HomeMy WebLinkAboutMiscellaneous - 93 CRICKET LANE 4/30/2018 (5)I
D a t e . A /��/A/ ..........
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that . /V!!q �.Q g .........
has permission for gas installation .,,5'e k-, . . j .....
in the buildings of . ..................
at . V. eric kV-., ........... , North Andover,,Mass.
Fee. Lic. No. X�Z9.1(e. . 4,14� �.. " /". .
GASINSPECTOR
Check # 653-6q 73
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
City/Town: Al d -I -I-1-F LkM , MA. Date: JD a // Permit#
Building Location:
/L1f Q L!/1 Owners Name: f,&�&f e y -fj'p_jj
Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential
New: ❑ Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes [j; No' ❑
FIXTURES
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BASEMENT
1 FLOOR
2 FLOOR
3 FLOOR
4 FLOOR
5 FLOOR
—FT FLOOR
7 FLOOR
8 FLOOR
%19 �� 6f Check One Only Certificate #
Installing Company Name:
i ]�v�r�ii? 5
Address: .9 �rJC%C(,�,�Q�� �� City/Town: MA / �2YI State: A � Corporation
❑ Partnership
Business Tel: 5t-%-7230 Fax:
Name of Licensed Plumber/Gas Fitter: mid441tl hke, [Firm/Company
FINSURANCECOVERAGE:
e a current liabilitV insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes �iNo ❑
If you have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy k] Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of tNe
Massachusetts General Laws, and that my signature on this permit application waives this requirement. !
Check One Only
Signature of Owner or Owner's Agent Owner ❑ Agent ❑"`^J
By checking this box ❑; I hereby certify that all of the details and information I have submitted (or entered) regarding this applicatio are true an
accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will b n
compliance with all P2rtinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General �_
"I / / .-7
By ��
Type of License:
❑ Plumber
Title❑
Gas Fitter
=�USEO�NLyi
Master
City/Town❑Journeyman
APPROVED0
LP Installer
Signature of Licensed Plumber/Gas Fitter
License Number: _ 0 Sr %
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k
9i 62
Date 1��4�k. . .
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that Iyl�.4!�
has permission to perform
....................
plumbing in the buildings of
at ... I -e. Z17 ..... North Andover, Mass.
A
496. . /C
Fee. 9?f 09 . . Lic. No. A5.
PLUMBING INSPECTOR
Check #
a
I MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
City/Town: Akin 4 MA. Date: /o
Y-1
41 Permit#
Building Location:_ / .3 R I ciq* L n
Owners Name:!"aNS°1ftGE�•cy
Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional
❑ Residential
New: ❑ Alteration: ❑ Renovation:
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-SUB BSMT
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ZND
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3RD
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FIXTURES
Plans Submitted: Yes O No
DEDICATED
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InSi7iiiii Er+'�iify`Eiii Name:1��%1y1 O►jl9 EE]FirmfCompany
Address: 39 ,/�0<<Lri���� f_
City/Town:/1 Stater
Business Tel:'_ 7l- �jl_�
Fax:
Name of Licensed Plumber: r
C�i1�4-�
INSURANCE COVERnr�'•
C�..tic;�Ai -- ;.
i nave a current Iiad ygs, insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes A No
If you have checked Yes, please indicate the -type of coverage b checking the ❑
g y g appropriate box below.
A liability insurance policy a
Other type of indemnity ❑
OWNER'S INSUhe insurance coverage required by Chapter 142 of the
Bond
RANCE WAIVER: I am aware that the licensee does not have t ❑
assachusetts General Laws, and That my
Msignature on this permi�__, t application waives this requirement.
Si nature of Owner or Owner's A ent Check One Only
Owner ❑ Agent ❑
thereby ge an that all of the details and information I have submitted (or entered) regarding this app►ication are true and accurate r
Knowledge and that all p[��mbing work and installations perr'ormed under the permit issued fort is a 1lcatio
Pertinent provisio of the M ssachusetts State Plumbing Code and Chapter 142 0, the Gene • to the best o my
p s pp ! be in compliance with all
aws.
3y
Type of License:
•itle
❑ Plumber Signature of Licensed Plumber
Ry/Town ❑ Master
PPROVED (OFFICE USE ONLY) ❑Journeyman License Number. _ /,I'*'
Q�(
6�/
DEDICATED
SYSTEMS
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InSi7iiiii Er+'�iify`Eiii Name:1��%1y1 O►jl9 EE]FirmfCompany
Address: 39 ,/�0<<Lri���� f_
City/Town:/1 Stater
Business Tel:'_ 7l- �jl_�
Fax:
Name of Licensed Plumber: r
C�i1�4-�
INSURANCE COVERnr�'•
C�..tic;�Ai -- ;.
i nave a current Iiad ygs, insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes A No
If you have checked Yes, please indicate the -type of coverage b checking the ❑
g y g appropriate box below.
A liability insurance policy a
Other type of indemnity ❑
OWNER'S INSUhe insurance coverage required by Chapter 142 of the
Bond
RANCE WAIVER: I am aware that the licensee does not have t ❑
assachusetts General Laws, and That my
Msignature on this permi�__, t application waives this requirement.
Si nature of Owner or Owner's A ent Check One Only
Owner ❑ Agent ❑
thereby ge an that all of the details and information I have submitted (or entered) regarding this app►ication are true and accurate r
Knowledge and that all p[��mbing work and installations perr'ormed under the permit issued fort is a 1lcatio
Pertinent provisio of the M ssachusetts State Plumbing Code and Chapter 142 0, the Gene • to the best o my
p s pp ! be in compliance with all
aws.
3y
Type of License:
•itle
❑ Plumber Signature of Licensed Plumber
Ry/Town ❑ Master
PPROVED (OFFICE USE ONLY) ❑Journeyman License Number. _ /,I'*'
Q�(
6�/
4
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name (Business/Organization/Individual): N ' r7a4f—h I.�ct t4 , JtA, !i I
Address:
City/State/Zip: Aia�k. ��� Phone #: -7 a �S_'d
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
ployees (full and/or part-time).*
have hired the sub -contractors
2. Or, am a sole proprietor or partner-
listed on the attached sheet. t
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.❑ Plumbing repairs or additions
12. ❑ Roof repairs
13. ❑ Other
-Any applicant trial cnecxs box #I must also fill out the section below showing their workers' compensation policy information.
i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.Q
Insurance Company Name: G Z1
Policy # or Self -ins. Lic. #:�.5`®���� Expiration Date:
Job Site Address: �`� C,�`P yZ- it City/State/Zip:�`/
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under tl zns an pena es of ry that the information provided above is true and correct.
Si nature• Date:!� �,? f
Phone #:
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
Permit/License #
3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
Contact Person: Phone #:
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EXISTING DRAINAGE,
ACCESS AND SLOPE
EASEMENT
�zj NOTE
�JN/F
NENp�EY
SITE IS SHOWN ON TOWN OF NORTH ANDOVER ASSESSORS
MAP #107A LOT #285 SEE E.N.D.R.D. BOOK #11094
PAGE #206 FOR SITE DEED.
0
N
m "I HEREBY CERTIFY THAT THE BUILDING IS LOCATED
ON THE LOT AS SHOWN."
i OF
0
N
i
-- ---- .' ---I--.-r.-.
11/8/11
DATE
PLAN OF LAND
IN
NORTH ANDOVER, MASSACHUSETTS
DRAWN FOR
KEVIN & JENNIFER FLUTH
93 CRICKETT* LANE
NORTH ANDOVER, MA
SCALE: 1"=40' DATE: NOVEMBER 8, 2011
0 20 40 80 120
MERRIMACK ENGINEERING SERVICES
66 PARK STREET
AIVDOM aIASSACXIISMW 01810
PH01M (978) 475-3666 FAX: (978) 475-1448
EMAILJfiWJ NG®AOL COM
/,// '-w �?3 0', C//C-/
Location
No. — c/-, Date z
.:�, A
Check # / C� V
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
TOTAL
Building Inspector
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.FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
*****************************APPLICANT FILLS OUT THIS SECTION***********************
APPLICANT P4t, hy ta, f ei
r 6 -e, �(r�. �� 'C `
PHONE / / tt)—C°?1�-9
Vr
LOCATION: Assessor's Map Number �� _
PARCEL -4 (v
SUBDIVISION JcL
6&4
LOT (S)
STREET g tG e f
L. r /V is
ST. NUMBER
******* **"******************OFFICIAL USE
RECOMMENDATIONS OF
TOWN AGENTS:
CONSERVATION ADMINISTRATOR DATE APPROVED 1k1-x014
DATE REJECTED
ec, S s-od
Pj- e
COMMENTS
\.
TOW LA N R
DATE APPROVED
DATE REJECTED
/�
COMMENfk-,Z " ffi
V
FOOD INSPECTOR -HEALTH
DATE APPROVED
DATE REJECTED
SE�I CTOR-HEALTH
DATE APPROVED
oK
DATE REJECTED
, a I -i
COMMENTS
PUBLIC WORKS - SEWER/WATER CONNECTIONS le-' lZ-lO—�j
DRIVEWAY PERMIT
FIRE DEPARTMENT � l �f�'s' I!Ll� .GL`�^v!�� � 6:00�Z/
RECEIVED BY BUILDING INSPECTOR DATE
Revised 9197 Jim
rt
I
M 0739
Date .....
TOWN OF NORTH ANDOVER
RE_CE=
This certifies that...W4 CvT /
...... e✓
[� I/ .........
...
has paid ..... ....��.. D.
........
for....
/✓y(,� /Co 1...
rc
D
Received by ...................... L
DePartment ...................... t
WHITE: Applicant
CANARY: Department
PINK: Treasurer ,
0
N-0 929
APPLICATION FOR WATER SERVICE CONNECTION
North Andover,'Mass. 19 �L
Application by the undersigned is hereby made -to connect with the town water main in �✓�l�'C,L?I L4 4(f— Street,
subject to the rules and regulations of the Division of Public Works.
The premises are known as No. �,) �te
Street
or subdivision lot no.
Owner Address
T
Contractor
J I }arra Out fool Nt roti. ,a yr' i,.
1t f
Address
Applicant's Signature
Flo':� I
14� (Sf. o 0
PERMIT TO CONNECT
The Board of Public Works hereby grants permission to
to make a connection with the water main at
subject to the rules and regulations of the Division of Public Works.
Inspected by
Date
'H ^WATER MAIN
Street
.� oard f Public Works
By
See back for rules and regulations
TOWN OF NORTH ANDOVER, MASSACHUSETTS
DIVISION OF PUBLIC WORKS
384 OSGOOD STREET, 01845
DRIVEWAY PERMIT
Date:
Telephone (508) 685-0950
Fax (508) 688-9573
LOCATION: /0
BUILDER: phone:
OWNER: �06t� P(?(4o pel phone: 470- 3257
The North Andover Superintendent of Highway Utilities & Operations MUST be notified of the
grade and set -back from street established in any driveway entry onto any street or way maintained by
the TOWN. Call the -Highway Superintendent's Office, before finish grading and surfacing for approval
of such entry.
FAILURE TO COMPLY AND OBTAIN APPROVAL VOIDS THIS PERMIT.
1 Remarks:
Approval:
FRPMFHA NO. 9784702690 D. 03 1399 11:40PO F4
:Z��a1,'19�5 x'64
Pborw(732) 683.1700
FIX(732) 883-4000
WG Y 1101
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NEXTZ NSION KXXDVIJ
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WALNUT RI13GI? MYELOPIr>zw LLc
Fm 1012 I "0 To 1045/2WO
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7ZI TtJliNpU STBIT, SUM l d8 NOR'. AMOVM AAA 01885
Premium &silt Rao por
Coda Total NipNitrlated $400 Ofa"A+Ate+d
t=f"Wealwlno No. An#IUW mUnoraticri Rumunaftllon IursnwN Pnlrtetum
CAPD M'JLYWX 9403 ff ANY SU)
8ALMNIVIOM9CY'Olt81MW8J01TI8 w 674.' IJ ANY8G
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& MM70 AWU4 MINIUM
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WORItM C"ZNSA71ON AND EMMOY&M LIABILITY INSU,R.CNCE POLICY
INFORMA17ON PAGE
] Ol L ev Ne. 9!.,.,,��
1i1' •042L02
1INSUMOS TOM LAUD= /t 94N PITOCCAU1 DAA Reeowot of f 61102 N
WALMTT PMM MV1IDYNt647 LL.G NOW' �
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It tb+ !oaurrd's Rsaiiitta address -.--
3. CCVIIRAO&
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HOW him Marl fAum to
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llrbA11y mabr Part Two mw. Boduly jOw3r by Aed"O al W,000 buhraoident
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i. PREMNNa The preaNson ib! rids policy well be dlawg ned by aur Mm Ws n1'Rtol96, Claseilioatf m, Rattus ml Rxtfna
An law it s u ' to ve:i ucd change by audit.
10ali0J!!Protlriutst
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Total Eat1s .6 $100 of
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um Disaoun if appkabie
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INSURANCE
COMMNY
COMMMLCLAL GCWNAL LUBILM COVERAGE PART
SUPPLINUMAL DECLARATIONS
T1wu 5uppioa+rrmai Tkcleratisa fbrm a peri of policy d mnbar 3CD 1910
LIMI" TSi OF vau"Nct
Gawal Aggnft Limit (**or to Pradlats C-mviotad Opmadioua)
3I,000,00
hu&wWCnw*ed Opasat ou Agpvpte Lint t
EXCLUDED
Pw oaal Lt4 A& ntilinp ijury Limit
EXCLUDED
Flab Oceumwe Lisetit
$ t,000.WD
Fire DaateEo Limit
EXCLUZED Aay oar Fite
Medical &pow Limit
EXCLUDED Atiy Ode person
lii7liir, M A1(+f1C"iVxZl N A" LOC'Alt N OF M.Win COM20 9Y III$ POLICY
F= of Etafntrle:DWBLLt Q A RF.A.L FSTATE DEVELOPMENT
TstdJvtdr:al 0 jo{ut Vaattsra A PorCootx'tip a "on
.,p ;other than Partnersitip or Toil Vcnlwe)
I-Madon of iW prtltrtiaal you owls, rem, Or c goVy: CIWXET LANE AND 31J'ltiLM STREET
NORTH ANDoW.R. b A 0184S
MUM
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Code •PrCrnttlnR i�atti Advwm Pr*w m
TsssutsdClaavtilieatio�(1j Na Bates PYICRr AilOtilar Pr/Co A9I0lhsr
DWELL NO.ONE FAWLY 63010 T)i EXCL S150.% EXCL. $130.00
AL
')2STATS DEV11LOPMENT a�0)
R, Tjzs EXCL =00 EXCL 9550,00
PROFSRTY (334) ACRES
Tnsal
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7W,48tftPLSMi "AL 0BCMItA7MS &VO ng C.OMMAdtCIAt. W491LtTX c)BCLANn7;ONS, TO-AT1t8A W: H 7Hf L COMMON POLDY CONDITION&
COY6RAM 604tWID A.M ="911aCM CCMPLM THE ADOVI MVUSFUD POIJCY
otr.iasu ,aw; MSMORANDUUM OF INSURANCE
a
MAScheck INSPECTION CHECKLIST
Massachusetts Energy Code
MAScheck Software Version 2.01
DATE; 5-14-1999
Bldg.)
Dept.(
Use I
I CEILINGS:
[ 1 I 1. R-30
1 Comments/Location
WALLS:
1. Wood Frame, 16" O.C., R-19
Comments/Location
WINDOWS AND GLASS DOORS:
1. U -value: 0.32
For windows without labeled U -values, describe features:
# Panes Frame Type Thermal Break? [ ] Yes [ 2 No
Comments/Location
2. U -value: 0.33
For windows without labeled U -values, describe features:
# Panes Frame Type Thermal Break? [ j Yes [ ] No
Comments/Location
3. U -value: 0.97
For windows without labeled U -values, describe features:
# Panes Frame Type Thermal Break? [ j Yes [ ] No
Comments/Location
DOORS:
I. U -value: 0.32
Comments/Location
FLOORS:
1. Over Unconditioned Space, R-19
Comments/Location
HVAC EQUIPMENT:
1. Furnace, 92.0 AM or higher
Make and Model Number
I
I AIR LEAKAGE:
[ 1 I Joints, penetrations, and all other such openings in the building
I envelope that are sources of air leakage must be sealed. When
I installed in the building envelope, recessed lighting fixtures
I shall meet one of the following requirements:
1 1. Type IC rated, manufactured with no penetrations between the
I inside of the recessed fixture and ceiling cavity and sealed or
I gasketed to prevent air leakage into the unconditioned space.
1 2. Type IC rated, in accordance with Standard ASTM E 283, with no
I more than 2.0 cfm (0.994 L/s) air movement from the the
I conditioned space to the ceiling cavity. The lighting fixture
I shall have been tested at 75 PA or 1.57 lbs/ft2 pressure
I difference and shall be labeled.
I
I VAPOR RETARDER:
i Required on the warm -in -winter side of all non -vented framed
I ceilings, walls, and floors.
1
I MATERIALS IDENTIFICATION:
i Materials and equipment must be identified so that compliance can
I be determined. Manufacturer manuals for all installed heating
l and cooling equipment and service water heating equipment must be
I provided. Insulation R -values, glazing U -values, and heating
I equipment efficiency must be clearly marked on the building plans
! or specifications.
I
I DUCT INSULATION:
I Ducts shall be insulated per Table 04.4.7.1.
1
1 DUCT CONSTRUCTION:
I All accessible joints, seams, and connections of supply and return
4 ductwork located outside conditioned space, including stud bays or
I joist cavities/spaces used to transport air, shall be sealed
I using mastic and fibrous backing tape installed according to the
I manufacturer's installation instructions. Mesh tape may be
I omitted where gaps are less than 1/8 inch. Duct tape is not
I permitted. The HVAC system must provide a means for balancing
I air and water systems.
I
I TEMPERATURE CONTROLS:
I Thermostats are required for each separate HVAC system. A manual
I or automatic means to partially restrict or shut off the heating
I and/or cooling input to each zone or floor shall be provided.
I
I HVAC EQUIPMENT SIZING:
I Rated output capacity of the heating/cooling system is
I not greater than 125% of the design load as specified
I in Sections 780CMR 1310 and 04.4.
SWIMMING POOLS:
All heated swimming pools must have an on/off heater switch and
require a cover unless over 20% of the heating energy is from
non-depletable sources. Pool pumps require a time clock.
HVAC PIPING INSULATION:
HVAC piping conveying fluids above 120 F or chilled fluids
below 55 F must be insulated to the following levels (in.):
1 HEATING SYSTEMS: TEMP (F)
I Low pressure/temp. 201-250
1 Low temperature 120-200
1 Steam condensate any
I COOLING SYSTEMS:
I Chilled water or 40-55
1 refrigerant below 40
1
1 I CIRCULATING HOT WATER SYSTEMS:
PIPE
SIZES
(in.)
2" RUNOUTS
0-1"
1.25-2"
2.5-4"
1.0
1.5
1.5
2.0
0.5
1.0
1.0
1.5
1.0
1.0
1.5
2.0
0.5
0.5
0.7E
1.0
1.0
1.,
1.5
1.5
I Insulato circulating hot water pipes to •the following levels (in.)
I
PIPE SIZES (in.)
I NON -CIRCULATING I CIRCULATING MAINS & RUNOUTS
HEATED WATER TEMP (F): RUNOUTS 0-1" 1 0-1.25" 1.5-2.0" 2.0+"
1 170-180 0.5 1 1.0 1.5 2.0
1 140-160 0.5 1 0.5 1.0 1.5
I 1.00-130 0.5 1 0.5 0.5 1.0
I
----NOTES TO FIELD (Building Department Use Only) -------------------------
F11
Town of With Andover Planning Board
This form represents the schedule for allowing the following lots to be considered as eligible for
building permits under the Town of North Andover Growth Management by -taw Section 8.7 of
the Zoning by-law. Pursuant to 8.7 .5 this Development Schedule must be filed in the Registry of
Ceeds and be referenced on the deed of each of the lots below and be filed with the Planning
Board prior to the issuance of any building Permit or permit for construction.
name ana Aaaresa oT Appneant tar tots:
Name Of Development: —
Marie Pitochelli
I Ma.p and Parcel of Original Lot:
Walnut i nsion of Gx k�et lane}
C Date of Application for Lo s Division:
October 31. 1997 ,
Lots Covered by this Schedule:
1-10 Cricket Lane
The Planning Board by their signature below, or a signature of a duly authorized representative,
do hereby establish for the above named development the following Development Schedule for
the purpose of Section 8.7 of the G=Mh. managessient By -Law uhe-applicant, their assignees,
successors and or subsequent property owners shall conform to the following schedule that limits
the eligibility of the following lots for building permits. This form must be filed in the Registry of
Ceeds by the property owner or representative and be referenced ort each deed fcx each of the
fcllCwing lots. Such deed reference for the deed of each lot shall at a minimum reference the
book and page in .which this Development Schedule is filed and contain the language: " This lot
is subject to a De'&*kiowent Schedule Pursuant to the. Tonna of Narth Andover- Zoning SY-L aw alt
owners, representatives, and future purchasers should avail themselves of said restrrcNon by
reviewing the approved Development Schedule as filed in Bcok arxi Faye Tire fact
that a lot is eligible for a building permit is subject to Ita lirn►fadw of the number of building
s per yeaf ptirsuant tosectk)n 8.7.2.d of the Zoning By -Law'
The Planning Board hereby schedules the lot(s)-for the above development as shown on the
attached Schedule.
Signature of Planni em or uthorized Representative
f Dat
Signature of P _ vFhorized-Representative-
Gate ,
8.7 Growth iNlanaacment BvL•iw — Walnut Rid• ge
5- i O lots= S buiriding permits per year
' Year = July1 to July I
• Pe-'=ts are airmen out on a quarterly basis i.e. a elite
October, Jan dole lots would .be available in Jufy,
January, and �pnZ'
In the year that the tots are created the
schedtotal number of eligible lots for that year may be
uled in the month the decision appeal period expires
Late LLIglbk I Eligible permits
Cr.year
Yu Iv 1998 r
Oct 1, 1995
5
Total permits
5
10
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 061599
Birthdate: 05107/1943
Expires: 05/07/2001 Tr. no: 9627
Restricted To: 00
RONALD L PITOCCHELLI��
20 RIDGEWOOD DR
ATKINSON, NH 03811 Administrato,
I r
MAScheck COMPLIANCE REPORT I !
MassachuseLLs Energy Code I Permit I
MAScheck Software Version 2.01 I I
I
I Checked by/Date I
1 I
CITY: North Andover
STATE: Massachusetts
HDD: 6322
CONSTRUCTION TYPE: 1 or 2 Family, Detached
HEATING SYSTEM TYPE: Other (Non -Electric Resistance)
DATE: 5-14-1999
COMPLIANCE: PASSES
Required UA = 685
Your Home - 622
Area or Cavity Cont.
Glazing/Door
Perimeter R -Value R -Value
-------------------------------------------------------------------------------
U -Value
UA
CEILINGS 2232 30.0 0.0
79
WALLS: Wood Frame, 16" O.C. 2720 19.0 0.0
164
GLAZING: Windows or Doors 158
0.320
51
GLAZING: Windows or Doors 64
0.330
21
GLAZING: Windows or Doors 435
0.470
204
DOORS 21
0.320
7
FLOORS: Over Unconditioned Space 2040 19.0 0.0
97
HVAC EQUIPMENT: Furnace, 92.0 AFUE
-------------------------------------------------------------------------------
COMPLIANCE STATEMENT: The proposed building design described
here is
consistent with the building plans, specifications, and other
calculations
submitted with the permit application. The proposed building
has been
designed to meet the requirements of the Massachusetts Energy
Code.
The heating load for this building, and the cooling load if appropriate,
has been determined using the applicable Standard Design Conditions found
in the Code. The HVAC equipment selected to heat or cool the
building
shall be no greater than 125% of the design load as specified
in
Sections 780CM2 1310 and J4.4.
Builder/Designer Date
Z
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BUILDING TIES INVERT ELEVATIONS
BUILDING CORNER
A
B C
SEPTIC TANK
SEPTIC TANK OUT
34.4'
19.4'
PUMP TANK
PUMP TANK OUT
24.2
28.4
DIST. BOX
DIST. BOX OUT
31.5'
40.5'
CORN. LEACH
FIELD #1
43.1
49.7
CORN. LEACH
FIELD #2
30.7'
38.9'
CORN. LEACH
FIELD #3
43.6' 30.9'
CORN. LEACH
FIELD #4
53.0' 1 43.9'
io
0
rn
4" PIPE ® FDTN.
= 190.97
SEPTIC TANK IN
= 190.64
SEPTIC TANK OUT
= 190.58
PUMP TANK IN
0.54
PUMP TANK OUT
= 190.70
DIST. BOX IN
= 193.51
DIST. BOX OUT
= 193.35
END LEACH LINE #1
= 193.05
END LEACH LINE #2
= 193.03
AS—BUILT
OF
SUBSURFACE DISPOSAL SYSTEM
LOCATED IN
NORTH ANDOVER, MA.
AS PREPARED FOR
COPLEY DEVELOPMENT
50 COPLEY DRIVE
METHUEN, MA. 01844
SCALE: 1"=20'
DATE: SEPTEMBER 13, 2000
SUBDIVISION LOT #1 CRICKET LANE
MERRIMACK ENGINEERING SERVICES
PROFESSIONAL ENGINEERS * LAND SURVEYORS • PLANNERS
66 PARK STREET • ANDOVER, MASSACHUSETTS 01810 • TEL (978) 475-3555• FAX (978) 475-1448
a
R .11 V
CERTIFICATE OF USE & OCCUPANCY
Town of North Andover
Building Permit Number 6D�/�% Date 0/—/ g -OD
TH/IS CERTI�rFIES THAT
�j �41) THE BUILDING LOCATED ON _/�/n�CIC-� �—
MAY BE OCCUPIED AS Sl P L / 4 m/ I `PSt �.UG� IN ACCORDANCE
WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND
SUCH OTHER REGULATIONS AS MAY APPLY.
8 kvoMS )3 &a Q1,, oZ _Q)faI1 0 V 1�2
CERTIFICATE ISSUED TO�����- ��d5 �- �`�y
p ADDRESS 233 U IIA) I Kee
44ACHUS(Building Inspector
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3 -3 5' 2 Date. . ...............
'kORTN TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ...............................
has permission for gas installation /-4
A ................
in the buildings of ... ... ..............
at C� � / ,
.......... ............ ;,North Andover, Mass.
Fee. Lic. No. .....
�'S INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
0
✓IASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FITTING
or print) Kcvcus
MASSACHUSETTS
Building Locations
Date Lk _ lcj zjcy
s�
Permit # 3 ?
Amount $ ?�
(Print or type) Cck one: Certificate Installing Company
Name Galinskv Plumbing & Heating Inc. . it Corp. _.1,206 .
Address P . 0. Box 1701 Haverhill, MA 01831 ❑ Partner.
Business Telephone 978-374-1743 ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter SS.r:= C Galinskv 4
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes ® No❑
If you have checked Yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy ® Other type of indemnity. ❑ Bond ❑
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner ❑ Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
bgst of my knowledge and that all plumbing work and installations performed under ermit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts St4 Gas Cpde and 9fiaMer 142 of the General Laws.
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
® Plumber
❑ Gas Fitter (cense um er
"v Master
❑ Journeyman
1 ct -I C_
IUA Owner's Name
New
❑
Renovation
❑
Replacement
❑
Plans Submitted
(Print or type) Cck one: Certificate Installing Company
Name Galinskv Plumbing & Heating Inc. . it Corp. _.1,206 .
Address P . 0. Box 1701 Haverhill, MA 01831 ❑ Partner.
Business Telephone 978-374-1743 ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter SS.r:= C Galinskv 4
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes ® No❑
If you have checked Yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy ® Other type of indemnity. ❑ Bond ❑
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner ❑ Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
bgst of my knowledge and that all plumbing work and installations performed under ermit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts St4 Gas Cpde and 9fiaMer 142 of the General Laws.
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
® Plumber
❑ Gas Fitter (cense um er
"v Master
❑ Journeyman
CG
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SU B-BASEM ENT
BASEM ENT
IST. FLOOR
2ND. FLOOR
4
3RD. FLOOR
4TH. FLOOR
sTH. FLOOR
6T 11. FLOOR
7T If FLOG R
RT 11. FLOG R
(Print or type) Cck one: Certificate Installing Company
Name Galinskv Plumbing & Heating Inc. . it Corp. _.1,206 .
Address P . 0. Box 1701 Haverhill, MA 01831 ❑ Partner.
Business Telephone 978-374-1743 ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter SS.r:= C Galinskv 4
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes ® No❑
If you have checked Yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy ® Other type of indemnity. ❑ Bond ❑
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner ❑ Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
bgst of my knowledge and that all plumbing work and installations performed under ermit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts St4 Gas Cpde and 9fiaMer 142 of the General Laws.
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
® Plumber
❑ Gas Fitter (cense um er
"v Master
❑ Journeyman
N2 4382
Date. .........
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
.............
This certifies that
has permission to perform /4', A ;4� .............
plumbing in the buildings of ......
at . . . 14
... J -,--North Andover, Mass.
Fee3�1�)% Lic. No.. . ..... .........
PLUMBING INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
)+pe or print) 1-4-0-
-- MASSACHUSETTS
Building Locations
0
CA A'(— Owner's Name
New 0,-- Renovation [:] Replacement
Plans Submitted 11
Date. 1 0 '"r_) O
Permit #
Amount Z/3 r2—
Plans
2
(Print or type) Check one: Certificate
Installing Company Name G a l i n s k v Plumbing g,ati nv Corp. �Qn A
Address P . O .Box 1701 ❑ ppm
Navarhi 11- MA n1 t`3.il
Business Telephone 978-374-1743 Firm/Co.
Name of Licensed Plumber: Stephen C. G a l i n s k y
Insylag Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy ® Other type of indemnity Bond
Inst ce Walver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
signature Owner ❑ Agent 11
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Pqmit Issuej for this application will be in
compliance with all pertinent provisions of the Massachusetts State umbi Code apt 42 of the General Laws.
BY i a eo
Type of Plumbing License
Title �,�
City/Town �lI VuiTorr Master Q Journeyman 0
APPROVED (OFFICE USE ONLY
V
N22''27 ............................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ....... ;� ..........
........... t ................................................................
has permission to perform ... ...........................................................
wiring in the building of ............... ........ :'.:� ........ .........................
at ......................... .. .................. North Andover, Mass.
Fee Lic. No'�Z:�� ....... -'. ..........................
1,;' EcTRICAL INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
%�� �Er�1'CyitE%rr���.��st�-�?llr��=�4�?r►�d1.5��
BF}ARE}OF-PRE-PRE!fENTKWREFULATfONS 27 CMRA2.M
Office Use onty
O p(
Permit No-
Occupancy
aOccupancy & Fee Checked
APPLICATION FOR PERMIT TO -PERFORM- ELECTRICAL WORK
All work to be pef rated in accordance with the Massachusetts Electrical Code 527 CMR 12:00
Mlease.PdnUmink tgpsall infosnatior*
Town of North Andave
The undersigned applies for a permit to perform the electrical work described below.
# 9.2 CrtCte�
Owner or Tenanty.lJ�lJu-f �2 c� 11SL�/
,reg -
Purpose of
New Service I— C17 Amps �Zz&)LVoits
Date -
To the Inspector of Wires.-
Tom
ires:
Ns- (- (Check Appropriate Boz)
Overhead ❑
Number-ot
Location and Nature of Proposed Electrical Work
Author¢ation No:
Undgmd---C2No. of Meters
Undgmd No. of Meters
INSURAN68-G0Vt RAID Pursuarmo1 -requiremenSts-of Massachusetts General Laws
I have a.currentliaiAtyinsurance Policy plated-Operabonsiaoverage-orats-SVI=Mtial-aqui"- NO =
valid -proof of same to the Of� NO = if you have checked -YES please indicate the type of coverage by checking the appropriate box
N BONDF = OTHER = (Please Spedfy)
(Expiration Date)
Estimated Value of Electrical -Work$
Work'to-_$frt- — InspectierrRe�uestad- Rsugh /ik/l r!� C �� Final
Signed under the-Penaida ur%-(1'
F1RRt- MME �r r4 A) —0 - ry�i P r N r lY cc) LIC. NO.
NO.
Address 1?"e- a� � Alt TeL No.
OWNEW-S- ...,,s.. %X rtio r t�s...� dooanot have the insurance coverage or its substantial equtvatent as required by Massachusetts
General taws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one)
CJ
Tnlanhnnn Nn PERMIT FFF S
Total
No. of Ughtfing Outlets
No. of Hot fuse
No. of Transformers KVA
I
Abgve ❑
In ❑
No. of Lighting Fixtures
S wimming Poolgmb ❑
gmd ❑
Generators KVA
No.
. of Emergency Lgnang
No. of Receptacles Outlets
No. of Oil 8umers
NG.- ot_SwftMOudets—
No-oCGas-8onmrs-
FWMALARMS- No_o('Zone
No. of Detection and
Total
No.`bf Ran es-
Naof Air-Coru
Tons-
Initiating Devices- .
Meat Toter Total
No. of Diposal
No. Pumps
Tons
KW
No. of Sounding Devices
NoJ of Self Contained
No. of Dishwashers
Sosc:WAres Hearing
KW
Detection/Sounding Devices
❑- Municipai- ❑ Other
No ofOry
Oevirae
KW-
-Leak - Connection
No. of
No. of
Low Voltage
No_ of Water Meaters KW
Si s
Balases
LWring
No. Hydro Massa a Tuds
No. of Motors
Total HP
INSURAN68-G0Vt RAID Pursuarmo1 -requiremenSts-of Massachusetts General Laws
I have a.currentliaiAtyinsurance Policy plated-Operabonsiaoverage-orats-SVI=Mtial-aqui"- NO =
valid -proof of same to the Of� NO = if you have checked -YES please indicate the type of coverage by checking the appropriate box
N BONDF = OTHER = (Please Spedfy)
(Expiration Date)
Estimated Value of Electrical -Work$
Work'to-_$frt- — InspectierrRe�uestad- Rsugh /ik/l r!� C �� Final
Signed under the-Penaida ur%-(1'
F1RRt- MME �r r4 A) —0 - ry�i P r N r lY cc) LIC. NO.
NO.
Address 1?"e- a� � Alt TeL No.
OWNEW-S- ...,,s.. %X rtio r t�s...� dooanot have the insurance coverage or its substantial equtvatent as required by Massachusetts
General taws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one)
CJ
Tnlanhnnn Nn PERMIT FFF S
Town of North Andover NORTH
O 4-(%.10 X697.
Building Department �,? 9°; °.'a o
27 Charles Street o
North Andover, Massachusetts 01845
(978) 688-9545 Fax (978) 688-9542
O cocwiwiwc• 1.
�.o4�R�rto �P�,qh
APPLICATION FOR CERTIFICATE OF OCCUPANCY / INSPECTION
6?3Cn wed- Lir' /0� * 1
ADDRESS C(-vAeA L.ya,\Y wo -,C"\ Aho0,)gr
LOT NUMBER 1 SUBDIVISION W A jrut ? %o5e
DATE REQUEST FILED
DATE READY FOR INSPECTION
FIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED
ALL WORK AND SIGN-OFF'S MUST BE COMPLETED WITHIN THIS TIME
FRAME. A RE -INSPECTION FEE OF TWENTY-FIVE ($25.) DOLLARS WILL BE
CHARGED IF THE STRUCTURE DOES NOT MEET ALL APPLICABLE CODES.
SIGNATURE
OFFICIAL USE ONLY
ROUTING
CONSERVATIONN� !- DATE C111 3/oc/
PLANNING DATE _ S O -D
D.P.W. - WATER METER 6f t457 DT 30()0 DATE
s�I
D.P.W. MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED
PRIOR T INSPECTION REQUE T DATE.
SIGNATURE / DPW AUTHORIZATION
N
2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance--,V.ith the provisions of M.G.L. c. 143, § 3L, the A
Permit application form to provide notice Of installation of wiring shall be uniform throughout the Commonwealth,
on the prescribed form. After a pen -nit application has been accepted by an Inspector of Wires appo ted pursua and applications shall be filed
electrical permit shall be issued to the person
firm or corporation stated on the permit application in nt to M. G.L c. 166, § 32, an
T.L. c. 143, § 3L. -
notification of completion of the work as required in UC . Such entity shall be responsible for the
Permits shall -be limited ap to the time of.ongoing construction activity, and may be -deemed -by. the -Inspector -of -Wires abandoned-and-invalid-ifhe—
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 Cliapte 240 of the Actq 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 ail 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 existe�&' during the q,alif�bg period beginning on August 15, 2008 and extending -through August 15, 2012.
*U'ele 8 — Permit(Date Closed:
Pt Note: Reapply for new permit
[1D!--1Pe7rmitExtension Act — Permit[Date Closed:
i
I
This certifies that
Date ..... . —/r/
............... .........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
............. ..................
A
hLas permission to perform .....
wiring in the building of ............... .......................................
at ........... 13 ...... rel ek.,!;7 r
................ ............... A.North Andover M S.
Fee-, Lic. r, ..............
EL Ic N PECT ik
Check
10478
Q
l' 1
Official Use Only
Commonwealth of Massachusetts
Department of mire Services Permit No. IN 78
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (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•ININK OR TYPE ALL INFORMATION) Date:
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice )of his or her intention to perfofm the electrical work described below.
Location (Street & Number) 2_3 C %< i Cke 7'
Owner or Tenant ke V P1 Telephone No.
Owner's Address G1-4,�_
Is this permit in conjunction with a building permit? Yes ® No ❑ (Check Appropriate Box)
Purpose of Building Sly , AM 14. Utility Authorization No.
-T
Existing Service,2e Amps 1A611 ) •wVolts Overhead ❑ Undgrd N No. of Meters
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and.Ampacity
Location and Nature of Proposed Electrical Work: �u_ U.2' 4h 4,4L,_i
Completion of the following table may be waived by the Inspector of Wires.
No. of ReregSerl T,nmiYnairesNo.
02
of Ceil: mus addle Fans
Y' �'c
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires /d
Swimming Pool Above ❑ 'In- ❑
nd. grnd.
o, oEmergency Ligliting
Battery Units
No. of Receptacle Outlets S —
No. of Oil BUr'ners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
.of Detection and
No.InitiatingDevices
No. of Ranges %
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
I 1j!ppk r
Tons
KW
..........
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers f
Space/Area Heating KW , U
Muni ial
Local ❑ Connection El Other
No. of Dryers
Heating Appliances ICS
Security Systems:*
No. of Devices or Equivalent
No. of Water
'
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: �J
01 Attach additional detail if desired, oras required by the Inspector of Wires.
Estimated Value of Electrical Work: ,� .(roo •oc, (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE OVERAGE: 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 [N' BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties of perjury, that the information on this applic tion is true and complete.
FIRM NAME: , /Ilo :�?c4 leo Cyt LIC. NO.: A) -3)a9/
Licensee: Ph i I I I 10 60rc✓( A Signature LIC. NO.: /F -,p &-57/ l
(If applicable, enter "exempt" in the license numb r lin) Bus. Tel. No.: w"-1'.3 SZ21Z
Address: f 4 dza c7% Alt. Tel. No. -.6 /7- 6FV-L- 1f
TPer M.G.L c. 147, s. 57-61, security work requires Departrnent 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------P
-
o:.�...a..-... Til...,{....... PEEIIlIT FEE:
f l www.hzass gov/dia .
Workers' Compensation Insurance Affidavit: Builders/Contractor°s/Electriciants/Plumbers
Applicant Information Please Print Legibly
Name (Business/organization/Individual):
Address:
City/State/Zip: Phone #: .
Are you an employer? Check.the appropriate box: ,
The Commonwealth ofMassachusetts
IV !
'
Department of Industrial Accidents
have hired the sub -contractors
listed
Office of Investigations
L
VJR ,•' 'Boston,
Waykin 600 ton Street
g
MA 02111
f l www.hzass gov/dia .
Workers' Compensation Insurance Affidavit: Builders/Contractor°s/Electriciants/Plumbers
Applicant Information Please Print Legibly
Name (Business/organization/Individual):
Address:
City/State/Zip: Phone #: .
Are you an employer? Check.the appropriate box: ,
I . ❑ P dro' a employer with
4.❑ I am a general contractor and I
employees (full and/or part-time).*
2. (] I am.a.sole
have hired the sub -contractors
listed
proprietor. or partner-
on the attached sheet
ship and. have no employees
These suit -contractors have
working for me .in any capacity,
workers' comp. insurance.
[No workers' comp, insurance
5. ❑ We are a corporation and its
required.]
3. ❑ I din a homeowner doing all work
officers have exercised their
right of exemption per MGL
Myself, [No•vrorke'rs' comp,
c. 1.52, § 1(4); and we have no
insurance -required.] t
.employees. [No workers'
comp. insurance required_]
Type of project (required):
6. Q New construction
7. Q Remodeling
8. Q Demolition
9. Q Building addition
10.0 -Electrical repairs or additions
1 I.0 Plumbing repairs or additions
12.E] Roof repairs
13.M.Other
J-rr••w••. QUA n I muse aUso nn out the section below showing their workers' compensation policy infomtation,
t homeowners who submit this affidavit indicating they am doing all work and then hire outside contractors must submit anew affidavit indicating such.
$Corstracfots that check this box must rttncked an additional ehygt showing• s_he r,.ame of the sub -contractor and theSr Merl a r' camp. policy i pier elan•
I sari an emp lvyer thgtfm prgvzd'eFag:t��, +tep3' c® �per2seadorl isasarra"ce, j`0'_ my. eftTloyees: Below is the policy and job site
informadom
Insurance Company
Policy 9 or Self -ins. Lie,
Expiration Date:
Job Site Address; City/State/Zip:
Attach a copy of the workers' *compensmtion policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required. under Section 25A of MGL e. 152 can lead to the imposition of criminal penalties of a•
fine up to $1,500.00 and/or ane -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 of perjury that life information provided above is drue and correct:
Sienature:
Date:
Phone 4:
Of ficial use Dilly. Do not
-'I dzis !fir ea, to be Gi,:��7ieted by cu`,y or towii official
City or Town:
Permit/License #
Issuing Authority (circle one):
L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector
6.Oth6r 5. Plumbing Inspector
Contact Person: Phone #:
w