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HomeMy WebLinkAboutMiscellaneous - 99 HIGH STREET 4/30/2018 (2)Date ... 6 - z 7,*4 .............................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ................ M.. z. k- E ...... L.y.A.1q.Al .............................. has permission to perform ......... ' Pt wiring in the building of ...... T C -U ..... ................ at ...... ........Sr................................. . North Andover, Mass. Fee ... Lic. No.. ©4 s:7 .............. ....... WCEGTRICAL INSPECT6i' Check 3-5/ 6761.1 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS iii%ii�'�;'�]i if—c i, -i------------ 111a'Illlt U�. 1p {• (� 4 ! Occupanc\ and Fce Checked [Rev. l) 051 Il�a�e blank) APPLICATION FOR PERMIT TO PERFORM. ELECTRICAL WORK 11 '.pork to he lwrtornled in accordance \lith the \L1.,SUhuwub Hcctrical Colts t\1I:C). 5?;' CAI 12.00 (PLEASE PRL%T A INK OR TYPE. ILL INFO)RJ1.ITIONj Date: krj17 ee(a Citi or Town of: ..Al AV f)ove % To the- hispector u/ IVires. fly this ;IPPliratiun the undersigned gives notice of his or her intention to pertornl the electrical l%ork described below. Location (Street & Number) 94 /4 r6 (honer or Tenant -fT Owner's Address C- U Telephone No. ki,i ",c 0/ Is this permit in conjunction with a building permit? Yes 1+� No ❑ '(Check Appropriate Box) Purpose of Building uiG�6�hLtility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters _ New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ('0111 VIL-6011 Id dh 'i)lllm i1,11 (able 111(x1 i'e 1 n l 'w 1't ' 11ti ' ° !, l• �/ 11' OTHER: �. Ilh1I h uJ,.(,llunul /Colli r/ Jr,I; L 1. x „s lv' ji1,re'I1.1. ,ilc hoj,c,.l,,l' F.,,timatvd �•alue of Electrical l,Vrlrk: p(5)O I kk hen rcyuired by municipal policy.) kkork to Start: 6 -; S-dIo In:,pections to be requested in accordance �%ith NI EC Rule 10, and upon conlPlctiurt. INSLRANCE C'OVERA(;E: \.mess waivvd by the olrnvr. no permit for the perlornlancc of electrical �vork nlay i':sue unll', div licensee pr � ides proof of liability insurance incll.ldina "' omplvtedoperation" Covera --ie or its >tlb;lantial rqu4alc11t. I l,.—'cel—title" th:lt'alch Cokel*a,!,e I:• Ill 101•ce. ;Illi h:ls c•.hlhltcd proof Ct'Jalne to the perlllll I','.•ltlll" Itttli:e. 'I II:(: K U\I-: IN:,)'( R.\XC ❑ 13C;�1) �� ! i ftfl'R ❑ I'ipevil j:f 1hePe1.'11S,01dPelrldifte 1fPej1/Pt1, `ltiff !fie in , 1•'Nrfl%on ""'T 114 11,y),ical ill!.):1'/.li fv'dct)'.vj#1 Ye. t-icensee: _ :;i,:n;,rute °� n J —-yn' C ii _ 3 ill$. TO. �"Io.: KL,— Address: ��'PAAAiA-t � Q L l�ry dnA � CC) . iis. Tel. No.:ti$�_'�cf��� t. :security Sy,teln Contractor Licvnsv rly� ttircd tier this lrl,rk; if;lf�nle, voter �hc license numb\ ' here:: _ OWNER'S INSURA.vCE %V\IVER: 1 a111:1mire tl at the I.i:vn ec .11;,. ;10 hulr the liability insur:lncv :-),: �raL e n., rmalh, lulluired by I' w. By my ;icn;lttue bc'l hr. I herLhy '.r' VC thi:, I'CllLlll'111101t. 1 ;1111 the (\heck one) ❑ ,.>��ncr ❑ u« ncr':, .I _.\;lit. Owner/Aget t p / - ignaturc '�1,11cr�1 �._ Ip —� —06 �F .t1lT l:'V'' / ./ Ill �. 1. , , l ! .l 1. ,. 1. No. of Recessed Luminaires �, No. of Ceil.-Susp. (Paddle) Fans t4 No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No, of Luminaires Pool above ❑ In- ❑ o. of Emergency Lighting ,Swimming �rnd. rrtd. Battery Units FIRE ALARMS No. of Zones - No. of Receptacle Outlets ,'No. of Oil Burners No. of Switches No. of Gas Burners No. of Detection and Initiating Devices. No. of Ranges + No. of Air Cond. Total Tons t No. of Alerting Devices No. of Waste Disposers Heat Pum P totals: Numher .._ Tons KW No of Self -Contained Detection/Alertin Devices g No. of Dishwashers Space/Area Heating KW _ Local ❑Muntctpal Other Connection No. of Dryers 1 Heating AppliancesKW Security Systems:* No. of Water � No. of No. of No. of Devices or Equivalent Heaters 'KW _ A_ Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: "'-_..._ No. of Devices or E uivalent OTHER: �. Ilh1I h uJ,.(,llunul /Colli r/ Jr,I; L 1. x „s lv' ji1,re'I1.1. ,ilc hoj,c,.l,,l' F.,,timatvd �•alue of Electrical l,Vrlrk: p(5)O I kk hen rcyuired by municipal policy.) kkork to Start: 6 -; S-dIo In:,pections to be requested in accordance �%ith NI EC Rule 10, and upon conlPlctiurt. INSLRANCE C'OVERA(;E: \.mess waivvd by the olrnvr. no permit for the perlornlancc of electrical �vork nlay i':sue unll', div licensee pr � ides proof of liability insurance incll.ldina "' omplvtedoperation" Covera --ie or its >tlb;lantial rqu4alc11t. I l,.—'cel—title" th:lt'alch Cokel*a,!,e I:• Ill 101•ce. ;Illi h:ls c•.hlhltcd proof Ct'Jalne to the perlllll I','.•ltlll" Itttli:e. 'I II:(: K U\I-: IN:,)'( R.\XC ❑ 13C;�1) �� ! i ftfl'R ❑ I'ipevil j:f 1hePe1.'11S,01dPelrldifte 1fPej1/Pt1, `ltiff !fie in , 1•'Nrfl%on ""'T 114 11,y),ical ill!.):1'/.li fv'dct)'.vj#1 Ye. t-icensee: _ :;i,:n;,rute °� n J —-yn' C ii _ 3 ill$. TO. �"Io.: KL,— Address: ��'PAAAiA-t � Q L l�ry dnA � CC) . iis. Tel. No.:ti$�_'�cf��� t. :security Sy,teln Contractor Licvnsv rly� ttircd tier this lrl,rk; if;lf�nle, voter �hc license numb\ ' here:: _ OWNER'S INSURA.vCE %V\IVER: 1 a111:1mire tl at the I.i:vn ec .11;,. ;10 hulr the liability insur:lncv :-),: �raL e n., rmalh, lulluired by I' w. By my ;icn;lttue bc'l hr. I herLhy '.r' VC thi:, I'CllLlll'111101t. 1 ;1111 the (\heck one) ❑ ,.>��ncr ❑ u« ncr':, .I _.\;lit. Owner/Aget t p / - ignaturc '�1,11cr�1 �._ Ip —� —06 �F .t1lT l:'V'' pda�t 0/1�- f (. 1 -,p . --CZ Aq 1-36,07 /2n 1 NORTH 4 O ,.anTOW ,In FOPE A �p U Date ............. N QF NORTH ANDOVER IT FOR PLUMBING J`" J This certifies that . % , . '...: . ?:�'�' ..."'................. . has permission to perform .. J=-`. `-"........ ............ plumbing in,t a buildings of <.. h� :.."�.. , .. , . , , C' at ................ ........:........ .North Andover, Mass. Lic. No.172. LIJ . PLYMBI1G INSPECTOR Check of 70U3 14 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, Building Location / y 16T 14� od1Z. New Renovation of 0-6101w Date 0 v Name`�i9-ME_5 R -6101 / 40 Permit # Sy�/i/07%9i Amount Nancy Replacement Plans Submitted Yes ❑ No 1)71 \ (Print or type) Check one: Certificate `installing Company Name /yJlJ� cS (jam so ❑ Corp. Partner. Firm/Co. Name of Licensed Plumber: /Q4/f5 cJ v�y7b5 11d55 Ci Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy ❑ Other type of indemnity ❑ Bond *1 Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above ee insurance trlo�� e Ell/ nature Owner �� l/ Agent ❑ I hereby certify that a 1 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 ��eral cation will be in compliance with all pertinent provisions of the Massachuse�PlumbingAde any p Laws. IBy: APPROVED (OFFICE USE ONLY Type of Plumbing License —/ icense Number Master ❑ Journeyman E 2 �7' 1' •r �.-M..-..-®. m.-m ..........WL-1110IFF1.11"Un"M .....�-.-• NM mmmmmmmmm MM W 1 W' ......-..M..M--.M-.....-. ,.,1 a s.' -.MM-.M.. ....--. MMM ----- m I $.' m...-m-mmmmmm-m--mm -M-- c e ' MM--.M--M..M..--M-.--.--� W11116180-AMMMMMMM...............m.-. Mil'Ooof'i-$.Emmmmmmmmmmmmmmmmmmmmmmmmm ma.li:oout--#.-,EMMMMmmmmmmmmmmmmmmmmmmmmm \ (Print or type) Check one: Certificate `installing Company Name /yJlJ� cS (jam so ❑ Corp. Partner. Firm/Co. Name of Licensed Plumber: /Q4/f5 cJ v�y7b5 11d55 Ci Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy ❑ Other type of indemnity ❑ Bond *1 Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above ee insurance trlo�� e Ell/ nature Owner �� l/ Agent ❑ I hereby certify that a 1 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 ��eral cation will be in compliance with all pertinent provisions of the Massachuse�PlumbingAde any p Laws. IBy: APPROVED (OFFICE USE ONLY Type of Plumbing License —/ icense Number Master ❑ Journeyman E 2 �7' 6094 - Date .... e-.. cze - ........................ TOWN OF NORTH ANDOVER PERMIT FOR WIRING I This certifies that ......... k1A ........... ......... fL... .............................................. has permission to perform ..... ................... wiring in the building of ......... ............................. at 21r ... I.V�A .................................... . North Andover, Mass. .......... .. Fee ..&.In .......... ...... ELECTRICAL INSPECTOR Check # DIFFAMMEIVTOFP[1ffi1C'S�gFFM LtNv0B0M0FF=PWEfflYI1�OlVRB9JA1X� 527adRasFees Checked APPUCATTONFOR PERMIT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CO . , 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Town of North Andover To the Inspector of wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) Owner or Tenant Owner's Address Aj6A Is this permit in conjunction with a building permit: purpose of Building 1> Utility Authorization No. �s Existing Service l Amps 1 0 / Volts Overhead ©Underground No. of Meters A New Service � G0 Amps / o /%t Volts Overhead Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical work 7-17777 No. of LighBng Outlets No. of Hot Tubs -.. 3 "f� j No. of Transformers $ Total wadctostatt ><� DoRe�d Rao RW��� Fbrvftofpeglay. KVA No. of Lighting Fr:nua Swimming Pool Above '�OC> 3 7 Bei Oeaeratars KVA -300S? ; Bid m TKNa 791-740-0160'1 MA 0109� Akldlh —7.—.f Receptacle Outlets No. of 00 Burner ow1�It'S IlVSURAI�EwANFR;tamawaedletlheI�arnaed��r�th�theirntrtsrneoo�er,�oritss�b�alegiivala�ta�ra}iedbYNleeaxfirdisCnalaalLaws ardtttetmysfglteaaon dispe�z�pic�mwiiKsilrs No. of Emergency Lighting Battery Units No. of Switeh Outleu . . D AgentDy � Telephone No. pg� FEE No. of Gas Bnmma FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Tota Tons No. of Detection and No. of Disposale No. of Haat TOW Total 1 Pumps Tom KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW NO. of Self CWASbW ices Devces LDet Muni Local Other—� No. of Dryer Heating Devices KW Connections No,,,pf Water Hamm KW No. of No. of Si Balasle No., Hydro Massage Tuba No. of Motors Total HP 11—MEIM IhmestfrrrledvddpWofmw ID#aOltr- IIVStJRAI KB S BOND -.. 3 "f� j lVe�Of�iwdk $ -,0,Slgrtedmk wadctostatt ><� DoRe�d Rao RW��� Fbrvftofpeglay. FQtMNAME M2 [ t< e [. vwe A LiwwNa '�OC> 3 7 1 iaercaee !M[ )-<e- Lwvc N LizwNo -300S? Bid m TKNa 791-740-0160'1 MA 0109� Akldlh ?EI • 5g9 ,A90 3 ow1�It'S IlVSURAI�EwANFR;tamawaedletlheI�arnaed��r�th�theirntrtsrneoo�er,�oritss�b�alegiivala�ta�ra}iedbYNleeaxfirdisCnalaalLaws ardtttetmysfglteaaon dispe�z�pic�mwiiKsilrs �gtiaszes (Please check one) Owner [:3 AgentDy � Telephone No. pg� FEE D�F�TR7MFNl'OFPUB[1CS�F�S'IY 4 Ba4RDOFFZREPRF,vFV7lf vRBmAA7i 527c M W Lhemdtlio. ' PancY k Fees Checkd L-5 APPLICATION FOR PERMIT TO PERFORM EJ��'T'RICAL WORK 0 ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSM ELWMXAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Town of North Andover Date I —A,1 —0—� The undersigned applies for a permit to perform the electrical work described below. To the Inspector of Wires: Location (Street & Number) Owner or Tenant Owner's Address 1317 14 U this permit in conjunction with a building permit: Purpose of Building A e, j %„„�� Existing Service New Service Amps a / Volta Amps /�o�Volta Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work of LiQhtim Outleu Na of Lighting Fixtures s. No. of Receptacle Outlet, p or L� Nix of switch Outlets if Ranign rIe r� f Dispouls 1 No of Dishwashen spi bf Dryers I 4 Ha pf water Neaten KW No. Na PJRMID of tbdv*pa1ofsamelot1e0®an YM q+KJgUWb0L I BM °n o a Q pvo ftw** bs�t —� 3 �f j w, l c lI F�dvalue 80111"Drle Idundrr E��eMeofpajuy, kl�yot mD*Raqu� � ofl]�ctt W Werk $ 400c”, dU tNAh1E 4 t c ie � [, ct.� y.l LizwNa c I t t yrvG 1-1 ---� Lioan9eNo � o o �' ,� AdAvA. Al AA/ 41///2 X13 / AIAI 01A , o?q ;Z Rokm7UNn �8�-Jdo a6�1 ���t+ISR'S]NS<1RAI�EWANQ�IamawaedlatlheLtalae AkTdNa 181 -5�9 - eLSO .�.��dthetmy�leaaandlepearitappiCadoawai�tst�titreq ���aD1a`Beor�s�b�r�mc}iredb!' (Please check one) OwnerC's Agent SignTelephone No. PERMIT FEE S- '"'~ (Ulleck Appropriate Box) Utility Authorization No. FIRE ALARMS No. of Debcdw UW Initiadag Devioaa N& Of%unft Devicea Na of Sam cougabw Debwo-'souslonsDevices LocalMwdcipd 0 Comtectiom do If)cuhakdodiodYiMphrnicareebelwe.f. A. No. of Zanes Olhar"—M-- k04-t� ak- / a -- l LC - & 1� U -,/,m f2vcc.' r"4,ZAJ ek / :� �--o /2q Date. . 7 e< L'-�- TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ................. ................. has permission to perform .......................... plumbing in the buildings of . ........... at .... W 4.1 ................ North Andover, Mass. 114.1 . Fee 6/ic. No.. PLUM/ G INSPECTOR Check# 6622 zf/ MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print«Type) oAdLfAMUL Date-2--LL--of— PWM at` -Z- am, ` ' BuildingLocati«1 9 S Owners Name1C T�- Sca�JI T li Type d Ocampancy New O Renovation Re*cernmt O Plans Subn*tted: Yes O No O FIXTURES I IM -1111 , W,,.. �� iWA =714A� Business Telephone 6018 89:1 Name CO Licensed Plumber c5z. INSURANCE COVERAGE: 1 have a Ilabiity insurance policy or Its subdaritial equivalent which meets the requirements d MGL Ch. 142 Yes No Q if you have checked y". please indicate the type coverage by cheAft the appropriate boot. A IWARY ktautance PakY Other type d indernrwy ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does W have the insurance coverage required by Chapter 142 of the Mass. General Laws. and that my signature on this perm t appliatlon waNes this requ ement. Check one: Owner O Age O Signature of owwriii or Owrw s I hereby ow* that aA of the detab and iMomsation I have submitted for snteredl In above appGatm are true and aoaxate to the best of my turowiedge and that all pturabeg work and in Wiations pedormed under the permit Issued f« this sppkabm wAl be in owrPR nos with al pertinent previsions of the Mussachmetts State ++mbuw CoCode and Chapter 142 of lure umber Title Type of License: Mastsr .o D /Town Lterm Number 0 r z a Z Y Iz a a a i f ru a Y J .4 a s < 0 . r a � O o Z e c d a a z a < C a M Q a a 16= a z F v z C s a 3. t- a Q �= a o. C W o° r r a 'a ,� 3 a 0° c < W '' a° c r< ac C° W :s x W f tl< z _ L r. a E' Z O p a =_ W r 0 V Z it SUB—BSMT. BASEMENT IST FLOOR i 2ND FLOOR 3RC FLOOR 4TH FLOOR s.THFLOOR aTH FLOOR TTH FLOOR STN FLOOR I IM -1111 , W,,.. �� iWA =714A� Business Telephone 6018 89:1 Name CO Licensed Plumber c5z. INSURANCE COVERAGE: 1 have a Ilabiity insurance policy or Its subdaritial equivalent which meets the requirements d MGL Ch. 142 Yes No Q if you have checked y". please indicate the type coverage by cheAft the appropriate boot. A IWARY ktautance PakY Other type d indernrwy ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does W have the insurance coverage required by Chapter 142 of the Mass. General Laws. and that my signature on this perm t appliatlon waNes this requ ement. Check one: Owner O Age O Signature of owwriii or Owrw s I hereby ow* that aA of the detab and iMomsation I have submitted for snteredl In above appGatm are true and aoaxate to the best of my turowiedge and that all pturabeg work and in Wiations pedormed under the permit Issued f« this sppkabm wAl be in owrPR nos with al pertinent previsions of the Mussachmetts State ++mbuw CoCode and Chapter 142 of lure umber Title Type of License: Mastsr .o D /Town Lterm Number 0 name: :A&Tss• city state: zip• phone # I am a homeowner performing all work myself. I am a sole proprietor have no one working in Project Type: (J New Construction 1. ❑ Building Addition l am an employer providing workers' compensation for my employees working on this job. company name: address: city: _ _. _ _ phone #• -------- am a sole proprietor, general contractor, or homeowner (circle one) and have hired the contractors listed below who have the following workers' compensation polices: company name: address: city: phone #- insurance co. lice # / %%%%%%/%/%%/% company name: address: ci phone #• insurance co. lie # Failure to secure coverage as required under Section 25A of MGL 752 can lead to the imposition of criminal penalties of a fine up to Si,500.00 and/or one yea n' imprisonment as well a, civil penalties fn the form of a STOP WORK ORDER and a fine of 5700.00 a day against me I understand that a copy of ibis statement may be forwarded to the Office of Investigations of the D):A for coverage verifkwtioa I do hereby certify under rhe pains and penalties of perjury that the information provided above is true and correct Signature Date Print name official use only do not write in this area to be completed by city or town official city or town: permit/license ft ❑Building Department ❑ cbuk if immediate response is required OLicensing Board ❑Selectmen's Office contact person: ❑Hea)tb Department phone #; ❑otber tr<�sed s� X0031 11 Location— ? t /'t 6 #Loca S)' , No. r Q Date g?x (n d ti .. �oRTM TOWN OF NORTH ANDOVER + ; , Certificate of Occupancy $ 00 bis C NuEA Building/Frame Permit Fee $ s�s Foundation Permit Fee $ Other Permit Fee $ TOTAL $ �d Check # �� ` ✓ /' 184,015 �,� Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: l q VS SIGNATURE: Building Commissioner/Ing.3ector of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: ?q ,yrs -g 1.2 Assessors Map and Parcel 67 Map Number Number: q3 Parcel Number A/10 w Vt " bovc A` 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 Sppply M.G.L.C.40.154) 1.5. Public 1� Private ❑ Zone Flood Zone Information: Outside Flood Zone 1.8 Municipal Sew a Disposal System: [ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT I Fll8iorIC UfstriCt: Yes NO I/ 2.1 Owner of Record Name (Print) A^ t Address for Service Telephone 2.2 Owner of Record: ��4r� P�n Ai 9q 11 T -6-N 6-i. Nameri t Address for Service: J 6Z - �-7 Si ature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ MCC Licensed Construction Supervisor: 6 6 0 % 6 co- ^ p t e Ave �G� , s !� `^ S� U t QG License Number Add Address i`t0" G 200& 228 -536—? -6? -6 Expiration Date re Telephone , ,tRegistered Home Improvement Contractor Not Applicable ❑ owSr C� r (ny` / C pany Name Z U 4 3 (n c ,n , A �J l' A'J f A 160V V A , I Lj / Registration Number ✓ Expiration D?6-0 .. 0(0 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 builfng permit. Signed affidavit Attached Yes ....... IV No ....... ❑ SECTION 5 Description of Proposed Work cher applicable) New Construction ❑ 1 Existing Building V I Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ 1 Other Qr Specify �C, hJ .£/ Ad Brief Description of Proposed Work: 'CWl,6l/ * DL J) 7-C- jFp�j fly l2lCoetk C2_ t.J ER`s 13.4)"41r es �-1 M d 1) C �'_ I SECTION 6 - F.STIMATFn VONCTRTTf T1nN M -MZ I Item Estimated Cost (Dollar) to be OFFICIAL USE ONLY Completed by permit applicant 1. Building f a o 61 (a) Building Permit Fee 000. Multiplier 2 Electrical 0T_ 400 (b) Estimated Total Cost of 0 Construction 3 Plumbingd Building Permit fee (a) X (b) aD 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 dQ Check Number OM_1JLVA /a UWANK AU InUKILAHUN lU BE UUMYLE ED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION Date 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 9A Name (Ac cos. M'rc'�— 4� -l�-�S" Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TMMERS iST 2 ND 3 FD SPAN DIN ENSIONS OF SILLS DRAENSIONS OF POSTS DINIENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CH ANEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 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 at: 9 i &- G- 14, V 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. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 10A. The debris will be disposed of in: Fire Department Sign off: Dumpster Permit (Location of Facility) Signatur4 of Permit Applicant Date AR WCIP € ISSUING OFFICE 354 INFORMATION PAGE Workers Compensation and Employers Liability Policy UNT NO. SUB ACCT NO. Liberty Mutual Insurance Group/Boston 1-334159 1 0000 1 LIBERTY MUTUAL FIRE INSURANCE CO. 16586 POLICY NO. TD/CD SALES OFFICE CODE SALES CODE N/R IST WC2-31S-334159-015 XX X WESTON 102 REPRESENTATIVE 3000 2 YEAR Premiums muneration Premiums SEE EXTENSION OF INFORMATION PAGE ASSIGNED 2002 Item 1. Name of JAMES MCCORMICK DBA Insured J M MYLES CONSTRUCTION INC FEIN 01-3607637 Address 6 CRANE AVE RISK ID 39598 PEABODY, MA 01960 Status 01 INDIVIDUAL Other workplaces not shown above: SEE ITEM 4 Mo. Day Year Mo. Day Year Item 2. Policy Period: From 04-13-05 to 04-13.06 12:01 AM standard time at the address of the insured as stated herein. Item 3. Coverage A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3A. The limits of our liability under Part Two are: Bodily Injury by Accident 500,000 each accident Bodily Injury by Disease 500,000 policy limit Bodily Injury by Disease 500,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: SEE END WC 20 03 06A D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE Item 4. Premium - The premium for this policy will be determined by our Manuals of Rules Classifications Rates and Rating Plans. All information required below is subiect to verification and change by audit. Minimum Premum $ 500 ( MA ) Total Estimated Annual Premium $ 5,138 Interim adjustment of premium shall be made: ANNUAL This policy, including all endorsements issued therewith, is hereby countersigned by SEE ATTACHED FORM 1710 Authorized Representative Date 03-24-05 Loc. Code Term. Oper. Audit Basis Periodic Payment Rating Basis I P.I. H.G. I Home State I Dividend I RENEWAL OF: 03-24-05 1 1 1 NR MA WC5-31S-334159-014 GPO 4030 RI Copyright 1987 National Council on Compensation Insurance WC 00 00 01 A Premium Basis Rates LINE 110 Estimated Per $100 Estimated Code Total Annual of RE- Annual Classifications No. Premiums muneration Premiums SEE EXTENSION OF INFORMATION PAGE Minimum Premum $ 500 ( MA ) Total Estimated Annual Premium $ 5,138 Interim adjustment of premium shall be made: ANNUAL This policy, including all endorsements issued therewith, is hereby countersigned by SEE ATTACHED FORM 1710 Authorized Representative Date 03-24-05 Loc. Code Term. Oper. Audit Basis Periodic Payment Rating Basis I P.I. H.G. I Home State I Dividend I RENEWAL OF: 03-24-05 1 1 1 NR MA WC5-31S-334159-014 GPO 4030 RI Copyright 1987 National Council on Compensation Insurance WC 00 00 01 A ✓�ie t�ammui?uarP.cc%C/ ,.a�.i�actr�..�ve%ld Board of Building li platigm'and Standards ' HOME IMPROVEN dT 66NTRACTOR Registratwti 126713 k Expiratton' 718/2006 r: Typery DBA �.K 4 JAMES MCCORMCCONST b.6- JAMES MCCORMiCK 6 CRANE AVE W. 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