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Miscellaneous - 94 BLUEBERRY HILL LANE 4/30/2018
Date. A.5 ................ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that . ................................................. . .. ..... ........ . .. .... ....... ....... has permission to perform ........................................................................................................ wiring in the building of ...... erve- 6U, e- .................................................................................................. at ... vc ---t(m hA Andover, Mass. .... ... . ....... n .......... ......................... ................ ........ ........... ... Fee n..77)� . ....... Lic. No 2 ........ A ....... . . . .. ............ ELECTRICAL INSPECTOR Check # Commonwealth of Massachusetts Department of Fire Services a , BOARD OF FIRE PREVENTION REGULATIONS Official U e Only Permit No. 1� Occupancy and Fee Checked [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (NEC), 527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL )NFORMATION) Date: "/-1 i j City or Town of: NORTH ANDOVER To the Inspec or of ices: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 3?,dI' �e�r�e- ��. o 4r- e Owner or Tenant Telephone No. 15 /17sjj��j�%%� Owner's Address�►� Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service '�[7 Amps 117>1rVY0Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: ev,yr oar Completion of the; 4 No. of Recessed Luminaires No.of Ceil: Susp. (Paddle) Fans 4,e No. of Luminaire Outlets 40No. of Hot Tubs No. of Luminaires No. of Receptacle Outlets No. of Switches No. of Ranges No. of Waste Disposers No. of Dishwashers - No. of Dryers o. 11AA Swimming Pool rnd. rni No. of Oil Burners No. of Gas Burner No. of Air Con Total Tons Heat Pump umber. Tons K1 Totals: Space/Ara Heating KW Heati Appliances KW No. No. of .... - Ballasts ortrevices or INo. Hydromassage Bathtubs INo. of Motors Total HP I'-tT o of Devices or iWu WaNent OTHER: Attach additional detail if desired, or as required by the Inspector of 97res. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: /J Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE GE: 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 pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME:. /� LTC. NO.:�;616;b Licensee:�%%��e� /�yrv,.,✓ Signature LIC. NO.: (If applicable, enter "exempt" in the lice e nzrm�?er Zin) / Bus. Tel. No. ''T.3 re3� Address: �4;w cam d 6Aw /&C-3.✓ ow— /%l� Dl � Alt. Tel. No.: *Per M.G.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 agent. Owner/Agent PERMIT FEE.- FEE. $$ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall -be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose.of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending -through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass F?1 Failed Re- Inspection Required.($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signat re: Date: FINAL INSP TION: Pass IN V Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date:—l�-� DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com Commonwealth of Massachusetts i Official U e Only PermitNo. �� Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. l/07j (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 INMK OR TYPE ALL XNFORMATION) Date: " j City or Town of. NORTH ANDOVER To theIns�ofMires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street &Number)!7 A. Y74,e 4. e, ����,., C _ Owner or Tenant Telephone No. egz7z J,j agj l-; Owner's Address 5a-,nc Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service dlJ Amps lJ1V1eVY0Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity No. of Meters l No. of Meters Location and Nature of Proposed Electrical Work: eVoxe r e ui ,&9" Ir P— .moi/ Completion ofthe 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 - ❑ rnd. rnd. o. o mergency ig ting BatteU Units No. of Receptacle Outlets 3 No. of Oil Burners FIRE ALARMS No. Zones No. of Switches No. of Gas Burner No. of Detection an Initiating Devices No. of Ranges No. of Air Con Total Tons No. of Alertin evices No. of Waste Disposers Heat Pump !I mber - ' """" Tons '" ......._.....""' KW "".........""'" No. of Self- ontained Totals: I Detection/Alerting Devices No. of Dishwashers Space/Ar a Heating KW Local unicipal El j/' Connection No. of Dryers Heati Appliances KW Securi# Systems:* N . of Devices or Equivalent No. of Watey KW No. 9f No. of Dat iring: tersins Ballasts o. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Te communications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of 9 res. Estimated Value of Electrical Work: p�f,GGCJ (When required by municipal policy.) Work to Start: /J Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE GE: 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: INSU_RIANCE ❑ BOND ❑ OTHER ❑ (Specify:) X certify, under tlae pains and penalties ofperjury, that the information on this application is true and complete. FIRM NAME: _ L �� Pa LIC. NO.: Licensee: �%%�c� /�y✓.� Signature LIC. NO.: (If applicable, enter "exempt" in the lice a num}er liny)� / ^Bus. Tel. No.•jl_7 �03� Address: ��//cam d �6/ �y�l�.t�tr' %%J� 6!%'�J Alt. Tel. No.: *Per M.G: 0 147, s. 57-61, security work requires Deparhnent of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE. $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. `. Permits shall -be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose.of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8—Permit/Date Closed: � *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass 0 Failed Re- Inspection Required.($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass R Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signatre: Date: FINAL INSP TION: Pass IN V Failed (] Re- Inspection Required ($.) ❑ Inspectors Comments: AA Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com -a The Commonwealth of Massachusetts Department oflndustrialAccidents I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information y� Please Print Lel_ibly Name (Business/Organization/Individual): Address: y 4 a/ City/State/Zip; Phone #: f% Yom.? ylo Ff Are you an employer? Check the appropriate box: Type of project (required): 1. am a employer with _employees (full and/or part-time).* 7. ❑ New construction 2.❑ I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 9. ❑ Demolition ❑4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my properly. I will 10 Building addition ensure that all contractors either have workers' compensation insurance or are sole 11. c ical repairs or additions proprietors with no employees. 12. ❑Plumbing repairs or additions 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. 13. ❑ Roof repair's These sub -contractors have employees and have workers' comp. insurance.# 6. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 14. ❑ Other 152, § 1(4), andwe have no. employees. [No workers' comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submif 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 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 P Co Policy # or Self -ins. Lie. #: Expiration Date: /�� �•�� Job Site Address: Z--7 /�/rC/�t/�y `�� Grr r' City/State/Zip:/!/a,,/4/ Attach a copy of the workers' compensatio policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. 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 z s andpenalties ofpeijury that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/'I'own Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Phone #: Information and Instructions �� ' Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should'enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia �(�` COMMONWEALTH OF MA55�GHUSETTS BOARD OF EiCRICIANS ISSUES THE F0LLOWING>LIGENSE AS A ,, % I — R STERED MASTER :ELECTR I IAN` '¢ E" Mf U.- EL W DAMOUR 6 MOODY:`ST c NANDOVER MA 01845-171... 20080>A 07/3:.1/16 56963 C . oil .. This. certifies that........ has permission to perform ... plumbing in the.buildings of at......... 4.... 2 ... !� ..... ... Fee .4.1� .... Lic Check#w. Dated/i. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ......... .................................... U) .... fe..W.PZIA ............................. ................................................. � LO ....... No h dover, Mass. ��L m ... ................ .... ... ............................. I�sp c PL MBIN6G INS CTOR 19010 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY r% X70c� MA DATE6� i5 � [ PERMIT# _� OWNER'S NAME br1 JOBSITE ADDRESS 4 B�� - � �'� tiE�U- TEL FAX P OWNER ADDRESS �� � �` EDUCATIONAL RESIDENTIAL, TYPE OR OCCUPANCY TYPE COMMERCIAL Q PRINTPLANS SUBMITTED: YES ® NO Ell CLEARLY NEW: RENOVATION: REPLACEMENT: � R 9 10 11 12 13 14 FIXTURES FLOOR- BSM BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASl01LISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN F00 ER FLOOR I AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ,_. �;HOWER STALL SERVICE./ MOP SINK TOILET WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PI�PINNG---- OTHER INSURANCE COVERAGt: I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES]E NO 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY4 OTHER TYPE OF INDEMNITY 01 BOND E1 OWNER'S INSURANCE WAIVER: I am aware that thIon this does not h the insurance cove . permit on waves this requirement. CHECK by Chapter 142 of the Massachusetts General Laws, and that my signaturep CHECK ONE ONLY: OWNER [] AGENT i[D SIGNATURE OF OWNER OR AGENT I cation true accurate to the best of my hereby certify that all of the details and information Ihave b he I t m t issued fo thasdapplicationpwill be i acompl ge ance with all Pertinent provision of the and that all plumbing work in performed Massachusetts State Plumbing Code and Chapter 142 of the General Laws. SIGNATURE PLUMBER'S NAME A �I ✓J .. �d 14 "`� I LICENSE # CORPORATION#�PARTNERSHIPQ# s LLC ._.__1 IMP EI JP I ADDRESS �T L Ayers. t7- COMPANY NAME < t�:4v ��% n1 fN� "� ` f 3 Y I STATE .417ds I ZIP D / 9 TEL 7e CITY Yr'1 �-i WO FAX E= CELL __.._...I EMAIL 'n Z f. Q ., f. oM The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): 12.4 0 10 /4 L- N t2 Address: J 6 A Y'64-- gi'4L- e City/State/Zip: n4 e --r t"- "' , 144�S o t V4`4 Phone #: 9 7 F G Y7 tt 2f- Are Y Are you an employer? Check &e appropriate box: Type of project (required): 1.❑ I am.a employer with employees (full and/or part-time).* 7. [:1 New construction 2 I am a sole proprietor or partnership and have no employees working for me in 8.Remodeling any capacity. [No workers' comp. insurance required.] n 9. Demolition 3.Q I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 10 ❑Building addition 4.F1I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole 11. ❑ Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5. ❑ lam a general contractor and I have hired the sub -contractors listed on the attached sheet. 13. Q Roof repairs These sub -contractors have emploYees and have workers' comp. insurance.$ 14.Fl Other 6.❑ We are a corporation and its officers. have exercised their right of exemption per MGL c. 152, § 1(4), and Nye have no. employees. [No workers' comp. insurance required.] '.. *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submif 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 state whether or. pot those entities have employees. If the sub -contractors fiave employees,1hey must provide their workers' comp. policy number. I am an employer that is piovidhig workers' compensation insurance for my employees.' Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lie. Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Phone #• 57 7 a— G ,- -7 11,3 r 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): i 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, expres's 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 foi• 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-NUSSAFE Fax # 617-727-7749 Revised 02-23-15 www.iri ss.gov/dia Ono °IRATION W �� /rii2y 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L, Permits shall -be limited as to the time of ongoing construction activity, and maybe-deemed.by thelnspector_of-Wires abandoned.and-invaliddfhe—_.. _ or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this puipose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15,A 8 and extending -through August 15, 2012. KRule 8—Permit/Date Closed: ' /,,._ZCP---/V f� * * Note: Reapply for new perr ] 0 Permit Extension Act — Permit/Date Closed: 1 1 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall -be limited as to the time of ongoing construction activity, and maybe.deemed-by the lnspector_of-Wires abandoned-and.invalid.iflre—_.. _ 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 Chaoter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this puipose by establishing an automatic four-year extension to certain permits and licenses concerning the use of 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, 2A8 and extending through August 15, 2012. >&We 8 — Permit/Date Closed: ❑ Permit Extension Act—Permit/Date Closed: *** Note: Reapply for new M Al � 3 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..... ..f�.. .............. .. �.; - ,>.�....... has permission to perform---!. ............................................ wiringin the building of................................................................................... at .. Iny . ......... ... ..... -.. , North And ver, Mass. ..... Lic. No. .. .. .c .....` ... ...... ` ELEcrRic I sPa " x ! Check # 9340 ----------— (_cco��mmorweaa o a�3aclucsetfi .1JaPar�mrnE o��irs �ervics9 BOARD OF FIRE PREVENTION RE'SULATIONS Official Use Only Permit No. 5'3N0 _ Occupancy and Fee CheckedS . Rev. 1/07) (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All wort: to be performed in accordance with the Massac'nusetts Electrical Code (MEC). 527 CMR 12.00 (PLEASE PRINT IN INK OR 7TPE ALL INFORMATION) Date: V-7- 140 City or Town of: JV , A (1,.1�n Q 1ES""' 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) ' -9 Owner j tQ,•e�i�� (�� y 1 Owner or Tenant n Car- k n in Telephone Noq%S Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps 1 Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps I Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: -e tdFe s7fw ramnleiion ofthe following table may be waived by the Inspector of 6flires. No. of Recessed Luminaires No. of Ceil.-Susp- (Paddle) Fans Tr o Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA )\ o. of Luminaires Swimming Pool Above In- ❑ d _rnd. prnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS TNo. of Zones No. of and No. of Switches No. of Cas Burners evices InitistinDevices No. of Ranges No. of Air Cond. Tonsl No. of Alerting Devices Heat ump Number Tons KW o. of Self -Contained No. of Waste Disposers P Totals: Detection/Alerting Devices No. of Dishwashers ace/Area Heating KW Sp >; Local ❑ 4uniectio ❑ Other Connection No. of Dryers Heating Appliances pp KW Security S stems:, No. of 6evices or Equivalent) ;\o. of Water KNV No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wirine. No. of Devices or E uivnIent OTHER: q "7- �_. _n.:r �_----� , d 6.• ,h,, !nc»wriro• of !!'Ings. Anacn amenionat avert, 1� c,ra-4. v, -, --w ••.•• •: •.._ ..._,------ -+ _. Estimated Value of Electrical Work: ✓- (When required by municipal policy.) Work to Start: J�S 9-'P 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 ; l BOND ❑ OTHER ❑ (Specify:) 1 certifi'. tinder the Pains and penalties of perjun•, that the infornnation on this application is true and cunnplere. S FIRM NAME: LIc. No.: Signature �7�~ ..r�� LIC. NO.: Licensee: , (If applicable, enter "exec ren the /.yen a miaiher Iine. 1� �,�s Bus. Te.. i�0.:_ Address ? a rs, _ All -Tel. NO.: *Per c. 1a7, s. 57-61, se work requires Department of Public Safety S License. Lic. No.�S Oo *Per M.G.L..G.LRIS INSURANCE \J'A1�'£R: i am aware that the Licensee does not have the liability insurance coverage normally ONVrequired by law. 13y my sienawre below, I hereby waive this requirement. i am the (check one) r-1 e�+Per ❑owner /gent. OwTelephone No. EPIR;ner/Agent917FEr: Signature 9q Department of PUb(ic Safety One Ashburton Place, Rm 1301 Boston, Ma 02108-1618 License: Certificate of Clearance Number: SS CC 001975 Expires: 10/09/2011 Restricted To: 00 KENNY WONG 18 CLINTON DR HOLLIS, NH 03049 ;-CAI u 40M-0a0&DBS1JF0RMCA10e212ooa ✓/u IOovsr9ssoTuyea� /,GGaasar/.r�srt Vj DEPARTMENT OF UBLIC SAFETY Certificate of Clearance Number: SS CC 001975 Expires: 10/09/2011 Tr. no: 558.0 S -License: ADT SECURITY KENNY WONG 18 CLINTON DR HOLLIS, NH 03049 C : O141,AC)14 .E ALTH O; 1AASSkC14LIG E c l , LEC iR REGISTERED SYSTEM TECHNICISAN ISnJ'ca'1H15ib:EI:SE7t? . KENNY Q WDNG-. 22 FIELDSTONE DRIVE BURLINGTON -- HA 01803-42.13 5966 D y, 07/31/1.0 284072 Tr. no: 558.0 Keeptop for receipt and change of address notification. 1-3 to 64 h DIG SAFE CALL CENTER: (888) 344-7233 n Date.. "dam ......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING ......................... .......... This certifies that .............. has permission to ........... wiringin the building of ................ .................................................................. at .... North Andover, Mass. Fee.!IRs..e ....... Lic. NofilllvA�l .......... ELECTRICAL INsP OR Check # 794 511 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. /79yxs' Occupancy and Fee Checked [Rev. 1/07] (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 ININK OR TYPE ALL INFORMATION) Date: ? •-� '8 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) 9 H 3i��� � W,\l �6 \ Owner or Tenant ��hC\ Telephone No. Owner's Address Cj A. -Q Is this permit in conjunction with a building permit? Yes 0 No ❑ (Check Appropriate Box) Purpose of Building (&C)n Utility Authorization No. Existing Service a(X3 Amps Jdp / Volts Overhead ❑ Undgrd New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity -1(\!* 61Z- �\� Location and Nature of Proposed Electrical Work: \' IS, r, lvf;.,...,f sl. ! 17_. .'. _L7 No. of Meters No. of Meters No. of Recessed Luminaires d No. of Ceil: Susp. (Paddle) Fans — u 2lnuy ae wulveu a Ine inspector oI wires. No. of Total Transformers KVA No. of Luminaire Outlets .S No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- ❑ rnd. rnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches d No. of Gas Burners No. of Detection and Initiatin Devices No. of Ranges No. of Air Cond. 1 Total 3 1Tons �7 No. of Alerting Devices No. of Waste Disposers Heat Pum Totals Number - Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers ' Space/Area Heating KW Local ❑ Municipal ❑Other Connection No. of Dryers ' No. of Water KWNo. Heaters Heating Appliances KW of No. of Signs Ballasts Security o Systems:* Devices or Equivalent Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Aaacn aaaulonai detau v desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: is, cx�) fj (When required by municipal policy.) Work to Start: ,- Ip -68 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:) S(49r+e('y I certify, under the pains andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: v (� �� �L(� �� (Q }] L� LIC. NO.:� (o iJ Licensee: CC_ Signature ✓jlt cf LIC. NO.:k3)3/ (If applicable, en er "exe pt " in the license number line.) Bus. Tel. No.: C3 — Address: �n�Sh�,�c\n� A �� 1,� (i�.�z c�>a 6 1s'�O\ 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. $ 40'e -L Vt O'k 12a AtT IV- a The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.nwss.gov1dia . Workers' Compensation Insxranee Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Chone Are you an employer? Check the appropriate box: Type of project (required): I . ❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑ New construction employees (full and/or part-time).* 2. ❑ 1 am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet 1 7. ❑ Remodeling ship and have no employees These sub -contractors have 8. Q Demolition workingfor mein an capacity. y �p Y [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its 9. ❑Building addition required.] officers have exercised their 10.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL 1 I.❑ 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' ME] Other comp. insurance required.] •f+ny applicant that checks boat # I 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 a new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub -contactors and their workers' comp, policy inSrmation. I am an employer that is prpviding workers' compensation insurance for my employees: Below is the policy and job site information. Insurance Company Name: 'MQ1«OC\ k -,-O Policy # or Self -ins. Lie. #: ��� 6a� �b �' p Expiration Date:_Lt-d Job Site Address:\—V City/State/Zip: �!��Ove' 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 DTA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Phone #: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: 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 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), ad.dress(es) and phone numbers) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, 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, nofthe Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for,you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need. only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and. fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617-727-774 www.mass.gov/dia DANfEI WEbb, P. E. STRUCTURAI ENgiNEER STRUCTURAL AFFIDAVIT January 12, 2008 John Carbone 7 Wyoma Road Gloucester MA 01930 Dear John, 291 PEAR[ STREET REAdiNq, MA 01867 (781) 779,1330 94 Blueberry Lane At your request I have verified the adequacy of the major framing components supporting the wood framing at 94 Blueberry Lane. The scope of work at 94 Blueberry Lane involves the renovation of a large portion of the first floor including extending the living space to the rear approximately 4 feet. To accomplish the architectural goals, 4 major support members were required. The size and support requirements of each are listed below. 1. 4-1 3/4"X14" LVLs -Spanning 19 feet — Eb=2X106psi, Fb=3100 psi Running front to back and supporting tributary load from the 2° floor and attic. 2. 2-1 3/4"X14" LVLs -Spanning 14 feet — Eb=2X106psi, Fb=3100 psi Running side to side and supporting tributary load from the main roof and lower shed roof 3. 2-1 3/4"X14" LVLs -Spanning 11 feet — Eb=2X106psi, Fb=3100 psi Running side to side and supporting tributary load from the main roof and lower shed roof 4. 3-1 3/4"X7 1/4" LVLs -Spanning 6 feet 6 inches— Eb=2X106psi, Fb=3100 psi Running side to side and supporting tributary load from the main roof and lower shed roof and 2nd floor All support beams are of proper size to carry the load demand and have been properly installed and posted down to transfer the loads to the foundation elements below. I did require the footing condition under a new lally column be verified. A minimum of a 24"X24"x12" deep footing is required under that lally. Please feel free to call if you have any further questions about the structural work on this project. Reg 4,11s, Daniel Webb, P.E. NORTN o' o Mk �sS CHOS This certifies that Date. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING has permission to perform ivf ......... ......... plumbing in the buildings of ..... ��t .� 'i........... . 9�/ at........... .. 1-'. .. ...! ......... , North Andover, Mass. Fee. 4f. �b.. LP ic. No.. 18058 ............................ ,yr Check # &&? 7611 PLUMBING INSPECTOR MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location 9�' y����1�� NV (z Owners Nameate / L�� 11,9 7 — �' �12 �0 Al� I Permit # ��' Ll Type of Occupancy 0 LdCL-L Amount New Renovation10 Replacement Plans Submitted Yes No FIXTURES (Print or type) Installing Company Name_ t2110 y /9 LVPVyi1-'y W Address 36 /4 y ot, <-i—I? til-' i � • vyl NJC/t1 ✓i�l�� Check one: Certificate ❑ Corp. E] Partner. QFirm/Co,. Name of Licensed Plumber: 0 q ✓ I i) 4 Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy ® Other type of indemnity ❑ Bond F1 Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature IOwner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachuse Plumbi 11 de and Chapter 142 of the General Laws. By: igna ure o icehsea T lulliurzi Type of Plumbing License Title ` ) S� City/Town icense N umber Master ❑ Journeyman FM APPROVED (OFFICE USE ONLY • .r • ` ::4►I I ����������� --.--..-.�--------------- 1 I ... • MMMMMMMMMWWMMM (Print or type) Installing Company Name_ t2110 y /9 LVPVyi1-'y W Address 36 /4 y ot, <-i—I? til-' i � • vyl NJC/t1 ✓i�l�� Check one: Certificate ❑ Corp. E] Partner. QFirm/Co,. Name of Licensed Plumber: 0 q ✓ I i) 4 Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy ® Other type of indemnity ❑ Bond F1 Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature IOwner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachuse Plumbi 11 de and Chapter 142 of the General Laws. By: igna ure o icehsea T lulliurzi Type of Plumbing License Title ` ) S� City/Town icense N umber Master ❑ Journeyman FM APPROVED (OFFICE USE ONLY M Date ... 7..�—. HOAT#j pf ,ao ,° 1b0 ° TOWN ORTH ANDOVER 4 f • PERMIT FOR GAS INSTALLATION This certifies that ......... b ... E!,��V.?'5.4Va ............ . has permission for gas installation in the buildings of ...... �1�©?�� ...................... . at ..q.,l.I..1-: ...... North Andover, Mass. Fee.�� . �Lic. NoJ�8 '. ......... ...............�/yj GAS INSPECTOR Check # to 6i 7 6282 ;4 MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FITTING (Type or print) DateZ/3/ e) % NORTH ANDOVER, MASSACHUSETTS , Building Locations yuellie 1.1 dILL L Permit # .. 61/ toy Amount S 00 /U• %iNY,�UCtz �-t�9-SC_ Owner's Name � New ® Renovation D Replacement Plans Submitted (Print or type) Check one: Certificate Installing Company Name_ 11 Corp. Address - 6 f1 </ih_ X7/2 L21 Elpartner. t -P) Buauicsa Telephone 7 7�-- /1 7'112 ® Firm/Co. Name of Licensed Plumber'or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance, policy or it's substantial equivalent. Yes 13 NoO If you have checked ves, please indicate the type coverage by checking the appropriate box. Liability insurance policy ® Other type of indemnity Bond13 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 13 Agent 13 1 hereby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts Sta Code and Ch_,jfb142 of the General Laws. By: Title y City/Town: APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter m Plumber /�jS-e Gas Fitter License Number Master 0 Journeyman Ed v� y V CG y F, W O O z C7 U w x E• a+ C > Ew. d C7 F Z e x W C W > Z Q W W o C x C =" F" 3 C Q p L" O W g O y x SU B-BASEM ENT 0 a v z> o a H O B A S E M ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8TH. FLOOR (Print or type) Check one: Certificate Installing Company Name_ 11 Corp. Address - 6 f1 </ih_ X7/2 L21 Elpartner. t -P) Buauicsa Telephone 7 7�-- /1 7'112 ® Firm/Co. Name of Licensed Plumber'or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance, policy or it's substantial equivalent. Yes 13 NoO If you have checked ves, please indicate the type coverage by checking the appropriate box. Liability insurance policy ® Other type of indemnity Bond13 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 13 Agent 13 1 hereby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts Sta Code and Ch_,jfb142 of the General Laws. By: Title y City/Town: APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter m Plumber /�jS-e Gas Fitter License Number Master 0 Journeyman Location No. 739 U Date NORTN TOWN OF NORTH ANDOVER i • OL Certificate of Occupancy $ \saA,•„5 tt' Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ ° Check # �- G l 17357 B(Aiding Insp&(or TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING �yy 1 ,�= - ; •say �)E`- ,; kR � � "�` z z. BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioner/Ingwor of Buildin2 Date SECTION 1- SITE INFORMATION 1.1 Prope4y Address: 1.2 Assessors Map and Parcel Number: 00 / C - 00 /3 0,100 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 Infontation: Public ❑ Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ S CTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT r Historic District: Yes No 29.. Owner of Record i"Diy Name (P' t) Address for Service — �Z�. 14� S' re Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3. Li nsed Constructione`rv/iso(`/y, J Td Construction Supervisor:� / Address (J / v Signature Telephone'-? Not Applicable ❑V4�(Jy License Number Expiration Date 3.2 Registered Home bnpmkement Cjqntractor Not Applicable ❑ Registration Number Company Name I U Viwd R66ft/ p,0. Box 637 \i� !W& MA Address�/' Q1� 4 A 54yJ) 7 Si ture Telephone Expiration Date 40Vvr—, 09 rn X Z O v rn L SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildi miit. 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: cid -4- h �� r i I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I Item Estimated Cost (Dollar) to be Completed bypermit applicant OFFICIAL USE ONLY ".. 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 PlumbinE Building Permit fee (a) x (b) Odd py 4 Mechanical HVAC 5 Fire Protection 6 Total. 1+2+3+4+5 `;. T J- �i4' ; ffwor' Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matter rela e t or u orized by this building permit application.-- y_ o Si nature of Own Date SECTION 76 WNER/AUTHORIZED AGENT DECLARATION I, 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 Si ature f owner/A en Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINMERS IST 2 ND 3RD SPAN 7 DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS IIE- IGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE U NOTICE TO EMPLOYEES NOTICE TO EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 — http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I (we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: THE TRAVELERS INSURANCE COMPANIES NAME OF INSURANCE COMPANY ONE TOWER SQUARE. HARTFORD, CT 06183 ADDRESS OF INSURANCE COMPANY (7PJUB-73OK535-4-04) 02-17-04 TO 02-17-05 POLICY NUMBER EFFECTIVE DATES m ARGEROS INS AGCY INC 360 MAIN STREET o� READING MA 01867 NAME OF INSURANCE AGENT ADDRESS PHONE # DUVAL, KENNETH P DBA 184 PARK. STREET DUVAL ROOFING NORTH READING �— MA 01864 a_ EMPLOYER ADDRESS m— —' EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases -of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided .by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED.BY EMPLOYER 006208 W20PIG02 ' Page No: of Pages SalBuilders License # 58443 Home Construction Reg. # 109288 M IAL CertainTeed/Certification # 1911 UUMN GAF Certified Master Elite ' REFI G Roofin LLE T1 (781) 944-1994 (978) 664-2557 CertainTeed 0l "The Areas Oldest Roofing Company" P.O. Box 637, North Reading, MA 01864 R PROPOSALS STREET %� /p J / . ) DATE q Nw b e r Y (! JOB NAME CITY' STATEAND If CODE . btfnr JOB LOCATION We hereby submit specifications and estimates for: d� l! QACc � Recommended Optional K v c{t (Included In price) (Not included in pric !, Rip &`Remove. all shingle debris from roof & job site: fl 1 layer ❑ 2 layers ❑ 3 layers or more -- If> 0� `{ ✓ Repair/or Replace any roof decking; not to exceed 50sq. ft. Install 8" aluminum drip-edge/and rake -edge along entire perimeter. Choice of mill, white or brown Install ICE & WATER underlayment along horizontal eaves, valleys, sidewalls and sky -lights & chimneys �1 Install 30# felt underlayment between roof deck and roofing shingles • Install 25yr CertainTeed/GAF/Tamko or Owens &Corning traditional 3 -tab roofshingles ❑ 30 year I/ Install 30yr CertainTeed/GAF/Tamko or Owens & Corning architectural roof shingles ❑ 40 year ❑ 50 year ❑ 60 year ❑Lifetime See manufacturer warranty policy for more details a • Install new aluminum vent -pipe flange (s) Chimney (s) -counter-flash and re -step existing flashing ❑ Cut & Install new lead flashing Ridge-vent/exhaust vent with low profile design, hidden by shingle caps ❑ Soffit -ventilation ❑ Roof louver -vents • Seamless style aluminum gutters - custom fabricated at job site ,y ❑ downspouts ❑ aluminum leaf guards Other Al roof Gdl V p0 j QVP/ C •iTi�P e c kfA %rrr1,7 fif e awl r lila 0Jel e -A Ie! } r „r ti PMst fA td( CSGTIat ;� "CJi%P% E' f f 100 t t e ( c veA , Re sf, -4 er F -F If r. i 6' Price includes all items above that are checked only / others may be priced separately upon request. le propose hereby to furnish material and labor - complete in accordance with above specifications, for the sum of: Total price not including options. dollars ($ 6 0 Payment to be made as follows: f' 2 )• 30% deposit required before ordering materials. Balance due in full upon day of completion. Please make all payments out to Kenneth Duval, mailed to: P.O. Box 637, No. Reading, MA 01864 Late charges of $50 per week for all outstanding bills due upon da of completion. Y Authorized -Accepting proposal means agreeing to the terms of the enclosed binder Signature contract. co Note: This proposal may be Please sign contract & return top copy (white) with deposit. withdrawn by us if not accepted within ,� t� days North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: (Location ,df Facility) Signature of Permit Appmwlt leyDate NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing-=Tkems comper ation for my employees working on this job. Company name: Address City Phone #: Insurance Co. Policy # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to $1,500.00 and/or one years' imprisonment -as _wellas.civil..penaltiesin thefnrm-ofa_S_T_OP WORK_ORDER.and_a fine_of_(.$100.OA)..aidayagainstme. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify u ,d p s and penalties of perjury that the information provided above is true and correct. Signature �— Date Print Phone # Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing Building Dept ❑Check if immediate response is required ❑ Licensing Board ❑ Selectman's Office Contact person: Phone #: ❑ Health Department ❑ Other N • w O a i�cn O b °o w v cn o H A o w o P2U v Cd X � w � az w' cis c w � � W a W o w G V. x O w to o w c x Ca W O _ cn Q °. cn z am C C � G s� ON : yr G O ca CJ CL=m m G O CD CD Ea �O. G ;= 22w �0.. O. N ' O L O m C d i:+ O m c3 CD G m eo 'O N A ' � N O 06C.3 ` CD O:,D. r O :spCLa ID 0. y O M'j Z c � O O. � O O� " 1 c =5 v� v•N e O .a as Cm. m J a� CD CD cr- L 0 0 CD Z C. O y icoCD cm O y m m CD 0 CD �3 CD 'L7 cc O d M:co v�Q C cc v q o co C.3 y c C C cc CLh