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Miscellaneous - 92 BRIDGES LANE 4/30/2018
N LE 1<6 XI— �../...... ..... �.... has permission to perform .U.�, r �Pss ,/¢ L. i wiring in the building of .......................... . at .....p�...16Y .,-USS . L J .......... , N94 Andover, ass. Fee . ..... Lic. No. s/w/ .. ..M...... .... ... . ELECTRICAL INSPEC OR Check # /5-16) Date . 1. �//Z—. .. . TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that 11067 Q� 4 Commonwealth of Massachusetts Official Use Only --� Department of Fire Services Permit No. It 0 Occupancy and Fee Checked JV. BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: q. q, ),4, City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigneedd. Ives notice of his or her intention to perform the electrical work described below. Location (Street &�mber) Owner or Tenant R -0 it W.3'$ Telephone No. Owner's Address Is this permit in conjunction with a build*RvEuzivG- permit? Yes 1:1 No Tit(CheckAppropriate Box) Purpose of Building c -rw>L C ri4h Utility Authorization No. Existing Service -:;100 Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters 1 New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 7Ae /HClc-T t &55 5Pt.3T A 'G 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. rnd. o. of Emergency Lighting 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 g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers p Heat Pump Totals: Number Tons J.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 SecNotof yDevls ices 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 No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: 06 e `' (When required by municipal policy.) Work to Start: 1 19 - )a- 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 the and penalties of perjury, that the information on this application is true and complete. FIRM NANV 611 96 V & 01`1,i t o LIC. NO.: C-- S161 C/ Licensee: `j, nEs %�oU7ov#`►� ���� Sign ur LIC. NO.: (Ifapplicable enter "exempt" in tl�e license umber line. A- f Bus. Tel. No ->X70-��4� Address: �S LawEu ®_ L )-/y ,4,pgtUG // !q f'8� Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lie. 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 Signature Telephone No. PERMIT FEE. $ r • JC'f)GYMd.Cil.C.C](�'!tt./C-(.[�'�.ryLi�l.�F'.L�„Jj�{,9y®p.�YpyY�(+� _ i�6 Ii1.Ll..�0.A�.f'�,Y..l.LlgFSi..IL'tsl.r,f.1l!',IL9." � .. � •. � a . ��sset�-^ [ � -- �'ailefl-�[ � �e-xnspee�ioxt z'eciuzxecX'(��O.OQ) -• ( j �izspectQzs' cop�nents: . (IIIppeetore signature -m knitials) date �'asse�i•-- �+'aiTeti--j � � �t�-�us�aectio�.�'e�tsixec� ($9.00)-• [ � . Titspec �- mtne�xts: ' /441 �. be M&Wectoxs' i9ignature - na dfj s) date 3. MQ DYR iGRODND MgpgCTXON- �assed--[ Cnspectors' comments; [�spectozs�,�ignaiure�no?niiiais) Pale AXPI, CAI,'- r-0 WAT±OXM� 010,1 ; 3ssell--C I s,�ectbx's9 eo9nmeptfs: Vaned-- (�rtspectoxs',�ignatuxe ••7ao an.itials . r z���c�xoz� •- �T.�z�: • to xnspeetionx Pate sect --•F) �azIer -[ j. atenspectioxtzeguixe� ($50.00) �[ - �ectors' p OR TAGS .ARE TO 33E F ` LED 017T.AM YXFT Odd' KITE N TM .A_PXA TO WMECTED 19 NOT t The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations 600 Washington Street Boston, MA 02111 www mass gov/ilia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual)�� : �'AME.5�OCJYoyV-77-Zn t Address: 6-1 COW,- t z CCD, City/State/Zip:_ V • P6,4,z .2 oy6- H4.01 2k `i Phone I' e�>6-0 /,9 - 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 employees (full and/or part-time).* have hired the sub -contractors 2. I am a sole proprietor or partner- listed on the attached sheet. �• ❑Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10;PElectrical repairs or additions 3. ❑ I 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 insurance required.] t employees. [No workers' comp. insurance required.] 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 ace doing alt work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:, Policy # or Self -ins. Lic. #: Expiration Date:, Job Site Address: 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 certto under�unirn(Ippnalties ofperjury that the information provided above is true and correct. Phone #: ') e ) - > 4 d - CSa to - Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # -41 •) cis Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person Phone Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current. policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, M,A, 02111 Tel, # 617-727-4900 oxt 406 or 1-877:AMSSAkIa Revised 5-26-05 Fax # 617"727-7749 wWW mass.govfdia This certifies that .Le.o.rr.r.-Jj has permission to perform ... plumbing in the buildings of.... G%o6z at .... C1,2, -601,Q.c,' zj.. �.. N........... , North Andover, Mass. Fee.. (W% -.� Lic. No(.'507-V. ..% :................ ... PLUMBING INSPECTOR Check # P TYPE OR PRINT CLEARLY FIXTURES 7 MASSACHUSETTS UNIFORM APPLICATION FOR A CI CITY _ Y .--I MA DATE I JOBSITE ADDRESS OWNE' (� �,, 1 I V-p— OWNER ADDRESS OCCUPANCY TYPE COMMERCIAL DE EDUCATIONAL1 NEW: Q4 RENOVATION: REPLACEMENT: Q r o1 -� _ lk Vv'-," v\-G✓J FLOOR - BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN MWOMrM—NOWN—M A OWN FM -WN FW— FM— FM— _ I II®IMMIMMIM! W.,,�3HING MACHINE CONNECTION-- I�IWIIr WATER HEATER ALL TYPES W FW --K FM— 0-0 FM- FI—M WATER PIPING FmWFM- FW- FM ----WW ��FMF�— F�—�� f �t,c,�✓z� INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES .. - NO E] IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY2----- OTHER TYPE OF INDEMNITY I BOND _I 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 M AGENT I 1 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 that all plumbing work and installations performed under the permit issued for this application will be in comp Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I LICENSE # accurate to ne best of my Known With all Vftinent provision of the SIGNATURE MP 0 JP K CORPORATION Q# r PARTNERSHIP FJ #= COMPANY NAME; ADDRESS - -- - - CITY 1 � STATE ZIP ®,��!!�% � TEL $-/ FAX �.rr - f CELL_.7�1f.'.._ ..MAIL FLOOR/ r��r�r®�rMr INTERCEPTOR (INTERIOR) (fir®l�C®IWIW •,FW—WFW—MMFMlM—FMf rFW— FW—�rWfMFM— ff -. • . • MM—M—I®r®I — SHOWERrrr® I II®IMMIMMIM! W.,,�3HING MACHINE CONNECTION-- I�IWIIr WATER HEATER ALL TYPES W FW --K FM— 0-0 FM- FI—M WATER PIPING FmWFM- FW- FM ----WW ��FMF�— F�—�� f �t,c,�✓z� INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES .. - NO E] IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY2----- OTHER TYPE OF INDEMNITY I BOND _I 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 M AGENT I 1 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 that all plumbing work and installations performed under the permit issued for this application will be in comp Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I LICENSE # accurate to ne best of my Known With all Vftinent provision of the SIGNATURE MP 0 JP K CORPORATION Q# r PARTNERSHIP FJ #= COMPANY NAME; ADDRESS - -- - - CITY 1 � STATE ZIP ®,��!!�% � TEL $-/ FAX �.rr - f CELL_.7�1f.'.._ ..MAIL orl z w w w tv-1-1 1 �1 'P. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK I61TY / MA DATE yr 1 11PERMIT# JOBSITE ADDRESS OWNER'S NAME POWNER ADDRESS ge r_ TEL - FAX TYPE OR OCCUPANCY TYPE COMMERCIAL © EDUCATIONAL © RESIDENTIAL, PRINT CLEARLY NEW: Q RENOVATION: REPLACEMENT: ® PLANS SUBMITTED: YES ® NO�-f-( FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM I DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM 1 _ ._,! ( .. I I 1 ___..._ I _.._ _1 _ I -.Y - DEDICATED WATER RECYCLE SYSTEM DISHWASHER _I .__ ._ _3 __.....J DRINKING FOUNTAIN 1 _-_._....1 _--_-ii---._.._! ______1 _ __( --___.-.__I _..._._ i.._____4 _--..__�--..__..� ___._._..1 1._..._ .1 _._.._.._f _....... FOOD DISPOSER _._I .._ -_ _ _-- - .__.._f i I i _.__.._.1 1 1 I ..__...._1 FLOOR /AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE /MOP SINK ___ 1 -___._I ____( __-_� ._—__.1 __.___I ___.__I _-__-.� ..-_-___l ._..._.._1 .--__1 ___--__-f .._-___f ...--j 1 TOILET URINAL 1 ._.___. __-_I _..___ __.-i -.__-.-f .__.____r ,.._...__l ._.._.___E __I ...... 1 ....__f I WASHING MACHINE CONNECTION � _...._ � J _.. I _.._J ___--- _ _ _ i _ _ 1 .. _ . (. _ 1 _I A.... _; _-- _J WATER HEATER ALL TYPES WATER PIPING OTHER _1 _I ._._.._._..I _..._._._( ..._.-_-_....I (.__.___i _-- -� _ I _I F 1 __,1 .._._ _! _ _ ._-1 _..._...1 ___� .... ___1 _-.._._.J .. 1 I INSURANCE COVERAGE: have liability insurance its a current policy or 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 OTHER TYPE OF INDEMNITY BOND [-J 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 �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 he best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in comp nce with all P inept provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME l L� (ILICENSE # . % , { SIGNATURE IMP Q JP CORPORATION [:]# _ I PARTNERSHIP # LLC COMPANY NAME C f ADDRESS CITY I STATE ZIP i-D,�B�r TEL: FAX CELL 19f'... . / MAIL The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Apulicant Information Please Print Legibly [dame Address: X City/State/Zip: &2 � C�/� �/��191AVI Phone .re you an employer? Check the appropriate box: ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 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 E] I 9m 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 y applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. )meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. itractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. n ian employer that is providing workers' compensation insurance for my employees. Below is the policy and job site Irmation. trance Company N icy # or Self -ins. Lib. Site Expiration Date: City/State/Zip:. ach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ure to secure coverage as required under Section 25A of MGL c. 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 in the form of a STOP WORK ORDER and a fine p to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of ;stigations of the DTA for insurance coverage verification. hereby cer$fy under the paj4nd penalties of perjitty that the information provided above is true and correct ffrcial use only. Do not write in this area, to be completed by city or town official. :ity or Town: Permit/License 4 'suing Authority (circle one): Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Other I nformaflon 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 Athe affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. ?lease be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant hat must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current )olicy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or :own)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the Ipplicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each rear. 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. he Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, Tease do not hesitate to give us a call. he Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial A.coldents Office of Investigations 600 Washington Street Boston, MA 021.11 Tel. # 617-7274900 ext 406 or 1--877-MASSAFE a ainibuofs ui to • L4; Cn a - LU C6 ui z V: W LU Z, -L-LJI > • ZO 0 < m z Qa w V) M Ul) LU LD • tzZ.I:N• =LU, - uj L I a Date ..... .... 3.'..�. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........ST L has permission to perform ............t`,..C......(. / ........................................................... wiring in the building of...............� .....................: ............................................... at ........ 2-......1 �jCat� , North Andover Mass. 9 .... . .. . .. . ... . .. . .. . . ....... -. j.. . .. . .. ... .. . .. . .. . 2. Fee ...............:....... Lic. No....7..4.�Zf�............. ............ ........................................ ELECTRICAL INSPECTOR Check # 115705 C.Ommonuwealth 01 VWMJI elfs Official Use Only cc�� c� Permit No. 1 J— .7 fp eUeP.4.d o/ }ire Sevuieea Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 30-/3—/.3 City or Town of: NO %TH AN D&QF T, 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 L e V Owner's Address 6.0 Is this permit in conjunction with a building permit? Yes Purpose of Building 1e%s l Q *%c C Telephone No. No ❑ (Check Appropriate Boa) 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: K I' clue" IRON o VAT/ o/%> Completion of the following table may be waived by the Inspector of Wires_ No. of Recessed Luminaires8 No. of Ced. Susp. (Paddle) Fans No. o Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs _Xbove Generators KVA No. of Luminaires ❑ - ❑ Swimming Pool grnd. d. o. o Emergency ng Battery Units No. of Receptacle Outlets Q No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners of Detection and No. Initiating Devices No. of Ranges No. of Air Cond. Tat l No. of Alerting Devices No. of Waste Disposers l Heat Pum Totals Number �_ _. Tons KW _.._.._...__ No. o Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security ystems:* No. of Devices or Equivalent No. of Water KW Heaters No. o No, of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications irmg No. of Devices or Equivalent OTHER: e Attach additional detail if desired or as required by the Inspector of fres. Estimated Value o 5 Electrical Work: 00 • (When required by municipal policy.) Work to Starts 'S 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 prof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies thatsuch co rag is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (specify:) I certify, under the and penalties of perjury, that the information on this application is true and complete FIRM NAif: TAT s% I N E 1. E cT R: Ac N c. LIC. NO.: 4 ZA Licensee:'I7%t % Ql ANNA &Lo Signature LIC. NO.: (If applicable, enter "exempt llrn the cense number line.) Bus. Tel. No.-,,)) 2 5 9i Address: I I 0 A ftorw 5T MOTI641/w+1 M. R O / Vy Alt. *Per MG.L. c. 147, s. 57-61, 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 a ent. Owner/Agent Signature Telephone No. PERMIT FEE. $ IN I r The CowP10wweaft of ti wxad=Y4ft DepffrtmentglXrzdustPza AcdAw& Office offAvestagwions {IID Washington Strad Burton, MA 02M �ww.massgovldzrx Workers' Compensation Insurance Af'tdavit: Builders/Conimetors/FIectriciam) Plumberq Applicant 15aformation Please Print Le Xy Name (}3tUsineWOrpWzaiiondindMduaQ-. 7A:ItL a nib 14.0.4.44L, ='NC. Address:_ AC kQW 57 • city/State/zip:'T�il �'� t S! t �� ��t �l Phone #:_ Axe yon an employer? Check 1&e, appropriate box: 1.)KI ant a employerwith__5 _ 4. 1 I am a genexa7 contractor and employees (fall • and/or part thne)have hired ihe 2. ci lama soleproprieta orpanfner- ship and have no employees working ivrme in any cagaW [No worms' comp. insane fid-) 3. Q I am a hamxeowner doing allworlc myself [No workers' comp. h maucc eregnized ] t listed on the attached sheet # These sub -cont[ atols have workers' camp. Awmamce. S. ❑ We are a corporation and ft ofte s have womwedf$eir right of exemption per MOL a M §I(4), audwehaveno employees_ [No ward's' came. insmraacnrea fiedl Type oiproject (required) - 6. ❑ New construction 7. Remodeling _ S. ❑ Demolition 9. Q Bing addition 10.Blec�ric�i repairs or additions II.II.rI Plambh*xWtirs or additions 12 O Roofrepaks 1311 Ofer J-,v.kw...cn"ana�ooxIFsmuwrawomourmaacaroaOO waOwMXthOwwOAweuompauS8tfwpoliayfn�atfcm f who9IU*t*affcdav$umdicat�gffisgamdomgatiweakaid�enhdmoulaidacamasamstsnbmitsnest/�idavitia8icatmgau'ezh. tCo�setma�atoLeatc�fsbuatmaetati�hedsaadd�iamelahastshotvmgfhe�nteafti�ers�ltfiair'comg pctlieyint'o�ivn, .tam an erxployerfhatisprovicift mrkeW compmsadm hmwanceformy MWIO'eei BdOW is the -volley andjob site irr}ormatfon. - Insurance Company Policy # or Self -ins.: rob site Attach f atYYsww4: IV - A*ZW-4 ft ag the policy number and ern ra tions date). Pftilure to secure covmage as regvnmedmader Section 25A ofMt}L c.152 can leadto the imposition of cmhnh l penalties ofa. fine up to $1,500.00 and/or one• -yeah i pdsomm ens, as well as oM penalties in tbo foron ofa STOP WORK ORDM and a fine ofvp to $250.00 a day agabdiheviolatoi. Be advisedfmd a copy of'Mb stat memEmaybe fmzwarded to the 0fdoe of Tnvwdgudms ofiheDJA. for ip�cecovm%zeverification. I do hereby ik�r�fonw&nprovidedabove truerdeorrect _- Date: aJJWaluse only. Do not wAte in tl* area, to be corxpl&8d Ay coy ortown &.D?dd City or Town: PermWUcease# hsuimg.&ut#tod(y (circle one): L Board OfHealtlt 2.lh&dbmg Department 3. CTit rown Clerk 4. EiwWc:al inspector S PlunbIng inspector 6 Other ContactPerson: . Phone #: - Date....•.......................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that..................................................................... has permission toprform ....... '-:� a ............................................................ wiring in the building of ............................................ . at,/..c>.( ... .. . .. .................... North Andover, Mass. ...... Lic. N9lq ?,3.3 ................. (2tZL. ]ELECTRICAL INspEcrO R Check # =A Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 9�0 Occupancy and Fee Checked�r or BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the I pect r of Wires: By this application the undersigned gives notice of his or her ' ention to perform the electrical work described below. Location (Street & Number) Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a b ' ding p mit? / Yes No ❑ (Check Appropriate Bog) Purpose of Building%/lti 6 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: vin table may be waived by the Inspector of Wires. No. of Total Transformers KVA Generators KVA 0.0 mergency ig g Batte Units FIRE ALARMS No. of Zones No. of Detection and I nitiating Devices No. Alerting Devices Mumctpat al 1:1Connection ❑Other urity Systems:* No, of Devices or Equivalent :a Wiring: No. of Devices or 1F.—ft-1— No. Hydromassage Bathtubs INo. of Motors Total gp Telecommunications No of Devices or 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 ' urance including "completed operation" coverage or its substantial equivalent The undersigned certifies that such cove a is in force, and has exhibited proof ofj to f� permit iss ing ffice. CHECK ONE: INSURANCE , BOND ❑ OTHER ❑ (Specify:) 1%J"TCI 'zt�J f I certify, under the paintll penal ' of, , ththe in ormation on this application is true and complet FIRM NAME: �-j(� C LIC. NO. uri 33 Licensee: Signature LIC. NO.": (If applicable, enter exemfj t`' in th license number I' e Address: S c l.�t lG f �n rn rj Bus. Tel No.: Alt. Tel: - *Per M.G.L c. 147, s. 57-61, security wor requires Department o Public Saf "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 Signature Telephone No. PERMIT FEE. $ ' (,;O --'-Ion of the No. of Recessed Luminaires — No. of Ceil: Susp. (Paddle) Fans No. of Luminaire Outlets ; ',,No. of Hot Tubs No. of Luminaires Swimming Pool Above ❑ In- rnd. No. of Receptacle Outlets No. of Oaf Burners — i lz No. of Switches No. of Gas Burners No. of Ranges No. of Air Cond. Total Tons No. of Waste Disposers Heat Pump Totals: Number Tons 1 No. of Dishwashers Space/Area Heating KW No. of Dryers No. of Water KW Heaters Heating Appliances KW No. of No. of Sims Ballasts . vin table may be waived by the Inspector of Wires. No. of Total Transformers KVA Generators KVA 0.0 mergency ig g Batte Units FIRE ALARMS No. of Zones No. of Detection and I nitiating Devices No. Alerting Devices Mumctpat al 1:1Connection ❑Other urity Systems:* No, of Devices or Equivalent :a Wiring: No. of Devices or 1F.—ft-1— No. Hydromassage Bathtubs INo. of Motors Total gp Telecommunications No of Devices or 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 ' urance including "completed operation" coverage or its substantial equivalent The undersigned certifies that such cove a is in force, and has exhibited proof ofj to f� permit iss ing ffice. CHECK ONE: INSURANCE , BOND ❑ OTHER ❑ (Specify:) 1%J"TCI 'zt�J f I certify, under the paintll penal ' of, , ththe in ormation on this application is true and complet FIRM NAME: �-j(� C LIC. NO. uri 33 Licensee: Signature LIC. NO.": (If applicable, enter exemfj t`' in th license number I' e Address: S c l.�t lG f �n rn rj Bus. Tel No.: Alt. Tel: - *Per M.G.L c. 147, s. 57-61, security wor requires Department o Public Saf "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 Signature Telephone No. PERMIT FEE. $ ' Q • Location 9�- .. No. � � Date NORT1y TOWN OF NORTH ANDOVER 3? ' °c Certificate of Occupancy $ ,SSACMUSE�� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ X34 • `� Check # w11,37 17316 `'✓ Building Inspect TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: j DATE ISSUED: _ 900 SIGNATURE: Building Commls'sloner/Inspector of Buildings Date _ ' to _ SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard. Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private 0 Zone Outside Flood Zone 0 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT Hstul ic bistl c. • yes O 2.1 Owner of Record SRa�far �.. ��g 9 Z Name (Print) Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone 00 M ic --4 Z O M -I Q r O z M 90 O ic M r v z ^ YI SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 2506) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work(check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: Cc�\ar 51�� FS ,c % SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to beOFFICIAL C-ompletedbypermit applicant USE p;y - 1. Building 00 O (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (e) X (b) J? 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby authorize to act on M ehalf, in all relative to work authorized by this building permit application. ' A-' z\ 3G.2..cOH Signature of Owner Date'— SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Signature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINMERS OT 2 ND 3 RD SPAN DIlv1ENSIONS OF SILLS DMIENSIONS OF POSTS DINIENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE ere.° FORM - U - LOT RELEASE FORM Y`3 0- o INSTRUCTIONS: This forth is usedto verify that allnecessary approval/ permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and` or landowner from compliance with any applicable requirements. r■.....rlr.....■.r..l�.l...■r...•r.....■.■.r.r.�.srequi omen rrrr.r.:rrrr.rrrr APPLICANT S ..� L . L .s NONE I:k - Loi & - 'S-1-1 y ASSESSORS MAP NUMBER. LOT NUMBER SUBDIVISION LOT NUMBER STREET 9 Z fie.\ >i LSatw �ki`TREET NUMBER 0. l. . . 0000...........!... t !00!00. r 1. I--- .... �...... .....l. 0l..'ir.l. i.'0 i!■ OFFICUL USE ONLY ............................................w......l.........•..............i.,...r.......... RECOWRAENDATIONS OF TOWN AGENTS s.i..................................�.......................■ ■..i..l.r.�■ DATE APPROVED CONSERVATION ADMINIS TOR -- -4- �e - DATE REJECTED COMNIIIVTS DATE APPROVED TOWN PLANNER COMMENTS FOOD INSPECTOR - HEALTH SEPTIC INSPECTOR - HEALTH COMMENTS PUBLIC WORKS - SEWER / WATER CONNECTIONS DRIVEWAY PERAW FIRE DEPARTMENT DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR - DATE _ Town of North Andover Building Department 27 Charles Street North Andover, MA. 01845 D. Robert Nicetta Building Commissioner (978) 688-9545 (978) 688-9542. Fax HOMEOWNER LICENSE EXEMPTION Please print. DATE Cf— JOB LOCATION \� C\C—Number Street Address Map / lot "HOMEOWNER `fes I L . :::n% • (,--b8 ' 15 7714 -1$k -5D'� - (obZ\ Name Home Phone Work Phone PRESENT MAILING ADDRESS -a City Town State The current exemption for "homedwners" was extended to include owner -occupied dwellings of two units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. (State Building Code Section 108.3.5.1) DEFINITION OF HOMEWOWNER: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures ac- cessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned "homeowner" certifies that he/she understands the Town of No. Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFIC Zip Code E K SURVEY INC ♦ HAVERHiLL, MA i 3 Phone 978489-19&i 0 Fax 978469.7046 MORTGAGOR _ jj G MAS A640 %M ADDRESS OF PRINCIPLE BUILDING Ad .4ti MkM, AA DEED REF. /73 5 „3 PG. _1 PLAN REF. 5w , DATE OF INSPECTION (mtfga/ Zs� Loos/ SCALE: 1'=6o' 1oTg CERTIFICATION TO:kAULS J&f IA2LjQd4 jfttya4fig RUDEI This Mortgage Plot Plan was prepared speeftatiy for No. 36U t The location of the principle structurels mortgage Purposes only and It is not intended or represented �`F �C < alk dOM,G(7rt!ng C!S 1 t� F with the local zoning bylaws In effect when constructed to be a lisp any line a land Survey. This plan is not to o used SIV UX9 S� and! or is exempt from violation enforcemnent to establish any Of the property lines for any purpose. No action under Mass B.L. Title VII, Chap 40A, Sec. 7. responsibility is extended to the land owner or occupant. • SubJect building is not in a Flood Hazard Area, This certification is based on the location of survey marker O Subject building Is In a f=lood Hazard Area. W others. Flood Hazard determined from the FIRM map#. JOB Dated 1A LJ m m m C m mm LTJ CO) C � CO) CD CD O CL d 0. .O o 0 v CD Cr EL - O to CD CA CD 0 d C'! CD 0 CD a y CD O CD O CD cnw n O z .� M M y 0 0 c ro :3o � �• fA O Q EL N CO2 � w o B m o m Cl) C H C2 dlO� m Z •� m CD M O m y p � y S' O fmmi m a rAo m '+O y, Cf CA ►� W O o co so CL o � O H ' ;� m Om •: �..�y CL . m An O N d H U cr CL; C H2 a r �CD N H� O 16, W w y CD :Z ®� O mo 's N � O CD Eor 40 m" H O a=m� � CLW: nC.) S CD: C* M M y 0 0 c ro :3o � 0 � w z 0 C m :j w G b n M M y 0 0 c