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HomeMy WebLinkAboutMiscellaneous - 940 GREAT POND ROAD 4/30/2018 (2)L_ Date ...! ...... .�.1..'.. L............ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that.......:f'..0...................77 .................................. has permission to perform ........:.a�..:� v+-- ..........:.....................................:.... wiring in the building of.........Cri �, C? ......................................... at ......t�..:.....f'`'..mGu �i` North Andover, Mass. ................................ Fee...f'?Z`........ Lic. No.......... .................................................................................. ✓ ELECTRICAL INSPECTOR Check # 2 1 (�p� '` 1-2756 r Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS ' M Official UsUse ^Only Permit No. �1 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 MR 12.00 (PLEASE PRINT INMK OR TYPE ALL .INFORMATION) Date: -4 � City or Town of: NORTH ANDOVER To the Insp ctor of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Y, ,, (J C:) cVq Owner or Tenant Owner's Address 975 Is this permit in conjunction with a building perm't? Yes ❑ Purpose of Building 04,6_ - Existing Service V Amps I 1/� olts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Telephone No,pTBCY'z,03��c No ❑ (Check Appropriate Box) Utility Authorization No. Overhead ❑ UndgrclJE4-_, No. of Meters _/_ Overhead ❑ Undgrd ❑ No. of Meters Completion ofthe followine table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd, grnd. o. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No, of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number..Tons "' '"' "" KW " ***"* " " No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of lectr' al Work: 72Aaa e-' (When required by municipal policy.) Work to Start: % �A� inspections to be requested in accordance with MEC Rule 10, and upon completion. TNSURA.NC O E: 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 D� BOND ❑ OTHER ❑ (Specify:) X certify, tinder the sins and penalties of per u , fhat tlae information on this application is true and complete. FIRM NAME:.f �(. �= 'r LIC. NO.: Licensee: �6,, /�1` Signature 1 LTC. NO.: (If ``applicable, e r "ex%e�pt" in the license nay ber line.) Bus. Tel. No. • 0l'l8� Address: Tel. No.-©� *Per M.G. c. 147, s. 57-61, security work requires De artment 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. $ G/ Signature Telephone NO. c 0At ❑ Rule R—Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench In ion Y� ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with -the provisions of M.G.L. c. 143, § 3L, the y permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed Re- Inspection Required ($.) ❑ on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an f electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written Inspectors Signature: ` application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written Date: request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of Pass M the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this Re- Inspection Required ($.) ❑ 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 R—Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench In ion Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: ` Date: SERVICE INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass P Failed M Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts - Departinent of Inc%strialAccidiints Office of Investigations 600 Washington Street .Boston, MA 02111 www.mass gov/clza Workers' Compensation Insurance Affidavit: Builders/Cont°actors/ElectriciansfrIiimberq Applicant XnformationPleasePriintLe�ibZy Name (Businessiorganizaiion/individual): Ir Address: CitylSiaie/Zip: '% / Phone M � L3 �4C/T� Are you an. employer? Check the appropriate box: Type of project (required.): 1. [[ I am a employer with 4. ❑ I am a general contractor and I 6. New construction f employees (full and/or pax- time) * `� am a sole proprietor or partner have liixed the sub -contractors listed on the attached sheet. 7• Remodeling ship and`have no employees These sub -contractors have 8. [] Demolition working forme in any capacity. workers' comp. insurance, S. ❑ We are a corporation and its 9. ❑ Building addition [No workers' comp. insurance required.] officers have exercised.their 10.[] Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL 11. ❑ Plumbing repairs or additions myself. [No workers' comp. c.152, §1(4), andwehaveno 12.QR.00frepairs insurancere tied. � a employees. [No workers' 13.❑Other comp. insurance required.] XAny applicantthat checks box0f mustalso fill outthe section below showingtheir workers' compensationpolicy information. 7 Homeowners who submit this affidavit indicatingthey gdoing allwork and then hire outside contractors must submit anew affidavit indicating such. tContractors that cheAthis box must attached an gdditional sheetshowingthe name ofthe sub -contractors andtheir workers' comp. policy information. I am an employer that is providing workers' compensation insurance formy employees Bellow is the policy and job site information. Insurance Company Policy # or Self -ins. Lic. Expiration Date: Job Site Address: City/state/Zip: Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date). Failure to secure coverage as regio dunder Section 25A ofMGL o.152 can lead to the imposition of criminal penalties of a fine up to $1, 50 0.0 0 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 o£ Investigations of the DIA for insurance coverage verification. X d0 hereby CBYt llYi p d penartles ofperluYy that the information provided aboyos true an[l correct �y Official use oitly. 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. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - Contact Person: Phone I 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 thi the service of another under any contract ofbire,- express oar implied, oral or written." An employer is defined as "an individua% partnership, association, corporation ox 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 dan 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 orrepair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employes." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced:acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have beenpresented to the contracting authority." Applicants Please f11 out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are notrequired to carry workers' compensation insurance. If an LL C or LLP does have employees, a policy is required. Be, advised thatthis affidavit maybe submitted to the Department of Industrial Accidents for confrmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be retumed to the city or town that the application for the permit or license is being requested, not the Department of industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please tali the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be. sure that the affidavit is complete andprinted legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be -sure to fill in the permit/Rcense number which will, be used as a reference number. fn addition, an applicant thatmust submitmultiple 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 tow:n):' .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 affidavitis 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 ox p ermit not related to any business or commercial venture (i.e. a dog license orpermit to burn leaves eta.) 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: Thoato�veaXtla o£assarhuSeit - Departaent of InduaWal &61dents- Me of ImStIgAtim 694as agka- S-tKm< Boston,, MA 02111 Tool # 617-72,.7-4900 ext 496 or 1-8,77 MASS.A.F`E Revised 5-26-05 Fax # 617-727-7749 749 www.zr s,%gov1cha a :A71111 03461-06"8; • 37900 LICENSE N.UMBER�EXPIRATION DAT'ESERIAL NUMBER O Date .... 5/11***`*/*"*�*��""..; .............. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .......... P ... n .... 4�,eap . .................................. has permission for tall tion ....c1 ............................. inthe buildings of .............. .......................................................................... at .........9... 0 .... ...................... . North Andover, Mass. 17) 'Fee. ..... Lic. No. ..................................................................... GASINSPECTOR Check 9543 C7 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY �Y� � - MA DATE J-�1- — PERMIT # . JOBSITE ADDRESS . �� �r't�I- �o��IOWNER'S NAME GOWNER ADDRESS TE Q 7 (.�g%3 4 FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL ( EDUCATIONAL RESIDENTIAL CLEARLY NEW: FA RENOVATION: ® REPLACEMENT: ® PLANS SUBMITTED: YES D NO APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVEC C.- .. C .. _ I __ .... _ �- �! - _. DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR- FURNACE _ L—J GENERATOR �a GRILLE INFRARED HEATER LABORATORY COCKS .. .__I _ _._ _. L�j _. MAKEUP AIR UNIT OVEN I . = �-1 1 L -J POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHERFt® INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch.142 YES I&NO [l IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY EI BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT y__( -._)l SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information 1 have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co nce ith all Pe ' ent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. s7� PLUM BER-GASFITTER NAME r�.��.�� LICENSE# Z J SIGNATURE MP 0 MGF El JP [9 JGF LPGI E1 CORPORATION Ej#PARTNERSHIP ©#= LLC E]# COMPANY NAME: ADDRESSM r-L� CITY STATE CT'.JZIP o6S� TEL FAX CELL _ _g-(36 EMAIL LA f W H ' z z, H U W w z O N❑ W } � W O w O H a z w W � � En w � a O w � w Cf) O a U J H a CL .< iui x w LL W H °z 0 H �a U a y � C7 C�h ' The Commonwealth of Hassachusetis Department of IndustriglAceielenis Office oflnvestigations 600 Washington Street .Boston, NIA 02111 www.mass gov1d1a Workers' Compensation Xnsurance Affidavit: Builders/Contractorsfflh. An•nReant Information - - -- Name (Businessiorganizairon ftdividual): Address: L -2 City/State/Zip: Pt w�Q , 4 t�- 0 �6 S Phone #: 00 32 — 5"73 Are you an employer? Check the appropriate box: Type of project (required): 1, ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part time) * have hired the sub -contractors 2. I am a sola proprietor or partner listed on the attached sheet. 7. ❑ Remodeling ship and`haveno.employees These sub -contractors have S. E] Demolition working for me in any capacity. workers' comp. insurance. g, E] Building addition [No workers' comp. insurance 5. ❑ We area corporation and its 10.0 Electrical repairs or additions required.] officers have exerdsed.their 3. [J X am a homeowner doing all work right of exemption per MGL 1I. [[ Plumbing repairs or additions myself. [No workers' comp. c.152, §1(4), and we have no 12.Q g_oofrepairs insurancerequired.] t employees. [N'oworkem' 13.❑ Other comp. insurance required.] -Any applicant that checks box#1 must also fill out the section below showingtheir workers' compensadonpoEry information. i -Homeowners who sabmit this affidavit indicat'mgthey k� doing allwork and then hire outside contractors must submit anew affidavit indicating such. TContractors that checkthis box must attached as 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 em ployees Below is thepolicy and jab site information. Insuxance, Company Policy ## or Self-ius. Lic. Expiration Date; rob Site Address: City/state/Zip: Attach a copy oldie workers' compensation•policy declaration page (showing the policy number and expiration date). Failure to secure coverage as req,"'Aunder Section 25A ofMGL o.152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of. Investigations of the AIA for insurance coverage verification. xd0 X1eYeby ceY�' u72deY Zeliains a enalties ofpeilmy that the information provided above is true and correct Rionafiira� �.lWA '� Date: �'— � � Le 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 Terson: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires O employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...everyperson in the service of another under any contract ofhire,- express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation ox other legal entity, or any two or more of the Foregoing engaged in a j oint enterprise, and including the legal representatives of a•deceased employer, or the receiver or trustee of art individual, partnership, as§ociatlon or other legal entity, employing employees. However the owner of a dwelling house having not more thaw three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, constiucilon 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 Ideal licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the comImonweaA 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapterhave beenpresentedta the contracting authority." x Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if n6cessary, supply sub -contractors) name(s), addresses) and phone number(s) along with their certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are notrequired to carry workers' compensation insurance. If an LLC or LLP does have employees, apolicyisrequired. Be advised Mat" affidavit maybe, submitted tothe Department of ludustdal 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 pemnit or license is being requested, not the Do' aartment of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain, a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure thatthe affidavit is complete and printed legibly. The Department has provided a space at the bottom Of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be -sure to fdl inthe permit/license number whichwill be used as a reference number. In addition, an applicant thatmust submitmultiple peimif/license applications in anygiven year, need only submit one affidavit indicating current Policy information (if necessary) and under "fob Site Address" the applicant should write "ail locations in. (city or Iowan): ' A! copy of the affidavit that has b eon officially stamped or marked by the city or town may b e provided to the applicant as proof that a valid affidavit. 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 ox permit not related to any business or commercial venture (i.e. a dog license orpermit to burn leaves eta.) 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 guestions, please do not hesitate to give us a call. The Department's address, telephone, and fax number: The onw. oMssarhvetis - Depad ent OffaadusWal .Acc delfts Revised 5-26-05 Moe oflimstigfraona Rostw., MA 02111 TOL 9- 61.7-727-4900 eyt 406 ox- 1;-8,77, Fax 0 617-727-7749 _Wmmlis,govaa. f - LOCAxia� • OWNERS NAME: GENERATOR kw .71717 .. .Will�r ti • `lI P CONTRACTOR: IUVr,� PHONE NUMBER: �LO� ;?)92 ELECTRICAL GAS RESIDENTIAL COMMERCIAL LOCATION OF GENERATOR: �� t *ZONING DISTRICT: mPLANNING APPROVAL (IF IN *CONSERVATION APPROVAL TEMPORARY Ryo GSA k"N » �� ���� 2«��� / 03865-25kV::;' Date ..31al.1 i ....................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 1� ,Q .. This certifies that ........ &-O.— C.... . Q W.'.` ....................................... has permission for gara.(9A.t\,A1 .stallation .. coo...... .a ... �.. . %..... m the buildings of..........................:.............::....................................... cam" at .....�`�it?...&." P;,LG J..... RA.. ............ I North Andover, Mass. c� Fee.��...."'.... Lic. No.22�3.......................................................... NGAS INSPECTOR Check #-w w �� •` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATED -7 f y II PERMIT #. JOBSITE ADDRESS OWNER'S NAME GOWNER ADDRESS _ TEl �FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL [ EDUCATIONAL RESIDENTIAL CLEARLY NEW: F-1 RENOVATION: REPLACEMENT: El PLANS SUBMITTED: YES a NO APPLIANCES 7 FLOORS- BSM' 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTERS CONVERSION BURNER COOK STOVE DIRECT VENT HEATER- I DRYER FIREPLACE I f._ FRYOLATOR [ —� .... L r:l - FURNACE I GENERATOR GRILLE INFRARED HEATER I _ J �� LABORATORY COCKS1-:- MAKEUPAIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOFTOP UNIT. TEST I.� I-- — J UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 _ --_- I _....._ . __ _ (..— I ..._ L- . _ •=-1 �M OTHER.. INSURANCE COVERAGE ,I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 1911 NO D Is IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [01 OTHER TYPE INDEMNITY BOND F OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT 011 ;o►" SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and a rate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in pl' nce ith all Pe ' provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME t.� T�v+-�er-.I LICENSE#"SIGNATURE MP ED MGF EjI JP a JGF LPGI © CORPORATION ©# PARTNERSHIP DI #= LLC D#= COMPANY NAME: "�_ Ptybs ADDRESS CITY I STATE ,� �rl ZIP 3 6 TEL p3 3g�'S 73 FAXCELL �(�3�-tfEMAIL �� _ �sv,u-7?3_ C!v�►,. ,r.l �� W H U W a R W o F] Z O �+ El W � � W O w O H a Z LU a � � •w Cl) w co a O LU > w L LU w c a 0 a w a U J E, a IL a 40- �2 Iii s w I-- LL H °z 0 H U W C7 JTY 114 i A The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston, MA. 02111 VV www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leibly Name (Business/Organization/Individual): 1 o -C— i3 e_X— Address: 1,`? _T,�, City/State/Zip: Phone #: 6 6:3 - 6 733 Are you an employer? Check the appropriate box: - Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).` 2.X I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. �• Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 5. ❑ We are a corporation and its g, ❑ Building addition [No workers' comp. insurance required.] officers have exercised their 1011 Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs insurance required.] employees. [No workers' 13.❑ Other comp. insurance required.] xAny applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they ace doing all work and then hire outside contractors must submit anew affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company N Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A ofMGL c.152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of 'Investigations of the DIA for insurance coverage verification. Ido hereVc* er the pain penalties of perjury that the information provided above is true and correct. Si ature/�'' Date: ^� L� Phone 6 ®3 -7 11 Official use only. Do not write in this area, to be completed by city or town official. City or Town: PermitUcense # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector 6. Other - - Contact Phone #:, Information and Instruction's 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 ofpublic 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 maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be retained to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone anal fax number: The COMM. p onwealtb of Massa chusPtts Department of IndusWal Accidents Office o£Iuye"stigatlons 600 Wasbiugtoxi Street Boston} MA 02111 TO, # 617-727-4900 ext 406 or 1.-$77,MASSAFE Revised 5-26-05 Fay ,# 617-727-7749 vvvvti�r"mace anzxfil;a -aA PET.11IT NO. APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1 MAP NO. I LOT NO. 2 RECORD OF OWNERSHIP iDATE I BOOK iPAGE ZONE SUB DIV. LOT NO. - LOCATION PURPOSE OF BUILDINGq/y��� b yi O � a L !'/ OWNER'S NAME / p �- NO. OF STORIES SIZE Pte/ /> �•J/fj. f/�� OWNER'S ADDRESS ?,, (/ BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME c v S. SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS POSTS DISTANCE FROM STREET_.. DISTANCE FROM LOT LINES - SIDES REAR GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY U, --G IS BUILDING ALTERATION C ha l IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMTS OF CODE _1 Q floQ w� T' IS BUILDING CONNECTED TO TOWN WATER — BOARD OF APPEALS ACTION, IF ANY /m IS BUILDING CONNECTED TO TOWN SEWER .__. IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED SIGNATURE OF OWNER OR AUTHORIZED AGENT 42 FEE S0 PERMIT GRANTED 9p f / 19 U C ri/ Z. 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST L EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN NUILDING INSPECTOR + 1 I PJC• I Jf I A N4 It �c$ Aj�v lovi NV"ld lO1d S3ab'1d32! 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NOIm3INI •. S NOI1VONnoi z N011anHISNOo S1N3W1nVdV _ S3JIdd0 —_ AIIWVd 'lllnW S31ii0!S .+i AIIWVd 31ONIS NV"ld lO1d S3ab'1d32! SIHl 'a3SOdWl2l3dnS 'a13 'S3oV2I -V9 'S3H72I0d H11M 'S9NIa11n8 d0 SNOISN3WIa 17VX3 aNV S3N11 10'1 W02ld 3PNV1SIa aNV 101 JOSNOISN3Wla 17VX3 MOHS1SnW N01133S SIHl zt AONVdn000 L CV033V ONiciin9 Date ................ .............. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION Tris certifies that ..,Jo.e . .......... 0 ...................... ........................................... ... .... .... ...... ...... . ........... has permission for gas stallation . .......................................... in the buildings...... ............................................................................ .... at ........ 9 ....... 4 ...... 0 ........... ...... PVY-4 "., North Andover, Mass. Fee., .. Lic. No. .2 .... "'I"f ........................................................ ,?�P ..... Z .............. ...... GASINSPECTOR Check #62,12- 9175 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK uw-- CITY _ rain MA DATE- ��T I(PERMIT# ` l� JOBSITE ADDRESS !OWNER'S NAME A�\vim GOWNER ADDRESS TE Ly- 30qt JFAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL CLEARLY NEW: E1 RENOVATION: ® REPLACEMENT: PLANS SUBMITTED: YES F--Jl NOR APPLIANCES'l FLOORS- BSM' 1 2 3 4 5 6 7 8 1 9 10 11 12 13 14 BOILER _.._ . . E:D F__- —BOOSTER BOOSTER _ CONVERSION BURNER COOK STOVE DIRECT VENT HEATER �V _ DRYER _...... �, f_�!I FIREPLACE FRYOLATORr j _ [ — FURNACE GENERATOR- GRILLE- INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN (_ I POOL HEATER_- ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER s WATER HEATER OTHER F - z r INSURANCE COVERAGE I ha a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES J&Z NO El IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY - OTHER TYPE INDEMNITY © BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and acc'ate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co e Wall Pertin provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME i r�. _�vca.!_ LICENSE # SIGNATURE MP ED MGF ED JP E?3L JGF LPGI CORPORATION [1# = PARTNERSHIP ©#� �� LLC E3#� r COMPANY NAME: � U� �<.r�ADDRESS _- f,5 cr1 c% CITY STATE �.___ _ ZIP 6 TEL 733 FAX _2KjL_6-ZZ414 11 CELL 663 �_'.11� EMAIL iv r �- . _ rA H z 0 U w a ConO w y V 1 �+ ° ❑ Z O y� W r F- W O� O a U w �* z w I— rA QCO w O LU > a w w o a a a GO U J ' F, a IL Q � � w x w LL H O z 0 H U W U' C�7 r� The Commonwealth of Massachusetts Department ofIndustriglAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLribly Name (Business/OrganizatiorAndividual):_ _ �,•{- \ �1�v c,� Address: cl X r F,& City/State/Zip: ,, s�� o �, 0 6 Y b Phone #: Are you an employer? Check the appropriate box: 1.0 I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. I am a sole proprietor or partner- listed on the attached sheet. # ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] i employees. [No workers' comp, insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i'Homeowners who submit this affidavit indicating they Aire doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy # or Self -ins. Lie. Expiration Date: Job Site Address: City/State/Zip:, Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine 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. X do Hereby c der ie pains andnaldes ofperjury that the information provided above is true and correct. Signature: , ,�,✓,� ���.-- Date Z,f^ - IL Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or. written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who.has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone anal fax number: The Commonwealth of Massachusetts Department of l dustrial .Accidents Office ofInvestigations 600 Washington Street Boston, MA 02111 Tel, # 617-727-4900 ext 406 or 1-877rMASS.A.FE Revised 5-26-05 Fay, # 617-727-7749 __WWW-mass,goV1dla . .. ... . -/\pLUm Ak§ ANQ GASFTTER \ \-I ENS(§ kS !?Y NEYMAN P/U - »=m r §� ( LICENSE 2 . y ..,.y, . \\ � $KRH m »GE&§.. ©: 2' y g . 2 . > / y. 1 /TIS kmL&NE R D' y \ /<z�a� . °.- mp Q « . N. -o 8 $ ): w \ # ƒ243, 65/0,1/14'', 69k! W u Z 0 a 1 0 IL 0 < W a W z u z 0 J ■ 0 u L O M r z W I W a ] �O a 0 r I a 0 W Z 0 u u z 0 J ■ J J ! I Y M ■ z Y W a z >� Y o r 0 u Z � a I 9 r x I n ° V z u S ]Z u W u Z 0 a 1 0 IL 0 < W a W z u z 0 J ■ 0 u L O M r z W I W a ] �O a 0 r I a 0 W Z 0 u u z 0 J ■ J J ! 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W < Q J a w H In Q O- z D I 0 W 0 M o. — Z Z u ` Z z O. z O a Z O is h ■ F S V Ir Q ■ O J J I ; = o h L u G W I yQy J ` N ` L W n z O C4 o w z a w COD a a CD a a U w a°' m w a W m a°' w oC n: w" c4 c v o cE LU om .o m� N O C C.3 �n'fl CL C cc m m C Cc O Ea CD _o 1 o CL E" CA E= O (n o CD oz `V �o t; of me E n :r H Cp m m O �y y �m3 = y � :Go yy o W O y E o c U �'� n ' C/) Los O f/1 O O) W c y ¢ w ►-� mor m V N Z p Cv y C ` cm n C Q O ti m C C _ _m aO"0 s 0 H C nos OLL- � 1= .y 0 = C Z W •E Ci .0 Cyt 'y O V O Ci •04H CL •� �� _ .0 L. = ti 0 F- .c $ n.,, m m O L Z o, O y p c cm ICD CD 0 CD O _� mm CD O OQ CL O cc 0 CL rL ca ca0 ccc v Ci O ca c Z CD CL C..7 y c c _cc CS. CO) e 5 No.. 3Date w J TOWN OF NORTH ANDOVER BUILDING DEPARTMENT Building/Frame Permit Fee $� -' Foundation Permit Feed -"o OtheryPerrni# Fee�'dC • Colo biiiiding Ins a for No.: 3l i Date TOWN RIBN OF NORTH ANDOVER AMF FITMENT rr EKU,,iI.png/jra@8§rmit Fee $ 'I', Qo Foundation Permit Fee $ZOO (rz Building lnspeb��_ PER"x�u Nb. APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. V �, �7 •� �j PAGE 1 MAP +40. a G. 71PNE i, LOT NO.2 SUB DIV. LOT NO.6 /,y RECORD OF OWNERSHIP IDATE 2Q� C BOOK `PAGE �g LOCATION 9YD gy6r �Ahlb ;2 d, _(�� PURPOSE OF BUILDING Jam% '1 "� OWNER'S NAME f-�GTG/�, / O��. 1 KCCCJJCC I� ` 'V NO. OF STORIES / SIZEtC/�1�1F / OWNER'S ADDRESS 9zlo BASEMENT OR SLAB ARCHITECT'S NAME 1 �O� SIZE OF FLOOR TIMBERS 1ST „T / BUILDER'S NAME //.'.���C/.�. // Q//X� SPAN DISTANCE TO NEAREST BUILDING f DIMENSIONS OF SILLS // /ft DISTANCE FROM STREET �Q POSTS T DISTANCE FROM LOT LINES - SIDES / REAR/j'�/�,� ♦ (� "' GIRDERS AREA OF LOT FRONTAGIE7^//�/_ t ®�(0Ll HEIGHT OF FOUNDATION �7 / �I ^n,¢ HICKNESS P7l[ IS BUILDING NEW A16, SIZE OF FOOTING// l/ X FOOTING/6 x 2Q IS BUILDING ADDITION A.191) A!F-' , MATER;AL OF CHIMNEY /\/ // IS BUILDING ALTERATION P, v- IS BUILDING ON SOLID OR FILLED LAND 311 1 WILL BUILDING CONFORM TO REQUIREMENTS OF CODE C G IS BUILDING CONNECTED TO TOWN WATER r�iC BOARD OF APPEALS ACTION. IF ANY . / �V IS BUILDING CONNECTED TO TOWN SEWER V IS BUILDING CONNECTED TO NATURAL GAS LINE 6 INSTRUCTIONS SEE BOTH SIDES PERMIT FOR FRAME/BUILDING PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 nATF• SI31 I �1. FEE PAId�� ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED P-1-89 SIGNATURE OF OWNER OR AUTHORIZED FEE PERMIT GRANTED / 19 -PERMIT FOR FOUNDATION ONLY REGULATED BY PAR 114.8-S.B.C. DATE: ' 8� FEE PAID:,4/-400 00 momfm _La2. CFO FIME • RMrr riff �r 7 3 PR.7ERTY INFORMATION r LAND C08 vio `^ � EST. BLDG. COST C++ti JJ �f EST. BLDG. COST PER SQ!FT4r 8 gi U5 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. N/^_ 4 APPROVED APPROVED Y BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN BUILDING INSPECTOR i `JNIIV3H P"L 1.W.9 JIa1J313 I , 40007 SV0 - I v i 1 I f�8N', f r '"9 ;.f;-2 T. 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W 9 ON h °/, /, 11f13 V3sy 1N3W3SV9 £ Sa31d 3NO1S NO )IJIa9 'X.19 3AdDNOJ 313 d DNOJ NOUVONnoi Z I FORM U a TOWN OF NORTH ANDOVER LOT RELEASE FORM SUBDIVISION /V 49— ASSESSORS ASSESSORS MAP 163 11-2Cg1�96 SUBDIVISION LOT(S) PERMANENT ADDRESS AS IGNED BY D.P.W. STREET a APPLICANT � �a; � , � 12tu , PHONE- _ b g 1 -i46 DATE OF APPLICATION / --- ,-�`7 -' TOWN USE BELOW THIS LINE CONSERVATION COMMISSION 6tz�� CONSERVATION ADMIN. DATE APPROVED DA'T'E REJECTED DATE APPROVED DATE REJECTED BOARD OF HEALTH pp DATE APPROVED HEALTH ANITARIAN DATE REJECTED DEPARTMENT OF PUBLIC WORKS DRIVEWAY PERMIT II J SEWER/WATER CONNECTIONS FIRE DEPT.✓ �j -5' 1000, REC IE VED BY BUILDING INSPECTION DATE T� This form shall be signed by the agents of the Planning and Health Hoards, the Conservation Commission prior to the issuance of any building permits for the subject lot. This form shall not releive the applicant from the compliance of any applicable Town requirement or Bylaw. PER111T NO. -� k APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 MP Pal90. LOT NO. 12 RECORD OF OWNERSHIP DATE BOOK PAGE ZONEI �� SUB DIV. LOT NO. I LOCATION i PURPOSE OF BUILDING f ? v� OWNER'S NAME NO. OF STORIES SI E / (07 S. _ OWNER'S ADDRESS �t �N BASEMENT OR SLAB ARCHITECT'S NAME ¢ -- SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME DISTANCE TO NEAREST BUILDING - SPAN DIMENSIONS OF SILLS DISTANCE FROM STREET 34- POSTS f/ , DISTANCE FROM LOT LINES — SIDES ed d REAR 31re i GIRDERS a FRONTAGE hep g/��/ AREA OF LOT 9 A (AAf W HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW r SIZE OF FOOTING X At - IS BUILDING ADDITION MATER:AL OF CHIMNEY IS BUILDING ALTERATION,, IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE / IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION, IF ANY IS BUILDING CONNECTED TO TOWN SEWER No IS BUILDING CONNECTED TO NATURAL GAS LINE I Ql �s INSTRUCTIONS SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS Pf ANS Ml1ST RF FILFM AND APPPn VFD RY RI111_DINr IN9PFGT0P FEE 96'" PERMIT GRANTED O S 19 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. C 4 APPROVED BY 7 BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN BUILDING INSPECTOR 'NtJ1d 10 -Id S30V-Id3U SIH1 'a3SOdwia3anS '013 's3ovu -VE) 'S3H02IOd H11M 'SONIC-IIn9 d0 SNOISN3WIa 10VX3 aN`d S3NI1 10'1 WOL1d 3oNV-LSIa CNV 10-1 JOSNOISN3Wia L:)VX3 MOHS1SnW N01103S SIHl z CaO:)38 ONlaiina '1753 00d kI 3SOIS3daS 3WVSd NO 3NO1S ONISIM ASNOSVW NO 3NO1S 'X19 S313NIJ SO 'JNOJ —I 3WVSd NO X0IS9 SOOl3 '8 'Shcs JIl1V kdNOSVW NO XJIS9 — — 3WVSd NOomms kdNOSVW NO 65551S 3111 'HdSV JNIGIOIS '153 _ NONJWOJ ONIOIS SO1S39SV _ 0.tykGdVH ONIdIS 1lVHdSV _ HldV3 S910NIHS DOOM E �—z 9 313SJNOJ SOSV1OUVID S110011 6 S11VM y N3HJ11X NS340W WOOS CIV3H S3JVl4 3SId 1.W.9 ON V38V JI11V 'Nld '/c 1/1 %i V3SV .1.W.9 'NH lln3 V3SV 1N3W3SVB £ NI3Nn 11VM ASa S31SVldSS3ld (JF 3NO1S SO XJIS9 _ 3NId ')I.19 3138JNOJ E L 1 9 _ 313SJNOD HSINId HOR131N1 8 NOUVONnOd Z NOIlonNISN00 =I S1N3W1SVdV S3JId30 kIIWV3 'ulnw 53150!5 A11WV3 310NIS AONddn000 L i a I JN11V3K ON is l I JIS1J313 _ I PSL uZ 1,W.9 110 SWOON dO 'ON L SVJ SS31V3H 11Nn 0.1.H 1NVIGVS JNINOI1ICINOJ SIV _ Sa31dV21 doom SOdVA SO S.l.M lOH _ 'S10D V 'SW9 13315 WV31S 'S10J T 'SW9 S39W11 'NSn3 SIV lOH 43JSOd _ 3JVNSn3 SS3i3dld 1SIOf BOOM 9NIMH L L II 9NIWVbd 9 OOVO 3111 60013 3111 —_ SHn1X13 N830OW 9N1dOOS 1104 83MOHS 11VIS 13AVSJ V SVl _ `JN19Wn1d ON 31V1S _ NNIS N3HJ11X 330NIHS 400M _ A80IVAV1 S310NIHS 1lVHdSV _ 13SO1J S31VM03HS 1Vld 131101 OSVSNVW 13S9WVO Xld Et H1V9 d. 319V0 9NIBWnld OL d008 9 'NtJ1d 10 -Id S30V-Id3U SIH1 'a3SOdwia3anS '013 's3ovu -VE) 'S3H02IOd H11M 'SONIC-IIn9 d0 SNOISN3WIa 10VX3 aN`d S3NI1 10'1 WOL1d 3oNV-LSIa CNV 10-1 JOSNOISN3Wia L:)VX3 MOHS1SnW N01103S SIHl z CaO:)38 ONlaiina '1753 00d kI 3SOIS3daS 3WVSd NO 3NO1S ONISIM ASNOSVW NO 3NO1S 'X19 S313NIJ SO 'JNOJ —I 3WVSd NO X0IS9 SOOl3 '8 'Shcs JIl1V kdNOSVW NO XJIS9 — — 3WVSd NOomms kdNOSVW NO 65551S 3111 'HdSV JNIGIOIS '153 _ NONJWOJ ONIOIS SO1S39SV _ 0.tykGdVH ONIdIS 1lVHdSV _ HldV3 S910NIHS DOOM E �—z 9 313SJNOJ SOSV1OUVID S110011 6 S11VM y N3HJ11X NS340W WOOS CIV3H S3JVl4 3SId 1.W.9 ON V38V JI11V 'Nld '/c 1/1 %i V3SV .1.W.9 'NH lln3 V3SV 1N3W3SVB £ NI3Nn 11VM ASa S31SVldSS3ld (JF 3NO1S SO XJIS9 _ 3NId ')I.19 3138JNOJ E L 1 9 _ 313SJNOD HSINId HOR131N1 8 NOUVONnOd Z NOIlonNISN00 =I S1N3W1SVdV S3JId30 kIIWV3 'ulnw 53150!5 A11WV3 310NIS AONddn000 L a,. I cic LAJ LAJ De LL. 0 U uj uj � z t/� o CL ca bCL c cD E :3 0 !E 0. C;) D 0 �6 c Jz 6W 0) :3 0 :3C 0 c c :3 E U ti a: ii lr En U- U - a,. I U � z t/� o CL ca Ci *a 16a cn U4 ck :D Ulf C4 LU: bo Building Permit Number 254 ®ate July 26, 1982 THE BUILDING LOCATED ON Lot #3 Great Pond Road MAY BE OCCUPIED AS Dwelling & 2—car Garage IN ACCORDANCE WITH TETE PROVISIONS OF THE r AASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. NORTM CERTIFICATE ISSUED TO Frederic B. Horne 3r •' 0 ADDRESS 940 Great Pond Rd., North Andover, Ma. t ��SS^cHUS" � Building Inspector June 10j 1981 Mr. Frederip(Bv Horne has permission to erect footings and a foundation on Lot #3 Great Pond Road, as per plan submitted. CI ff : ad CEARIES H. FOSTER iNSPIS,CTOR OF BUILDINGS October 20 1$80 Mr. Frederic B. Horne has permission to erect footings and a foundation on Lot #3 Great pond Rq per plan submitted. CHF:a d CHARLES OF Wr IS IsdoJIDO n,mtj")til .ulq xeq b n: 11-M