................................................................................................................... ai ..... ........................... North Andover, Mass. Fee7f:: . ...... Lic. No. ..... ... A-*-*�-� P-I�S�ici� R .1 ............................ Check# 3 t�61 '9 5 Qtq-- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK YI CITY �� MA DATE PERMIT # JOBSITE ADDRESS �T�N; /at-L ��OWNER'S NAME GOWNER ADDRESS TEl -jF7 -FAX TYPE OR OCCUPANCYTYPE COMMERCIAL EDUCATIONAL RESIDENTIALO CLEARLY NEW: �l RENOVATION: REPLACEMENT: 13 PLANS SUBMITTED: YES 0 N0�& APPLIANCES 7 FLOORS- BSM 1 1 2 3 1 4 5 6 7 8 9 10 1 11 12 13 14 BOILER I �l. _ _ ._ _. C_ m, ..1. - 1 . BOOSTER -� _ � r-=-_1 �� — - _- __ _ . E:] --- r-- CONVERSION BURNER -- 1 _IUzl=== COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT ml - OVEN.- -POOL HEATER ROOM/ SPACE HEATER I _ ROOF TOP UNIT TEST J= --J= — -UNIT HEATER- UNVENTED ROOM HEATER WATER HEATER OTHER I INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 0 I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND F 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 [3 AGENT �( SIGNATURE OF OWNER OR AGENT 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. PLUM BER-GASFITTER NAME- � --- t_ .� LICENSE # C SIGNATURE MP %MGF 01 JP 0 JGF Q LPGI 0 CORPORATION ©# L= PARTNERSHIP ©#= LLC ®#= COMPANY NAME:JJADDRESS� CITY _ STATE ZIP TEL ] -(176-417 FAX�_ i CELL-EMAIL rA H O z z H U W a w � � . O Nrl � W � W H a ftz w 5 rA a Wco CL oLM w w w Cl) a a 0con a a J H a a Q cfr v� • ui x w F— LL H z° 0 H w a F m The Commonwealth of Massachusetts Department ofIndustriglAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/individual): ti Address: 'r2, Nv-I•eS e.S�✓'J Phone #• city/state/zip: Are yo an employer? Check the appropriate box: 1. Wain 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 soleproprietor 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. ❑ 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.] 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.❑ Other I Any applicant that checks box41 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they die doing all work and then hire outside contractors must submit anew affidavit indicating such. #Contractors that checkthis 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. Lic. #: M 0 &1 (09 71Expiration Date:. V 1s//q Job Site Address, ( N D2.+J TT—k City/State/Zip: i��2 ii'( /1740 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A ofMGL o. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 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 maybe forwarded to the Office of Investigations of the DIA- for insurance coverage verification. I do hereby certlo under the pains and penalties ofperjurq that the information provided above is true and correct. Simatur� Date: Phone#• �/fO-g775 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 Phone #: Information and InstructioIms ' 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 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 h space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only. submit one affidavit indicating current policy information (ifnecessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew 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: Tho GoMMORMalth of Mmacahasetts } Departmeut of fadustrial ,A aczdo nts Office of Iayestigatilo.0 600 Washva&a Stroet Boston} M.A. 02111 Teel, ## 617-727-4900 ext 406 or 1-877,NfASSAFE Revised 5-26-05 Fax # 617-727-7749 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK �! CITY • ..�Sts� _._._.� MA DATE -_ (PERMIT # JOBSITEADDRESS OWNER'SNAME� POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL © RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:K REPLACEMENT: E] PLANS SUBMITTED: YES � N' FIXTURES Z FLOOR-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM (; _ I _ J I (_(_ (^ _^) � i =jT( DEDICATED GASIOILISAND SYSTEM ! _-„_• . _ _ 1 ,_ _-( T_- �__I _� „-1 „___ (___-. f f ___( DEDICATED GREASE SYSTEM ! -..____..J L-3 DEDICATED GRAY WATER SYSTEM ( I —AL DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER �. _ I ._. _ _(J ( f i ...____1 __._.._-__-( ._ FLOOR/ AREA DRAIN INTERCEPTOR (INTERIOR) 1 ___�! _.__.! __.__.( ..__._. I I i J __.._.._i 1 __._..._._.J .__.._� _._.E . I __...__.J KITCHEN SINK I _. _j ^_.._! _.._-( _-- I _._i .___.. f ( i _--.. LAVATORY__.._.._i ___.f ___ (_.___J J ._.__.._I _..... ... _1 ROOF DRAIN SHOWER STALL SERVICE / MOP SINK _ .I ! E --_. --i _._-__! ------J ------ _.-1 ___i _.._ i ._._-_{ ----._ .__ 1 _._-_ _i I TOILET I l _ '1== URINAL (...._...._ I -WASHING MACHINE CONNECTION WATER HEATER ALL TYPES I I WATER PIPING OTHER __ I I f1 --AL .f INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES - NO IF YOU CHECKED YES, PLEASE INDICATE THE T E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY 3 INSURANCE POLICY OTHER TYPE OF INDEMNITY D BOND E3 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 _I 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 in co p iance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME /U i LICENSE # I STATURE MPU/ JP 0 CORPORATION _J #PARTNERSHIP Q# s LLC i1 COMPANY NAME ADDRESS p CITY i �_.._.._._. _ ._STATE : p'►l1,e ZIP _ p�u3 ?� TEL - �7 FAX CELL H �i H U W a w 1 o o z �F ` O � W H LU LU u _ ~ F- � W o Qw 5 W N aLU w � w co O z a W F- �, a U J a Q U) ui x w F- LL W H z O H H U a z a a, o x � _ The Commonwealth of 1t2assachuse'&s Department of IndustriglAccidents Office of Invesfigations 600 Washington Street Roston, MA 02111 vww.rnass gov/iiia Workers' Compensation. bmurance davit: Bufflers/Contractors/Eh AmAleant Information_ Name (Business/Organization/Individual):, .Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction f employees (full. and/or part-time,).* 2111 am. a sole proprietor or partner have Hired the sub -contractors listed on the attached sheet. 7. El Remodeling ship and1aveno.employees These sub -contractors have 8. ❑ Demolition working fox me in any capacity. workers' comp. insurance. 5. ❑ We area corporation and its 9. ❑ Building addition [No workers' comp. insurance required.] officers have exercisediheix o ME] Electrical repairs or additions 3. El am a homeowner doing all work right of exemption per MGL 11 • ❑Plumbing repairs or additions myself [No workers' comp. c. 152, §1(4), and we have no 12. ❑ Roof repairs iusurancere �fired. ] employees. [No workers' 13.❑Oilier comp. insurance required.] 1%ny applicantthat checks box#1 must also fill outthe secfion bel6w showingtheir workers' compensagoapolicy information. 'Homeowners who submit this affidavit indicatingthey Aire doing allwont and then hire outside contractors must submit anew affidavit indicating such. /Contractors that cheAthis box must attached ea additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is pr oviding workers' compensation insurance for my employees Below is thepolley afidjob site information. Insurance Company Name; 37YE f 462�� Policy # or Self las. Lic. #; Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requI dunder Section 25A ofMGL o.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 statementmay be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do Hereby cerqfy under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone #• official use only. Do not write in this area, to be completed by city or town official. City or Town: Permi-Mceuse # 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 1.52 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person tri the service of another under any contract of hire,• express or implied, oral or written." An em,ployer is defined as "an individual, partnership, association, corporation or other legal entity, or anytwo 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. 9wever 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 employes." 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 xiecessary, supply sub -contractors) name(s), address(es) and phone numbers) 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, apolicyis mquired. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confn" matron of insurance coverage. Also be sure to sign and date the affidavit. he affidavit should bo 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 selfinsurance license number on the appropriate he. City or Town Officials Please be sure that the affidavit is complete andprinted 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 thatmust submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (ifnecessary) and under "Yob Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially scamp ed 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. Anew affidavit must be filled out each year. More 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: Tho Coa Ox-w.oaltho;f'Mussachu&oi�s - De-p.ar ent ofladust~rial A,cc%do is Ofte oZ�yeiigaQus 600 Wasbingtw Sftoa Boston, 02111 TOA, # 617-7-21.7-49-00 _49-00 ext 406 or. 1• -877 -MASS Revised 526-05 Fax 0 617-727'7749 Www.=agoV1dia ■ % z 9 . M, M mm o> Ln . 3 z . E :.z 'm �n : (Do 09/03/2014 08:38 7817290600 SCOTTI INSURANCE PAGE 01 ■ .�c T OP ID: SF CERTIFICATE IFICATE OF LIABILITY INSURANCE DATE(MM/o0/YYYY) 1 00//2014 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 13ETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, tho P01400s) 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 FPR0).OUOER ertificate holder in lieu of such endomement s , t) & Company Inc. Rhone: 781-729.9200 NaMencT ount Vernon Atre®t Fax: 781-729-9500 PHONEx Box 1000 (alC. No.�xt): (ArcN��hester Mg01B90-8300 a"MAIL -`ent A Glalise ADOREssI PRODU�'' - - H UNA N-1 INSURED M 2thew NUrlett INgURER(S)AFFORDINO COVERAGE NAIL 6 3 Noyes Rd. INSURERA:The Hartford 22367 GeOrgetoWn, MA 01833 INSURER B I INSURER C: INSURER b: ENSURER E ; - •• •- - ' - ckKTIFICATE 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, EEXXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. GENERAL WARILITY DDIYYYY MlDD/ ' LIMITS A X COMMERCIAL QENERAL LIABILITY 013SBMUN6971 �Y� CLAIMS -MADE I x i OCCUR 09115/2013 O9I15/ZO14 EACH OCCURRENCE g �A1�AGLTbREATE6 P(�EMI5E5 (Eo neCUrrenee $ MED EXP (Any one peraan) $ X EPL 5,000 PERSONAL & ADV INJURY g GEN'L AGGREGATE LIMIT APPLIES PFR; I GENERAL AGGREGATE $ POLICY P O- LOC PRODUCTS - COMP/OPAGO S AUTOMOBILE LIABILITY S ANY AUTO COMBINED SINGLE LIMIT (Eo RcclGent) S ALL OWNED AUTOS OODILY INJURY (Par person) S 9CHEDUIEDAUTO$ INJURY (Per sxldnpp g BrFROPE'�Ty A X HIRED AUTOS 08SBMUNG971 A 09/1512013 09!15/2014 AMAGE S X NON -OWNED AUTOS UMURELLA LIAB OCCUR 5 PX(=9 LIAR _ CLAINIS-MADE EACH OCCURRENCE $ - DEDUCTIBLE AGGREGATE g ETENTION P _- $ WORKER$ COMPENSATION g AND EMPLOYERS' LIABILITY ANY PROPRIFTOR/PARTNER/CXECUTIVE Y! N WC STA'ru-OTH- OFFICERA%M6FR EXCLLIOEr NIA __T.ORY_ (MJ5Sj... a ,•_ (Mandatary In NH) E.L.EACH ACCIDENT S Ir-SCa doxenbe Under D RIPTION OP OPERATIONS below _ Lr L. DISEASE - EA EMPLOYE S - E.L.DISEASE -POLICY LIMIT 3� beSCFUPT10N OF OPERATIONS /LOCATIONS /VEHICLES (AtIRch ACORn 101, Addlllonal RemArkR 9ehodula, if more epnce is Mqulrad) ?lambing residential Town of North Andover Richard Danforth 1600 Osgood St. North Andover, MA 01845 ACORD 25 (2009109) TOWNNAN 30 -SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOP, NOTICE WILL QE DELIVL°RED IN ACCORDANCE WITH THE; POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1998.2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD I#A 14 Date ..!..�.t�:l.�.�........... 10576 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that..........Q`�" ........ 1 ........................................................... has permission to perform 6 ..._ R..�rn, c�.c�,r Q { plumbing in th1e buildings of......./.��........4.(............................................................ at ........ae.?............,l r..► � -...., North Andover, Mass. Fee4...:.`?�.. Lic. No.' .(e !�......C'�.1I '. ............................................................. �y PLUMBING INSPECTOR Check # +12 SHOWER STALL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' CITY I MA DATE L `I ( PERMIT # JOBSITE ADDRESS OWNER'S NAME POWNER ADDRESS TEL FAX J TYPE OR OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL �j RESIDENTIAL �-- PRINT CLEARLY NEW: D RENOVATION:,] REPLACEMENT: Q PLANS SUBMITTED: YES ® NO 01 FIXTURES'l FLOOR--, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIL/SAND SYSTEM mf ( _ I _111-_J1_ - _11=J14 DEDICATED GREASE SYSTEM _.__. ____._ __._._ [= _ ,_____-_ —( t DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM I�JI� DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER i 1 ___.--_- FLOOR/ AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY r .( _— (..___ (..__ t -� _._-- ROOF DRAIN 1 � _— __- _ ._. _. _._ I ._.__ 1 _ - SHOWER STALL •' ��®������®rte WASHING MACHINE CONNECTION FOW�FOW FW_ �M-F1 W_ FW_ iMFIM C®W F� FW_ F0 WATERWATER PIPING I�JI� MMMAFMM1 FMMWF�� INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES [F.1 NO [__11 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY LTJ OTHER TYPE OF INDEMNITY ! BOND Ell OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER R AGENT 0 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in o pliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _'A1 PLUMBER'S NAME &e f' c LICENSE # ®.{0 1 �._�, SIGNATURE MP © JP 0 CORPORATION F]# PARTNERSHIP®# _ � LLC U� E COMPANY NAME _� �.�, ` tiz� 9 ADDRESSIN ad«- CITY �r�_. a�-- - - - —� STATE ZIP 83 Z Z TEL FAX �_ CELL �� EMAIL - -- ------ - --- - - --- -- -- ---- - --- N-I� 0 E z L w The Commonwealth of Massachusetts Department oflndustriglAccidents NAME Office of Investigations 600 Washington Street Boston, MA. 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers Applicant Information Please Print Legibly Name (Business/Organizatio0ndividual): Address:Zz �n �d,��� rio— t _ City/State/Zip Phone Are you an employer? Check the appropriate box: - Typo of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees (fall and/or part-time).* 2. KI am a sole proprietor or partner- have lured the sub -contractors listed on the attached sheet. 7. []-Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance.9. 5. El We are a corporation and its ❑Building addition [[No workers' comp. insurance required.] officers have exercised their 10.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing allwork right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c.152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] q ] employees. [No workers' 13.❑ Other comp. insurance required.] xAny applicant that checks box#I must also fill out the section below showing their workers' compensation policy information. 7 Homeowners who submit this affidavit indicating they tire doing all work and then hire outside contractors must submit anew affidavit indicating such. TContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. X 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: 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 maybe forwarded to the Office of 'Investigations of the DIA. for insurance coverage verification. Xdo hereby c90111 ynder the pains and, WFy -1.1 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 �y 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 ani. Instructions°ons 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." Applicahts 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 he. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be. used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only -'submit one affidavit indicating current policy information (ifnecessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each year. Where a homeowner 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 CoW. onwealth of Massachusetts Depafterat of Industrial Accidents Office ofJAVestigatio.m 600 Wasbivon, Street Boston, MA. 02111 Tel, # RM27-4900 ort 406 or 1.-877:MA.SS ,FE Revised 5-26-05 Fax# 6X7"727 7749 w _mace arvu li'n i.lw Division of Professional Licensure: License Search The Official Website of the Office of Consumer Affairs and Business Regulation (OCABR) Division of Professional Licensure Mass.Gov Home State Agencies A -Z Topics Home > Division of Professional Licensure > Check A Professional License By the Division of Professional Licensure LICENSEE Name:ROBERT K. LEROY CTR BARNSTEAD, NH Licensing Board: PLUMBERS 8 GASFITTERS License Type: JOURNEYMAN PLUMBER License Number: 20695 Status: CURRENT Expiration Date: 5/1/2016 c Issue Date: 11/20/1986 Exam Date: School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Wednesday, June 04, 2014 at 2:51:43 PM. © 2007-2011 Commonwealth of Massachusetts Page 1 of 1 Mass.Gov ONLINE SERVICES Check a License Locate a Licensed Professional Online Address Change Contact the Agency More... REFERENCES & RELATEDINFO Disclaimer Regarding Website License Searches Glossary of License Status Codes More... Site Policies Contact Us http://license.reg. state.ma.us/publiclpubLicenseQ. asp?board_Code=PL&type class=_J&lice... 6/4/2014 Date..617.to ..................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This.certifies that 0. has permission to perform ......... r,-2 AY) .... .................................. wiringin the building of........1... ............................................................................... at ... North Andover, Mass. ................................................................. ............. . . �—****' Fee .........1--.......... 1-'o Lic. No::�.,-2.z� .. 2)* . . . ............................................................ ELECTRICAL INSPECTOR Check # !7- % S4 Commonwealth of Massachusetts o Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Ori Permit No. rl�t�t 6 LJ� 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 (NEC), 527 CMR 2.00 (PLEASE PRINT INNK OR TYPE ALL INFORMATION) Date: 0-' / City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice his or her tention to perform the electrical work described below. Location (Street &Number)/�/v Owner or Tenant Owner's Address Is this permit in conjunction with a buil ing erim Yes [� Purpose of Building Telephone No. No ❑ (Check Appropriate Box) Utility Authorization No. - Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the_following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. grnd. No. of Emergency Lighting Battery Units No. of Receptacle Outlets 1 No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches Z1- No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number Tons "'"" '...... ""'""""' KW """"""' No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: 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 !"g6 ante including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cove ge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) X certify, under the pains and penalties of perjury, that the information an tlais applica ' n is true and complete. FIRM NAME: LIC. NO.: 7 Licensee: ✓ It y' Signature LIC. NO.: (If applicable, a ter "ex " in a li'c nse naam r line.) ` Bus. Tel. No.• _ Address: 1 i.A� Alt. Tel. No.: y�, -- *Per M.G.L c. 147, s. 57-61, security wortrequires Department 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 PERMIT FEE: $ Signature Telephone No. 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the Permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed o on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall -be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chanter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending -through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new per ❑ ❑ Permit Extension Act—Permit/Date Closed: Pass 0 Failed 0 ispectors Comments: Inspectors Signature: SERVICE INSPECTION: Pass 0 Failed Inspectors Comments: . Inspectors Signature: ARTIAL ROUGH INSPECTION: Pass 0 Failed Comments: Inspectors Signature: [LOUGH INSP + CTIOIS Pass rs Comments: Inspectors Signature: 'INAL INSPECTION: Pass 0 / Failed 0 Failed 0 .. 26� Inspectors Signa re: :B WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com Re- Inspection Required ($.) ❑ Date: Re- Inspection Required ($.) ❑ Date: Re- Inspection Required ($.) ❑ Date: Re- Inspection Required ($.) ❑ Date: Re- Inspection Required ($.) ❑ Date: y i The Commonwealth of Massachusetts - Department of IndustviglAccidents Office oflnvestigations 600 Washington Street .Boston, MA 02111 www.mass govldia Workers' Compensation Insurance Affidavit: Bu9lders/Cont°actors/Electricians[Pliimbers A Heant formation Please Print Le 1 Name (Business/organization/ln,dividual).* GL �,t�C�'i✓ Address: City/State/Zip: r� �, /' 7 �%% 3 Phone #: J . Are you n employer? Cbeck the appropriate box: Type of project (required): 1. Q a employer with 4. Q I am a general contractor and 1 6. [] New c6nstruction employees (full and/or part time) * have hired the sub -contractors 2. 1 am a sole proprietor or partner listed on the attached sheet 7• Remodeling ship and1ave no.employees These sub -contractors have 8. Q Demolition working :For me 'many capacity. workers' comp, insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.Q Electrical repairs or additions required.] officers have exercised.their 3. ❑ 1 am a homeowner doing all work right of exemption per MGL 11. Q Plumbing repairs or additions myself [No workers' comp. c.152, §1(4), and we have no 12.Q Roofrepairs insurancere edemployees. [No workers' �'. a 13.❑ Other comp. insurance required.] x.Any applicaatthat checks box#I must also fill outthe section bel6w showing their workers' compensation policy information. i, Homeowners who submit this affidavit indicatingthey 2're doing allwork and then hire outside contractors must submit a new affidavit indicating such. ,gContractors that checkthis box mast attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. X am an employer that is providing workers' compensation insurance for my employees Below is the policy and joie site information. Insurance Company Policy 4 or Self -ins. Lic. Expiration. Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A ofMGL o. 152 can lead to the imposition of criminal penalties of a ' /fine up to $1,500.00 and/or one --year imprisonIdIll as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. $e $visat a copy of this statement maybe forwarded to the Office of Investigations of the DTA fo urance cove�q e ' cation. X do hereby cert un erofperjury that the irg formation proviciecl above is true and correct. Simafore: Date. Phone Official use oily. Do not write in this area, to be completed by city or town official. City or Town: Permit/License 9 Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/TCown Clerk 4. Electrical Inspector S. Plumbing Inspector 6. Other Contact Person: Phone M Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provideworkers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract ofhim, - 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, contraction or repair work on such dwelling house or on the grounds or building appurtenant thereto shallnot 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 phonenumber(s) alongwiththeir eertif'icate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are notrequired to cant' workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised thatthisaffidavit maybe submitted tothe Department of Industrial Accidents for coniumation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be retumed to the city or town that the application for the permit or license is being requested, not the Depaartment 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 thatthe 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 givenyear, meed only submit one affidavit indicating current policy information (ifnecessmy) and under "Job Site Address" the applicant should write "all locations iu (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 fature 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 c (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 anal fax number: The Caxx monwealth o;FMassarhv.:SeiiS - J.Qeparir�e�.ii Q�X�du�al,AccXdcz�t� • Qfloe QfTIRVestfgattom 60 Wald&&, Stoa Bosun, MA. 02111 T01 # &M-21.7,4900 o7d 406 ox 1-877-MASS.AF', Revised 5-26-05 Fax # 617-727-7749 www.M,1mgQ-VMa Location n/�?`r, No. %_l4 -7 „V Date Check #_G,P- 2 544 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ r! dry Foundation Permit Fee $ Other Permit Fee $ TOTAL $ wilding Inspector Installing Company Address Ax Business Telephone Name of Ucensed Plumber or Gas Fitter Check one: Q Corp. EiPa nerahip Firm/Co. CertNicale INSURANCE COVERAGE: Check one I have a current liability Insurance policy or Its substantial equivalent. 'Yes ❑ No ❑ N you have checked yes, please indicate the type coverage by checking the appropriate box. A liability Insurance policy ❑ Other type of Indemnity D Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws. and that my signature on this permit application waives this requirement. Check one: Signature of Owner orOwner's en Owner ❑ Agent C1 I hereby certify that all of the details and Information 1 have submitted (or entered) M above application are true and accurate to the best of my knowledge and that all plumbing work and Installations performed under the permN Issued for this application will be M compliance with all pertinent provisions of the Massachusetts State Oas Gbde and Cfi t of CRY/'Town MP'TIt7NE0 (OFFICE USE ONLY) all er 142 the General LAwa. T of License: Plumber �n.re o nae um of or as or ,filter a as ster Mourneyman License Number _4Q_:57<9_ z 0 v w a N Z W a O 0 a a N w x U F - w x Vol z � o v • U n W I z• z N � 2 Q J ' a N z r = C • m a � LL a N O � F - W z J a p < W = a a � t7 ' O h_ ;h4 O � w � � � U m� IL o o z J u � 10.L O a O = w CL o, W w i O 0 W h ' m a V J IL CL 44w w U. N w x U F - w x Vol n r z • o o U n W I 0. z N � 2 Q J ' a N z n r 1a1 a o i n � I z w , Q a d a N r = C • m a � LL a O m F - W z a a p W 2 a a � O W h_ ;h4 � � � U < IL o z J 1a1 a o N . I w a a N r = N a c� a W F - z a W a a h h_ o .'f a w IL Date ......... . ";" 710 t_e NORTH TOWN OF NORTH ANDOVER O�ii IED r6 ��0 PERMIT FOR GAS: INSTALLATION o m ,R This certifies that F.? .. .......... . has permission for gas installation_ in the buildings of',...Andover.......... . at ....�1't: f` .:... , North , Massa Fee Lic. No..//,&3 ! .. .,.,..... z ... l.. . . -4 cam i GAS INSPECTOR v der WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File Location eg No. I3G — b -)S Date �p�ORTM TOWN OF NORTH ANDOVER O.s�e ,�,ti00L p Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permi�Fe�e $ cHU Other Permit Fee 57Mvkz $ Sewer Connection Fee $ Water Con . ection Fee s��W RECEIVED t e a--1 $ $ Buildind�Inspector NVO� pndoiVer collector Div. Public Works WOOD STOVE INSTA,LLA ON CHECKLIST --- �^t�rS� tie, i)a A4ver Permit A building permit is required for the installation of any solid fuel burning appliance. The building permit and installation inspection are limited to the stove installation and not to the stove construction. Stove A. New es Used B. Type/radiant LU606 Pe lel" rove Circulating yf-S C. Manufacturer NSA _Lab. No. Name/Model No. A&--�6qe Cellar size Dimensions/Height sw.w` _Length Width 45 Chimney A. New (Fa c— Ci —Existing . B. Size (flue area) 1� " C, Other appliances attached to flue (Number and flue size) . D. Prefab (Manufacturer—name and type) E. Masonry/Lined Rue liner Unlined F. Height (refer to diagrams) type d manufacturer) I O�'EP IrJ ` T CHIMNEY HEIGHT Hearth (non-combustible) A. Materials �'S. Sub -floor construction U Minimum dimensions (refer to diagram) Clearances and Wall Protection (see stove installation c!earances chart) A. Type of wall protection provided S. Clearances (refer to diagrams) FIREPLACE 02 77 Sof 1 184 , w_e_ . (sa CORr,JER ANS , \30_ cap 12t) hllf{• \\f 12tt \� ,MIN. 18 if MIN. HEARTH WALL/CENTER APPENII� t B - FLOOR PROTECTION MATERIALS Material Type Required Sheets/Layers K Factor Minimum Thickness Actual Thickness Cement 2.04 4.74 4.75 Den Shield 6 Sheets of 7/16" 1.1 2.55 2.625 Foam Glass .34 79 1 5 Homasote N.C.F.R. 3 Layers of 1/2" .59 1.32 1.5 Micore CV -230 2 Layers of 1/2" 43 1 1 Micore CV -300 3 Layers of 3/8" .458 1.06 1.125 Millboard 84 1.95 2 Wonderboard 6 Sheets of7/16" .98 2.27 2.625 Micore CV -230 is the approved and tested floor protection material. If you need to use a floor protector other than Micore CV -230, see the above chart of equivalent floor protection materials. AK factor is listed for each material type. The minimum thickness is derived from the chart on page 19. When you install a material listed above, the column labeled "Actual Thickness" gives you the actual thickness of the material you will be using when you utilize the required number of sheets or layers of material. All thickness listings are in inches. fH •�91i71 Use wa thimble N; ce"u, u,,- -.. --- - attic to help keep insulation away from pipe. 6" Minimum Figure 20 Inside Vertical Installation with Roo I f Termination Rain Cap 24" Minimum Length - Flashing 3" Minimum Clearance 90 Degree Clean out Tee optional Fresh Air Intake Pedestal 6" Minimum Optional Exhaust and Fresh Air Intake Direction 45 Degree Type "PL" V L� Fresh Air 1" Minimum Gap to Combustibles Figure 18 . Corner Installation of Freestanding Stove - - Wall Thimble Z- 45 Degree Elbow L < — Optional Fresh Air Intake 2' Horizontal Pipe \ Noncombustible Hearth Pad Figure 19 - Standard Horizontal Exhaust Configuration INSTALL{NGAN O 10NAL FRESH AIR INTAKE • For FREESTANDING installa n /with horizontal through -the -wall exhaust, it is recommended, but not required, that the optional outs= fresh air intake be installed. • For INSERT installations into an existing fireplace, or FREESTANDING installations with a vertical exhaust, the optional outside air intake is not required. • Outside fresh air intake is REQUIRED for mobile home installations. • Only steel pipe 1 5/8" inside diameter is approved to use for outside air connection (straight or flexible). PVC pipe or aluminum pipe is NOT approved, and should never be used. • If the air inlet is connected to the outside, it MUST be terminated with a vertical 90 degree bend (down) or with a wind hood. Failure to do so could result in a'burn back' during high winds blowing directly up the air inlet during a simultaneous power failure. • Blockage, excessive length, or bends in the air intake pipe will starve the stove of combustion air. A 90 degree bend is equivalent in restriction to approximately 30" of straight inlet pipe. WIND HOOD Fresh Air Intake Pipe l A -I- 3" Y_ 2" 6" Figure 13 - Wind Hood Termination Minimum Diameter 1 5/8 Inches Fresh Air Intake Pipe Figure 14 - 90 Degree Bend Termination STOVE EXHAUST/ TAKE INSTALLATION IT IS RECOMMENDED THAT ONLY AN AUTHORIZED DEALER INSTALL YOUR PELLET STOVE. THE FOLLOWING INSTALLATION GUIDELINES MUST BE FOLLOWED TO ENSURE CONFORMITY WITH BOTH THE SAFETY LISTING OF THE STOVE AND LOCAL BUILDING CODES. GENERAL GUIDELINES FOR INSTALLING EXHAUST SYSTEM • A listed 3 or 4 inch type "PL" pellet vent exhaust system must be used for FREESTANDING installations and attached to the pipe connector provided on the back of the stove. Use a 3 -to -4 inch adapter for 4 inch pipe. • The exit terminal must be located no less than 60" from any opening through which combustion products could enter the building, (i.e. windows and doors) not less than 24" from an adjacent building, and not less than 7' above grade when located adjacent to public walkways. The exit terminal must be arranged so that flue gases are not directed so as to jeopardize people, overheat combustible structures or enter the building. Keep brush, plants and shrubs at least 36" away from vent termination. • Ninety -degree elbows accumulate fly ash and soot thereby reducing exhaust flow and performance of the stove. Horizontal runs of pipe collect fly ash also. It is recommended that a single or double clean-out 'tee' be installed at every 90 degree turn so that fly ash can accumulate. If a 90 degree turn connects a vertical run of pipe to a horizontal run (as you follow the exhaust away from the stove), a tee is not required. At any other 90 degree turn, installation of a clean out tee is recommended tol permit periodic cleaning of both the horizontal and vertical runs of pipe. • Total length of horizontal vent must not exceed 25 ft. A 3" single-wall, stainless steel flexible or rigid exhaust pipe should be used for INSERT installations and must be attached to the stove with a single or double wall, stainless 'tee' with a clean-out cap. The stainless steel 'tee' can be inclined at 45 degrees to enable the vent to be centered on the stove, and allows the 'tee' to be cleaned out without removing the stove (see Figure 20 on page 18). • When venting into an existing chimney (masonry or factory built) the chimney must be cleaned, with all creosote removed. • The "PL" vent or single wall stainless exhaust system must be installed so as to be GAS TIGHT! The vent manufacturer's installation procedures must be followed. In addition, pipe connections, joints and all pipe seams within the home should be sealed with room temperature vulcanizing, high temperature silicone sealer (RTV). • If an insert is to be installed into an unlined masonry chimney, it is recommended that the 3" or 4" stainless steel pipe be extended to the top of the existing chimney. The top of the existing chimney should be sealed with a steel plate (see Figure 21 on page 19). ilbr&.s`e STOVE INSTALLATION CONFIGURATIONS l THE WHITFIELD "ADVANTAGE II -T" MAY BE INSTALLED AS: • A freestanding unit with a pedestal mounted on a noncombustible floor pad. • A hearth mounted fireplace insert into a masonry or factory built fireplace. • A built-in heater mounted on an insulated floor pad. A mobile home heater mounted on an insulated floor pad. FLOOR PROTECTION The Whitfield "ADVANTAGE II -T" must be installed on a noncombustible protective floor pad of minimum 3/8" thickness material or a masonry hearth. The hearth or floor pad must extend a minimum of 6" in front of and from each side of the stove (and 6" behind in a freestanding/vertical installation configuration) or to the nearest permitted combustible material (if less than 6").% Figure 10 - Hearth Pad Clearances CLEARANCES TO COMBUSTIBLES The stove must be installed with the following minimum clearances to side and back wall combustible materials: --------------- -- -- \ 1„ Clearance behind stove 1 Clearance on stove rear side 3" Clearance on stove front side j 6" Clearance to front of stove 18" Clearance above stove i' Figure 11 - Clearance to Combustibles S'r '�' u - } F.,", P' r_ 41 x b - i utactured by PYRO INDUSTRIES, INC. ENVIRONMENTAL PROTECTION `ATE MATTER (Smoke) CONTROL RE SOD HEATERS BUILT ON OR AFTE u 4th � •. D } ' - _ a s}. ►- N L f^nl� fY S �Np00W c a C c C o r O W a,+ •'4+ r. r ca�� U O 0 d •N do i ..... Ln /p L A ® � r C r V L W r ® z CC CO co c aR ° v �$ AF o co r C { c C C «• R U. 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ENVIRONMENTAL PROTECTION `ATE MATTER (Smoke) CONTROL RE SOD HEATERS BUILT ON OR AFTE Z w Q Z O W H m CL J Q W Z Z W C/)^^ V/ D s 0 c3D 0 m CD m O U- C/) O i- m Z W J w w I U- < < Oa,- cr- O Z Z 00 U � J O m E N Ir w w w Q 2 O O Q � J U � < J CL Q Q - Q wc) U) Z F- 0 w � Z a m0 Tm 0 Z r - z -� Om X -n N m r v D v D z �q n m H z DD m 00 D cc � cc m C/)� W CD om 0 mo Z 10 v cn C W -4 C C) o y oo� m oo —1 0 A z o (� o w N O O (D O O O W C v=r c S m D 14 OD 00 A n O D v D z v n v C z -i Z m 0 m 0 O z m Z n D m D Om z� 0 ZD 0-4 xm cn mD D� ca N W V m� mN N o s C o c 1 0 0 0 r v 0 0 0 m 0 r D 0 m m n a m T q .. JZ fi O O W pj « p 70 O O dG-tl'k O O qtr c 0 0 0 � - 1{■� U ■ V� � C h ��. O w UCL L $ ya e U L o U O ® aca O C Z 1 0 0 ^j ccs � � — 4 ": W 0 a) L l. a j r N w M }, W N E °� u $�� �Q I LLI-801 oz. L w W � Q aa)i U) t L U O t L ` 3 LL s o 0 o gg W cu a>LL o U E 00 f 1 mW 2 T L C cz F- Z cn O a) +n! y o 0 �-Z �'`v OOOZ� �n m La F- O:, Rt Ij9 a .M a dG-tl'k } O a A t Location ,S? P I A-,1 c rj No. Z 75'Date "3 ' SO °"r" TOWN OF NORTH ANDOVER ° °c Certificate of Occupancy $ u -v Building/Frame Permit Fee $ Foundation Permit Fee $ sACMUs t Other Permit Fee $ Sewer Connection Fee $ PAID BY C,I•I�� onnection Fee $$ 40 31991 No. Andover Collector Building, Inspector Div. Public Works I�ERAIJT NO. a MAP KVO. 1 APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE INSTRUCTIONS SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST�BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED SIGNATURE OF OWNER OR AUTHORIZED AGENT 3 PROPERTY INFORMATION • 1 ; LAND COST+40V%p ZL !r1A �In 1 EST. BLDG. COSTL - -- — G 1 EST. BLDG. COST PER SQ. FT. FEEb^ PERMIT GRANTED 19 wnCo9aJ OWNER TEL. CONTR. TEL. q CONTR. LIC. q EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. n Z 4- 4 APPROVED BY BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN M BUILDING INSPECTOR I LOT NO. "iws 2 RECORD OF OWNERSHIP iDATE BOOK 'PAGE - ZONE SUB DIV. LOT NO. mk"WA411c)x-TT—P t�m LOCATION L ,\ p , N�i .A� 0i84� _+ `vC`\ �-r�l PURPOSE OF BUILDING r�r r OWNER'S NAME �I " NO. OF STORIES /J SIZE OWNER'S ADDRESS SV �\ CR ANC_.e, N.P,&JL,r 1M C)%18 S- BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS 1ST/J 2ND 3RD BUILDER'S NAME SPANrr- DISTANCE TO NEAREST BUILDING V A DIMENSIONS OFSILLS DISTANCE FROM STREET /vA POSTS DISTANCE FROM LOT LINES - SIDES' REAR " GIRDERS / V AREA OF LOT xo,aeor FRONTAGE A� HEIGHT OF FOUNDATION )/ THICKNESS , 19 Lr O� T IS BUILDING NEW 06 ad "• ! SIZE OF FOOTING X IS BUILDING ADDITIONJ, o %C � MATERIAL OF CHIMNEY b elk IS BUILDING ALTERATION le -S - •� IS BUILDING ON SOLID OR FILLED LAND s�1i WILL BUILDING CONFORM TO REQUIREMENTS OF CODE ILS CII IS BUILDING CONNECTED TO TOWN WATER (%�S / BOARD OF APPEALS ACTION, IF ANY ro IS BUILDING CONNECTED TO TOWN SEWER �/` - ISiBUILDING CONNECTED TO NATURAL GAS LINE F S INSTRUCTIONS SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST�BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED SIGNATURE OF OWNER OR AUTHORIZED AGENT 3 PROPERTY INFORMATION • 1 ; LAND COST+40V%p ZL !r1A �In 1 EST. BLDG. COSTL - -- — G 1 EST. BLDG. COST PER SQ. FT. FEEb^ PERMIT GRANTED 19 wnCo9aJ OWNER TEL. CONTR. TEL. q CONTR. LIC. q EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. n Z 4- 4 APPROVED BY BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN M BUILDING INSPECTOR oh. S -r► �a n d <s— Jhl M \q J M N c rn 'NV-1d10—Id S30V1d3M SIHI 'a3SOdW12d3dnS '013 '83E)vu -VE) 'S3H::M0d H11M 'S9N1a1in9 d0 SNOMN3WIa 10VX3 aNV S3N11 101 WOUA 30NV1SIC CNV 101 d0SNOISN3WIC 10VX3 MOHS1SnW NO1103S SIHI aNODIN JNiaiina VNIIV3H ON PI lil I _ D180313 —I P.L TWA 110 SWOON d0 'ON L /1 SV0 Sb3_IV 3H 11Nn _ _ D.1.H 1NVIOVM 0NINOI110N00 WV MOdVA MO 6.i.M IOH _ Sd31JV4 DOOM S100 R 'sw9 1331S WV31S _ _ S10� V 'SW8 M38W11 _ _ NMn3 MIV IOH 03J803 3JVNMn3 sS313dId I 1s10f OOOM ONIIV3H ll I ONI"Vi 9 OOVO 3111 _ 60013 3111 S36n1X13 N6300W ON1300M 1106 /1 83MOHS 11V1S 13AVdO B MVl ON18Wnld ON ANIS N3HD11JI 31V1S S3ONIHS OOOM A601VAV1 A S319NIHS 11VHdSV 13SOlD M31VM 03HS I" /1 1'X13 LI 'W6 131101 06VSNVW 1368WVJ 'X13 EI HIV9 &H 319V0 oNI93NONIwwnld of II doom 5 3 — 600d I—I 60n1� dns ONIMIM _ 3WVdJ NO 3NO1S ASNOSVW NO 3NO1S A19 M3ON0 MO 'JNO: / 60013 9 -sM1S :)I11V 3WV63 NO AD169 A6NOSVW NO ADI69 —� _ E J1 t SMoo14 — 8 3111 'HdSV NIIIOI 3WV63 NO ODJnls A6NOSVW NO O»n1S ONIOIS '1M3A JNIOIS 101131SI O.NkGdVH `O11VHdSVM H16V3 S310NIHS OOO 3136�NOD 6 S0NMIS 6V109d060 srlvM 17 N3HJ11A NM300W WOOM OV3H S3JV1d 3613 1.W.9 ON V36V DI11V 'NH % 1/1 71 V38V .1.WA NH lln3 V3MV 1N3W3SV9 £ A — — - — E L �1 l E N13Nn 11VM Anae3I - V1d S631d .N\( O.M06VH A 3NO1S 60 )IDI69 3NId 'A.19 3136DNOJ 3136DN0: HSINII V0113INI 8 NOIIVONnOd Z N0110n H.LSNO0 S1N3WLMVdV 53D1330 AiiWV3 'I11nW _— 53160!s I A11WV3 310NIS AONVdn00o l !J rt O a f� n c POP IT mv 3 H H C z m U) MIR4241i T 7 K R. 1 cn tv 3 -n :1) 3 0 -n cn m m 0 > -n o m a 0 0 w c �� c T to r., ?n w c �n d c 3 co v` m r0 O Q��� o v M V4 Im` Building Permit Number 175 Date DECEMBER 2, 1991 THIS CERTIFIES THAT THE BUILDING LOCATED ON 88 LINDEN AVENUE .MAYBE OCCUPIED AS FINISH 1/2 OF BASEMENT IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH P OTHER REGULATIONS AS MAY APPLY. CERTIFICATE ISSUED TO Cindy & Michael Travers o 88 Linden Ave. ADDRESS North A�nrlcwar, MA 3' SACH 9SUSES Building Inspector I r. I l J9 • 1 �S Ilt f t Pjl it r 1� Ifs : 1