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HomeMy WebLinkAboutMiscellaneous - 91 BOSTON STREET 4/30/2018Date..../..z./..11.!, TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 'Q�caus This certifies that ............. Oc,................................................. has permission to perform.... 11. -PAS....-- .............................: ................. plumbing,in the bu' dings of -R/7--O � G.s �- ...................................................... at.................1.............. ............... ...... ^ ., North Andover, Mass. Fee .?3VLic. No. .�OP.. � V ...................................................................................... / PLUMBING INSPECTOR Check # ' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE � ERMIT# , bl 711 JOBSITE ADDRESS = OWNER'S NAME PVP S P TYPE OR PRINT CLEARLY OWNER ADDRESS I TEL [—___IIFAX OCCUPANCY TYPE COMMERCIAL �If EDUCATIONAL El NEW:9 RENOVATION: ® REPLACEMENT: Q FIXTURES Z FLOOR- BSM BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY f ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING RESIDENTIAL N PLANS SUBMITTED: YES Q NO©I EM®®M WWE F0 —W —FW— FPW " \. i NO�F�—r---r INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YESN NO Ell IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [!A OTHER TYPE OF INDEMNITY [] BOND M OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT 01 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 compli ce with all Pe jAeM provision of the h4assachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME 60 I LICENSE 9 SIGNATURE MPJ (( JP EI CORPORATION �_l #i��PARTNERSHIP PA LLC COMPANY NAME % ADDRESSI 14 CITY _ _ ]STAT 11 ZIP DYl TEL FAX j CELL 11 EMAIL 3 tr o El z W a iui w LL C` t 0 D The Commonwealth of Massachusetts Department of IndustriqlAccWnts Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information PIease Print Legibly Name (Business/Organization/Individual): (7;�v ko P I U � t\ Address: �`' C7. �S'l� Phone3 FV 'N city/state/zip:_Ek_ Are you an employer? Check t: appropriate bog: 1. I am a employer with �� 4. ❑ lam 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.] i 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 - 'Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they ai-e doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. ON / , Insurance Company Name:. / V Policy # or Self -ins. Lic. Expiration Date: Job Site Address: �d� .S� City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido herebycertify rider the pains and enalties of perjury that the information provided above is true and correct. Sienatu 7/ Date: 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 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 oflndustdal Accidents Office ofInvestigatlons 600 Washington Street Boston, M& 02111 Tel, # 617-727-4900 ext 406 or 1-877-:lYJASSAF.B Revised 5-26-05 Fax # 617-727-7749 ww-Mass,govfdaa --d ,z Date. ...........i.............. , TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ................................................. has permission for gas installation ..... ....... ............... in the buildings of...04�)-S,4- ................ ........................................................... at ...............9/.......... ......... ....... North Andover, Mass. — Fee. A0...................... Lic. No. .......................... ..................................................................... Ll 7 GASINSPECTOR Check #/-;? 72 -711 FIREPLACE FRYOLATOR € ^- FURNACE GENERATOR(1 t. --r. I - -� (,-1 I - zrJ T -1 _ �-J GRILLE - INFRARED HEATER ----- --. - -- -- - C- -- r ---- LABORATORY COCKS _1 ._.-� I _ _ �_. �1 .._ .....s . MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT _ 1 TEST UNIT HEATER UNVENTED ROOM HEATER (�- b ATER HEATERS _ OTHER INSURANCE COVERAGE - have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YESLIMP NO [�€ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY W OTHER TYPE INDEMNITY [j BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT E -J] 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 com liance with all Pertinen ision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME . jvv_i ® LICENSE # U SIGNATURE MP MGF ED JP ® JGF D LPGI [I CORPORATION ©# © PARTNERSHIP ®#=1 LLC D# COMPANY NAME: - -1 _ ADDRESS CITY L ON _ _ _1 STATE MZIP j] FAX CELL EMAIL 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY / f� OYQ _"� MA DATE `Z Z -- 0( PERMIT# ► { J l � JOBSITEADDRESS I�%^—O�IY'�Y1�=OWNER'SNAME � G OWNER ADDRESS TEL�VAX TYPE OR OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW: IU RENOVATION: REPLACEMENT: El PLANS SUBMITTED: YES 0 NO E] 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 -- -� - 1 FIREPLACE FRYOLATOR € ^- FURNACE GENERATOR(1 t. --r. I - -� (,-1 I - zrJ T -1 _ �-J GRILLE - INFRARED HEATER ----- --. - -- -- - C- -- r ---- LABORATORY COCKS _1 ._.-� I _ _ �_. �1 .._ .....s . MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT _ 1 TEST UNIT HEATER UNVENTED ROOM HEATER (�- b ATER HEATERS _ OTHER INSURANCE COVERAGE - have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YESLIMP NO [�€ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY W OTHER TYPE INDEMNITY [j BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT E -J] 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 com liance with all Pertinen ision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME . jvv_i ® LICENSE # U SIGNATURE MP MGF ED JP ® JGF D LPGI [I CORPORATION ©# © PARTNERSHIP ®#=1 LLC D# COMPANY NAME: - -1 _ ADDRESS CITY L ON _ _ _1 STATE MZIP j] FAX CELL EMAIL 1 O z"%: 0 H U W A4 w Z, ❑ O dr -1 W �- F-- W OF a Z U w � W � � Q w co W w co g a a a U J a ' < cf' co w s w N LL QO 04 Z F W v.) C�7 � °a Fit e 9 The Commonwealth of Massachusetts - Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organizationgndividual): —r,\l / Address: i -,o uj r\ City/Stale/Zip: 0 C� C� 1 Phone #: h Q 3 I LL9 �� Are you an employer? ChecktI}e 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. # 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 10.0 Electrical repairs or additions 11.&&lumbing repairs or additions 12. Roofrepairs 13.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew 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:. 0 Al Fi Policy 4 or Self -ins. Lic. 9: Expiration Date:. Job Site Address: ! /.7 D �� i� ✓ 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. I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct. Sienature: ( UI�i�/i , Date: %Z_ Z_& `Cr Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit0cense # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone 0: 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 employeils 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 Massachusetts Department of Industrial Accidents Office of In vestigatiom 6.00 Washington. Street Boston, STA 02111 Tel # 61.7-727-4900 ext 406 or 1-877, ASS.AFE Revised 5-26-05 Fax # 617-727-7749 www.masg,gov1dia Date ...... �....-...'.....4..-..7V TOWN OF NORTH ANDOVER RMIT FOR WIRING This certifies that...............G eT/Zi6 . ......................................................................................... /- D� has permission to perform ........... ..�...............................`.......................;................................ wiring in the building of .......... ...�..�-..�-.....<...................................l d s .............................. at ......r..���...1.....e.-r, �. f�.� ..........`.... ........................ North Andover, Maass. F+ee'f`0.!., 7�...... Lic. No. L..'..±1...................� r .:...1 r!.��, t`yff{! ELECTRICAL INSPECTOR 1 Check # � ��� f Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No, i ;oV -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 (MEC), 527 CMR 12.00 (PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date: _ ti _ j h ---- #L 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) Owner or Tenant Owner's Address Is this permit in conjunction with a building permit? Yes EK No F1 C} Purpose of Building _In�t � / � iCl -e Utility Authorizatio - Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service(Z Amps / Volts Overhead Undgrd ❑ Shone No. a45, . ropriate Box) 3 . o er No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of thef 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 [jIn-❑ o. o Emergency Lighting rnd. grnd. Battery Units No. of Receptacle Outlets No. of Oil Burners. FIRE ALARMS - No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Number . Tons '................."".."""""""'.""" KW No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal E] other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices 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 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under thep i s a d penaI sof er�ury, that the information on this application is true and complete. I FIRMNAME: Vl GLIC. NO.: 5 Licensee: rj(�j Signature LIC. NO.: (If applicable, enter "exe t" if the license er A e.) Bus. Tel. No. • �f Address: e 2�(` Alt. Tel. No.: b *Per M.G.L c. 147, s. 57-01, 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. $ �� �� 5� 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 a , electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the 1. 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 ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass F?1 Failed M Re- Inspection Required ($.) ❑ 4 Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INPECTION: T Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Co ts: Inspectors Signature: Date: FINAL INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Commentsi 2P l Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com 1 l Y�. The Commonwealth of Hassachusetts - Department q f Industrig1 Acdd&ts Office oflnvestigations 600 Washington Street .Boston, MA 02111 -wwt•I .mass govIdla Workers' Compensation Insurance Affidavit: Builders/Cont°actors/EIectricians/Pliimber.s Applicant Information Please Print Ledbly Name (Busyness/Organi'zaiion/,tndividuat): Address: m h, L City/State/Zip: T t'•c- 0 Phone #: Are y an employer? Check the appropriate box: Type of project (required): 1. I am a em to er with_ p y 4• ❑ I am a general contractor and I 6. ' ❑New construction employees (full and/or part time) * 2. ❑ I am a sola proprietor or partner- have hiredthe sub -contractors listed on the attached sheet. T 7. ❑ Remodeling ship and'haveno.employees These sub -contractors have 8. ❑ Demolition working forme in. any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions erequired.] 3. ❑ l am a homeowner doing all work officers have exercised.their right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c.152, §1(4), and we have no 12.❑Roofxepairs ins„rancerequired.] employees. [No workers' UnOther comp. insurance required.] NAny applicmtthat checks box#1 mustalso fill outthe section bel6w showingtheir workers' compensationpolicy information. 7 -Homeowners who submit this affidavit indicatingthey air doing all worX and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached m additional sheet showing the name of the sub -contractors and their workers' comp. policy information. X am an employer that is providing workers' comquensation insurance for my employees Below is flie pOliCy anriJOb site information. Insurance Company Name% 5tq$e= Tip4w Policy # or Self ins. ric. Expiration Date• Job Site Address: City/State/Zip: Altach a copy o#the workers' compensation-polley declaration page (showingthe policy number and expiration date). Ta .ure to secure coverage as re% iredunder Section 25A ofMGL o.152 can lead to the imposition of criminal penalties of a up to $1,500.00 and/or 'one-year imprisonment, as well .as civil penalties iu the form of a STOP WORK ORDER and a fine ofup 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 cert& jftdgy,*e pains a4fA 4t eq of perjury &at the information provided above is true and correct. official use Drily. Do not write in this area, to be completed by city or town official. Cityor 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 "...everyperson in. the service of another under any contract ofhim,- express or implied, oral ox written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or mole of the foxegoing engaged in a j oiut enterprise, and including the legal representatives of a•deceased employer, or the receiver or tnistee 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 ox 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 lie -ening 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, MOL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political sub6i''sions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapterhave beenpresented 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 certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are notrequired to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that thisafddavitmay besubmitted tothe Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affndavit. 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 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 that must submit multiple permit/license applications in any given year, need only submit one afldavit 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 b een officially stamp ed or marked by the city or town may be provided to the applicant as proof that a valid affidavit -is on file for fixture permits or licenses. Anew affidavit must be filled out each year. Where a homeowner or citizen is obtaining a license ox' permit not related to any business or commercial venture (i.e. a dog license orpermit 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 Depa'rtment's address, telephone aiid fax number: `the Ga ronwea�it o1a ssa.,cl,vsPtts Department offadustrial .A,ccxdanta Qfte ofTavestigationa 6.0O Washington Street Boston, UA 02111 Tel, #- 617-7.2'1-4900 epi; 406 AM Revised 5-26-05 `ay, 617"727'7749 vWW.ax w'govldia .0 • i 5 -41 03867 -z-74R4 /fie�;e� �or�sf�� f o �u.�lo. Pe��►�� upas �Oul/�r I�Z01I`- Date............................. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION IF I- �,,j K6,PS6A �j 'Shis certifies that......................................................V................................. has permission for gas installation ` .�- P.{ �i ati � � e . in the buildings of at -1A ....... 6 .C-.?... = -�-:...................... ,'North Andover, Mass. Fee... .� b.." .... Lic. No..1JV ....... .!.-. A .................................................... GASINSPECTOR Check # U G TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I NORTH ANDOVER MA DATE JAN.19 2015 PERMIT # JOBSITE ADDRESS 91 BOSTON ST. OWNER'S NAME JFS CONST INC. JOE FRANCIOSA OWNER ADDRESS JFS CONST INC. (JOE FRANCIOSA) 71 TE 978 476-1100 IFAX OCCUPANCYTYPE COMMERCIAL❑ EDUCATIONAL ® RESIDENTIAL❑ NEW: Ej APPLIANCES Z FLOORS 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 NATER HEATER RENOVATION: ® REPLACEMENT: [I PLANS SUBMITTED: YES❑ NOF_]-�I BSM 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 1 10 1 11 1 12 1 13 14 ?67 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ❑ NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E] OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be i co I ante with all Pertin ro ' i n of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME JOHN MARSHALL LICENSE # 778 SIGNATURE MPEI MGF ❑ JP ❑ JGF ❑ LPGI ❑ CORPORATION [:]# PARTNE SHIP ®# LLC ®# COMPANY NAME: EASTERN PROPANE GAS ADDRESS 131 WATER ST. CITY I DANVERS STATE MA ZIPJ 01923 TEL FAX I ICELL EMAIL 11)AK la-e-e"J 6 1 PA.,�,L k The Commonwealth of Massachusetts Department of Industrial Accidents J Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrriccachpns/Plumirint ber► Name (Business/Organization/Individual): Address: 131 Water St City/State/Zip: Danvers, MA 01923 Eastern Propane Gas, Inc Phone #: 978-750-6500 Are you an employer? Check the appropriate box: i . I am a employer with 45 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors listed on the attached sheet. Z. ❑ I am a sole proprietor or partner- These sub -contractors have ship and have no employees employees and have workers' working for me in any capacity. comp. insurance.+ [No workers' camp. insurance required.] 5. ❑ We are a corporation and its 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 11.7 Plumbing repairs or additions 12.❑ Roof repairs 13.0 Other Gas Fitting & Fuel Supply "Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy infonnation. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. xContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees. they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Safehold Special Risk, Inc — EWGCD000080614 Expiration Date: 031 15 / 2015 Policy # or Self -ins. Lic. #: _ � 5 �,.� S} � City/State/Zip: (i o, '� � hLj u►se J +�S � Ul �� b Job Site Address: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of investigations of the DIA for insurance coverage verification. I do hereby certify under thepains nsa d penalties of perjury that a information provided above is true and correct. Phone #: Tr875065UU official use only. Do not write in this area, to be completed by city or town official - City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Contact Person: Permit/License # 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Phone #: N'H477156 ACOR1.. CERTIFICATE OF LIABILITY INSURANCE DATE (M WO DiYYYY) L.� 3�13I2014 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(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER^OINTACT oLAst=_: Donna Desharnals Commercial Lines - 800-990-7465 (CA DOI m OG13561) PHONE = 003-559-1301 "AX 855-529-7034 Safehold Special Risk, Inc. aye ss: donna. desharnais; Dsafehold.com INSURER(S) AFFORDING COVERAGE NAIC x 230 Commerce Way, Suite 230 INSURERA : HDI -Gerling America Insurance Company 41343 Portsmouth, NH 03301 INSURED INSURER 3 Eastern Propane Gas, Inc. CLC_ A3GPE3.?'__),II'APPLIES '_R _ _' AGGREGATE 5 INSURER C P.O. Box 1300 ?RCD' CT3 - CCMC? AGG i 2CGX0G INSURER D INSUR_R E INSURER F Rochester, NH 03306 COVERAGES CERTIFICATE NUMBER: 7441964 REVISION NUMBER: See below THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED B=LOB`± HAVE BEEN I ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTNITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY COiNTRACT OR OTHER DOCUM=NT WTH R=SPECT TO N:HICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERM& EXCLUSIONSAND jD CONDITIONS OF SUCH POLICIES. LIMITS SHO`/`iN NIAY HA",/=- BEEN REDUCED BY PAID CLAIMS. ACCOROANCE'NITH THE POLICY PROVISIONS. INSR IADCL SUER POLICY EFF POLICY EXP LTR TfPE OF INSURANCE n^ /r POLICY NU1A3ER -1'd `A.DGrYYYYi 0d bLDC/YY'f'( LIMITS A X COMMERCIAL GENERAL LIABILITY EGGCDOC003061 3%15127 i 4 3,'15x`2015 EACH CCCJR,RE? C_ 3 2CCCCCO X 0!_A%1 J-MA.:i _ C CCUR P�-11is-J �_3 7-'Uf'�r'0. i 25%000 MED E;<? !Ary ore oeron; .. 3 5.300 ACV INJURY 3 20C G0 CLC_ A3GPE3.?'__),II'APPLIES '_R _ _' AGGREGATE 5 20CC000 POLICY'— JE'T LCC '. ?RCD' CT3 - CCMC? AGG i 2CGX0G A AUTOMOBILELIABILITYEAGODU'00092214 3;15;2014 3i 15;2015 .�33,v^,:i��;c�_..INnT 2.000.;:rc X AAr•( AJ -0 33ciL '! IPiJI;R i 30CILY INJLRY ,Per 3a;=e 3 !-IREO.AJ i'GS � AU � JJ � (fie. 3���d?,^[• UMBRELLA LIAB OCCUR EACH 3CCL'RRE`iCE S ;. EXCESSLIA3 C'-,y1`t3-;•AA.�= AGGR°BAT= 3 WORK RS COMPENSATION A E1j'/GCD000080614 03%15/2014 0311512015. X 07,- AND EMPLOYERS LIABILITY Y 1 N ANY PR PRI :3R PAR V ? EXEC'_'hi=_ vF. ICEF ,I_M3ER _X„_:.v_�' I�; N I A E _A, -1 A. !.. i. - C0.CCC ,(MandatoryinNH)_ EA EMPLOYEE 3 tAOC.00c If f_; de rbe drjer 7e!:vt .Is=A3= • P !ICY Li`d17 ' 3 '• OCC DESCRIPTION OF OPERATIONS I LOCATIONS l VEHICLES (ACORD 101, Additional Remarks Schedule, maybe a[tached if more ;pace is required) Evidence of coverage CERTIFICATE HOLDER CANCIPI I ATION Any cityltown in !Llassachusetts SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE NIA THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCOROANCE'NITH THE POLICY PROVISIONS. MA AUTHORIZED; REPRESENTATIVE /1. rI The ACRD name and logo ars registered marks of ACORD Oc 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) -ti I —11—,q ^5-,a Ire an.n- — L t I ,e. x. •n ,, ,n. , Fold, Then Detach Along All Perforations Location 91 90O�v No. EP< Date , Check #19 9 building Inspector MpRTh TOWN OF NORTH ANDOVER T (J Certificate of Occupancy $ orb+.. � '• • Building/Frame Permit Fee $� Foundation Permit Fee $ 0 Other Permit Fee $ / , 71 TOTAL $ Check #19 9 building Inspector Location No. —? I Date NORTpf TOWN OF NORTH ANDOVER • . • OL n Certificate of Occupancy $ Building/Frame Permit Fee $ �.- y�s Foundation Permit Fee $ rACMU`+E Other Permit Fee Sewer Connection Fee ;s Water Connection Fee $ TOTAL $`r n t2403 Building Inspector Div. Public Works a J J 0 LL 0 a z 0 N z W E Y 8 m' v Z z Z U U 1 O V = °- W N d W >; S00 Z Z W 0 Ir � W tr � 0 W LL 0 W ulIL0 O I N I6 C N d Z m i t>- 1cc i K W IL i s Z 0 v IL Z ° O � 0 1 Ni z W t O O W z 0 < u m z .1�N°0 n 8 a J J 0 LL 0 a z 0 N z W E N Z tr 0 N o Ix < O g�Z 0 LL 0 f - I I O W K � W z �o 4 0 J LL 0 t W a < O > W W W O J z < < a 0 u _z z_ _Z O O O J J J m m m N a N Z LL Z O H u N J W IL L < LL O 0 0 m at %ft * f J ..JUA LU rJ Z z Z U U z O V = 0 i i 0 ! 8 } W z W u W W W z F W O x u 0 uu u d z W< a o; 0 d a u u m 0 d J 3 m< o m m m u W J 0 0 Z M J W W a N Z tr 0 N o Ix < O g�Z 0 LL 0 f - I I O W K � W z �o 4 0 J LL 0 t W a < O > W W W O J z < < a 0 u _z z_ _Z O O O J J J m m m N a N Z LL Z O H u N J W IL L < LL O 0 0 m at %ft * f J ..JUA LU rJ v. Z z Z U U O V = v. O FM4 1 Ll OL W w V w i Cf) CL cY 0 z ►••a G co o w o w W c U c w h a a o W 0-4 w W 00 o Ol u G a o c X. F a H W G rA Q z cn r1 F11 o cn d z im uml CL z 0 w W a hs .a 0 4L co O CD • �• L O Z � 0. O y cm I c O C w La O •O •E mCD CD m CL. F - w ea � 3.0 Cl O O OL cc O d CL CMQ CA O � � c ev 2 •v CD C CD u V! c C C •� C cc V) D o CCD O C � O OC.) d C Ea CD C ca T cm m c E :CD CO� �y N N •+ CD m y mo .0 C N A C O EN m a�mCD c � m LA m m O C: __,,, C! O �a cCl 103m):9 O r C C O C m N m C = m m�3 COD W t •H .,, c • � C � CC �E d.0 v •N Z o LU cm H O. m� --o F. = A m ` H sa�m� z 0 w W a hs .a 0 4L co O CD • �• L O Z � 0. O y cm I c O C w La O •O •E mCD CD m CL. F - w ea � 3.0 Cl O O OL cc O d CL CMQ CA O � � c ev 2 •v CD C CD u V! c C C •� C cc V) D Location No. loo // " 5 e7Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ y'S$A eta Foundation Permit Fee $ s�cMus .. � J� Other Perffiit Fee Sewer Connection Fee !;�'Water Connection Fee Tpj 44 199, i Building Inspector Div. Public Works Location No. Date %oT;�tio TOWN OF NORTH ANDOVER .•` OWL Certificate of Occupancy $ �,_ Building/Frame Permit Fee $ \,cM�SEt Foundation Permit Fee $ Other Permit Fee $ Sewe+c,Cornf%fI"r "' $ Water Connection Fee $ TOTALNY 1 1 $ `-�41'1-' `" uilding Inspector Div. Public Works PERMIT+NO. // O v APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. C' PAGE 1 MAP +40. LOT NO. 12 RECORD OF OWNERSHIP IDATE BOOK !PAGE ZONE SUB DIV. LOT NO.I PAGE PAGE 1 FILL OUT SECTIONS 1 - 3 LOCATION C// ��J�l�� C� /%/�� ��C/ V URPOSE OF BUILDING j 9 �/( 1 OWNER'S NAMEI ,epoer DOWNER'S ADDRESS ,-'Y DOWNER'S cJf•� NO. OF STORIES a _/r ,, IZE �/� /Ge 17 -i J BASEMENT OR SLAB T- I� ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD 'ii�U1LDER'S NAME is SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS POSTS DISTANCE FROM STREET DISTANCE FROM LOT LINES - SIDES ^REAR/y�./ ' V `j ts 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 SEE BOTH SIDES 16 - PAGE 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 // —`— " �V y//PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR _ DATE FILED V SIdlfATURrL-ojF OWNER OR AUTHORIZED AGENT F+E E PEROIT GRANTED OWNER TEL. # CONTR. TEL. # CONTR. LIC. # 3 PROPERTY INFORMATION LAND COST -EST. BLDG. COST EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN -WgwIMV 11140PR6GTOR 'NV -Id lO1d S30V"1d3hl SIHl 'a3SOdW12l3dnS '013 'S3ovbi -VE) 'S3H02:I0d H11M 'SONIa-lln9 d0 SNOISN3Wia 10VX3 aNV S3N17 101 WOUA 30NV1S1a aNV 101 d0 SNOISN3 W 10 10VX3 MOHS 1Sn W N01103S SI Hl zL I ADNvdn00o t GIOD31 ONiaiin9 ONIIV3H ON _ I Pic I 01 P"L 1.W.9 D180313 110 SWOOM dO 'ON L SVJ Sa31V,3H 11Nn 0A.H 1NVIOVa ONINO1110NOD 81V _ SN31iya QOOM aOdVA NO a.1.M IOH WV31S 'Nana aIV IOH (13:)bOi 3JVNbni SS313dld _ _ 'S10:) 8 'SW9 1391S 'SIOD 8 'SW9 b39WIl 1SIOf BOOM ONIMH L L I ONIWVad 9 OOVO 3111 a001i 3111 _ S38nim Na300W 0NIi00a 110b _ a3MOHS 11V1S 13AVb`J 8 NVl. _ `JN19wnld ON 31V1S _ ANIS N3H:)1IX S30NIHS DOOM A801VAVI S310NIHS 11VHdSV 13501 831VM 03HS 1Vli 13a9wVJ ('Xli LI 'Wb 131101 ONVSNVW 'Xli E) H1V9 dIH 319V0 ONiownld O L iooa 5 3bo11a3das 11 good I I ONIaIM _ 3WVai NO 3NO1S ANNOSVW NO 3NO1S 'X19 a30NID a0 ':)NO:) _I 8001i ? Sats 7111V 3WVb3 NO ADIb9 ANNOSVW NO 1101b9 —� E l SbO011 _ 9 3wyai Noxis ANNOSVW NOO O��m1S 3111'HdSV ONIOIS '1N3A N' WWOD ONIOIS SO1S39SV O.MONVH ONIOIS IIVHdSV S31`0NIHS DOOM HidV3 313NJN0J I 6 SQbV09dV10 SIIVM 17 N3HJ11X NN300W wood OV3H S3JVld 3N-li 1.W 9 ON V3NV DII1V 'Nli IA °b % V3aV .1.W.9 NIA llni V3bV 1N3W3SV9 £ _ r L 1 P NIiNn 11VM Aa0 Sa3ld a31SVld 0. M0bVH 240is do )IJIa9 3NId 'X.19 313NJNOJ 313aDNOD HSINId 80183INI - 8 N011VONnoi z N0110nHISN00 SIN3WIbVdV s3Dli40 A11wvi 'ulnw _— S31a0!S AIIWVJ 310N1S zL I ADNvdn00o t GIOD31 ONiaiin9 � - ^.0 � 7 t Fri S� � �i F ,,, }�• u1.y � , ; }' 'A A' tai '3e 'yf �,�ST i rA �. i '° "• . 7,Td 4 j �r at' ', lr � �� a. `F�� .�L. r g. •• . 6 � } 7P2, :. rt v ^a' �" r'NT :,ids• %1' .t '�" :., i "; t;`*a.` i W:4 4 w .• 'F, ...ter:.... / 121 !fir yYh��t' .i � ��3.Fr fi}' f * � T • � r• i , y ✓ a h,may- t � � �� a , - ...«r_...........+r...»_. _ ".r.. u .«.. r -w •. e t . '. 4 �zAp6 a; SM1� �nr9o`� t' ai _V iv � i'n+�a4tS't .� •' 3 rr� J' ik is �1� F � *`'tii ! r .^-'k 4K 'i�yh 1��;+ f .'Y i yyP�,� t i 5 • k+G��h'M ' PrY f .� . �{� }�y,a � ) y ��� '"{��° a3 �.� J� eA cam,, i LP Aw � ,•� d � rw L.!„ {^" `. .���+ KiAh'�Y AX lid �7Y91i�}� �'�i .11-'i J �ry x' '• -` 4� ',t( ' • a`7,pi^�" K. O� OO f '�(x `f ) k 7�, `� t y�•�. j '!' f ,rj T' • • T, , S p, �r{F:i k r t l /t� 'ff ff•,� C • j +. { y)� h 4 h ; R °� �V `3- ' } i�+ � O y �� J N ++ Ni�,y •• [h 7 � ��k'r ►b ,�O ,.r� t , ,+ +YAC ,� jt� �k"' " f; r � is "� `f � ,y��i �,+ . 6+!' ;k',�,� �' , G F •S r IY r 7 t 'S'1f,} _r Sn *�tet' 't'�n'°•p�k t r () F.,t i�%(� ✓ ♦ �"4.°<ky"� f y� `.�+/� tr a�•+'r � it Si w t i''IY t r� e. �.: r i�` � �V- • a r,.,{,?�44, ✓ .�/ F r i r ., � �• rr P Y� �- } tri k , rtt�¢'��t Mit . �h �" <: ; r �•. .; ��" e (1�l Y i � 5f r' T 4 - ° � : av y t L• � r„', Y . �. b'.. h Ya ;,r h •.i} fit lig1K C � � ., � V�✓ t .f�• by f .. ., ' .a 1� � .. :. .. 1, �.�`• ,+ • 06 i ", 10 SO N` i FORM U TOWN OF NORTH ANDOVER LOT RELEASE FORM SUBDIVISION ASSESSORS MAP SUBDIVISION LOT(S) STREET ERMANEN�, AD RESSS (ASS GNED BY D.P.W. APPLICANT -13R-00,� A Al�(J /1/11-0" PHONE DATE OF APPLICATION J� q �/ TOWN USE BELOW THIS LINE PLANNING BOARD TOWN PLANNER CONSERVATION COMMISSION CONSERVATION ADMIN. BOARD OF HEALTH DEPARTMENT OF PUBLIC WORKS DRIVEWAY PERMIT SEWER/WATER CONNECTIONS FIRE DEPT. DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVF,D 4;hl DATE REJECTS RECEIVED BY BUILDING INSPECTION DATE This form shall be signed by the agents of the Planning and Health Boards, the Conservation Commission prior to the issuance of any bu.il.ding permits for the subject lot. This form shall. not releive the applicant from the compliance of any applicable Town requirement or Bylaw. 45 Z e.. ms's' Z J Q W O p Q m O V Z V z c cc L 0) 7 O T C E L C O W z V z m J d L O) 7 O C O W z < V wL yd cp 7 O V m O W v ? a u L OD 7 O W C LU oC C J o O E cc U iL Q 1L CC N lL Q U. m N r Z CO a`i G a C.0 =Z s r O > Lu rA O� �X W a'a CL 0 ao 0 N s 0 z O F Q O 0 w J . CG :O •z :z LN L w L m w m .c a � O Z Location ` - 1091 Date , l %1 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee Sewer Connection Fee Water Connection Fee PAUL lay �C i1i. 2 � 1991 Val- Andovew Qolja�ow $ Building Inspector Div. Public Works PER�ft NO3 APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1 MAP 4-40. LOT NO. 2 RECORD OF OWNERSHIP IDATE BOOK '.PAGE ZONE SUB DIV. LOT NO. F— LOCATION PURPOSE OF BUILDING 'l y rs'` OWNER'S NAMElad/l �l�,� V (f ,) N NO. OF STORIES SIZE y Y� a // OSI ,2,� OWNER'S ADDRESS BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME en u J o SPAN DISTANCE TO NEAREST BUILDING DISTANCE FROM STREET DIMENSIONS OF SILLS "' POSTS DISTANCE FROM LOT LINES - SIDES REAR GIRDERS AREA OF LOT /qJ FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW/f�.A ✓/1/(J SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION Ash 15 BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE 1' 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 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 FILE FEE PERMIT GRANTED CONTR. TEL. it CONTR. LIC. 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST s EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN 'NV -Id 101d S30V ld31:1 SIHl 'a3SOdW12I3df1S '013 'S3vvu -VV 'S3H02d0d H11M 'S9N1a-11(18 d0 SNOISN3W1a 10VX3 aNV S3N11 101 WONA 30NV1S1a aNV 101dOSNO1SN3W10 10VX3 MOHS1Sf1W N011035 SIHl El I A0N V d (1000 L - a4033a oNiaiina 0NI1V3H ON _I Pic I +sl P -L 1.W.9 :)I81:)313 110 SWOOV i0 SM0 S831V3H 11NI1 J LH 1NVIOVd JNINOI110NOJ 8IV MOdVA 80 8.1.M lOH MRS 'Ndnj aIM lOH MAW 3JVN8nj SS313dId I _ _ _ Sd31dVd DOOM SlOJ V 'SW9 1331S 'S10J'8'SW8M39W11 1SIOf OOOM `JNIIV3H it I 0NIWV114 9 OOV(l 3111 d001j 3111 _ S3dn1X1j Nd30OW JNIJOOd 1108 _ _ 83MOHS 11V1S `JN18Wnld ON 13AVdO 8 8V1 31M1s _ ANIS N3HJ11A S30NIHS 000M _ QOIVAV1 S310NIHS 1lVHdSV 13SOlJ 831VM 03HS 1Mlj _ 131101 08VSNVW 1389WV0 'XIA E) HLV9 dIH r 318MJ 'JNiownld OL 4008 9 r-1 800d 3801J3d S `JNIHIM 3WV8j NO.3NO1S ANNOSVW NO 3NO1S X18 830NIJ 80 'JNOJ _I NOO14 8 'SN1S JI11M 3W78—ANO XJI89 QINOSVW NO XJI89 — _I I E �V jjj"'��� _ 8 3111 'HdSV NIIIID Nomnis ABNOSVW NO OJ551S ONIOIS '183n `JNIOIS SlIS31SI ONIOIS 11VHdSV O.tACdVH H18V3 S310NIHS 0008 3138JNOJ SONVOUVlNIGIS j SM001i 6 II S11VM y W008 OV3H 1. 19 ON '/i % 1/1 llnj V38V N3HJ11X NN300W S3JVld —Td —1:, V3NV JI11V 'NIJ V38V .1.W.9 NIA 1N3W3SV9 £ £ Z _ I E N13Nn 11VM A80 N31SVld S831d O.MONVH 3NO1S NO XJINB 3NId 'X.19 3138JNOJ r 3138DNOJ HSINIi 210I831NI 8 NOI1VONnoi Z NOI10nUISN00 S1N3W18VdV _— S3JIHd0 —_ AIIWMj I11nW S31801S AIIWMj 31ON—IS El I A0N V d (1000 L - a4033a oNiaiina OFFICES OF: APPEALS BUILI-)ING CONSERVATION HEAL"I'H PLANNING �? Town of • - m •` NORTH ANDOVER 1)IVISK)N (W PLANNING & COMMUNITY DEVELOPMENT KAREN 1-1.1". NELSON, DIREC'FOR 120 Main Street North Andovcr, MilssilCI1115CIIS O 1847, (6 1 7) 685-4775 In accordance with the provisions 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 c ill, S 150A. The debris will be disposed of in:g (Location of F cility) Signature of P nit Applicant ate NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. 14• r V4. CONSERVATION DEPARTMENT Community Development Division June 4, 2015 Joe Franciosa Coastal Brook Realty, LLC jfranciosa95@gmail.com RE: Selective removal of 1 damaged tree and pruning of 2 additional damaged trees located within the Buffer Zone to Bordering Vegetated Wetland at 91 Boston Street. This is a follow up letter pertaining to your request to remove one (1) tree and prune two (2) additional trees which are damaged and hanging over the yard at 91 Boston Street. All three trees are within the Buffer Zone to Bordering Vegetated Wetland but are outside of the 25' No - Disturbance Zone. The trees were identified during a site visit by the Conservation Department on May 28, 2015. The trees which are permitted to be removed and/or pruned are identified in the attached photos. (A Wetland Delineation was completed in 2014 and is shown on the plan for the property, wetland flagging was still present and visible at the time of the site visit for the above referenced trees.) *Determination of property ownership is the responsibility of the property owner. Due to the potential danger imposed by the trees, the Conservation Department will permit their removal or pruning to prevent possible injury or property damage. These cutting activities shall be limited to the three trees identified and shown in the attached photographs. The approved cutting will be subject to the following conditions: ❖ No machinery shall enter the 25' No Disturbance Zone. ••• No work shall occur in resource areas. ❖ All tree limbs, brush, and other debris materials shall be taken off site and disposed of properly. ❖ Stumps of the trees shall not be removed and shall be left in place. Stumps may be ground down or cut flush with the landscape. ❖ Care shall be taken to prevent damage to surrounding trees during removal of the approved trees. ❖ Upon completion of the tree removal, all disturbed areas shall be properly stabilized. 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 918.688.9530 Fax 918.688.9542 Web www.townofnorthandover.com �'z1 w' c �. .'�}tit^ r'°"} �jac .41 i}t{--• P.� �' +�`'. y, f•' "`�- -� �i-. �yKh� may* . 1 FC e � YF�^- .���� o•_.Y .. Kyr. .�X� n �'r''�F13e`.r �'Y� r �-.,.s