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HomeMy WebLinkAboutMiscellaneous - Briarwood Court1 W d Date.... AZZJ.(.-.......... t I TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING Vw This certifies that kl— .rf"D ............ I .............. ........................................... Chas permission to perform .....V . 6 -4.6, -Ir b� .......... ...... ..... . — plumbing in the buildings of..W6,A.2,..,9- 0—, .. . ...................................... at ...... bl.;� .......... I ........... , North Andover, Mass. Fee ..N= .... Lic. No. law . ....... H .............. ................... PLUMBING INSPECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' CITY MA DATE n ._ _ Iq PERMIT# JOBSITE ADDRESS �.�Q , .H_�C?��Cty_ W R'S N MEI fitJG1J_._r.. ell POWNER ADDRESS r + TEL FAX f TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Ll RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION: © REPLACEMENT: Er' PLANS SUBMITTED: YES � NO FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM !___. I _f -__.__-! _._ _.J _.- -..... I .J --__ __ 1 _._-._I .__.__ .{ __ _._ J IJ. f - DEDICATED GREASE SYSTEM _� _..__.J - _ f .__...__E ._-- -� _- f I 1 L- . l .-.---.._J ( ..........f f I DEDICATED GRAY WATER SYSTEM f I. DEDICATED WATER RECYCLE SYSTEM _I _. J -. ([ I ' -A �.___I _ _..__! ____._J _.____( .__1 _I DISHWASHER DRINKING FOUNTAIN __.i __._. I (_.__._J ! __._._I ..._..__•` ..._.1 .__...J _ (....__..W FOOD DISPOSER FLOOR/ AREA DRAIN i INTERCEPTOR (INTERIOR) i -1 KITCHEN SINK --f F -7[ --- LAVATORY I ROOF DRAIN SHOWER STALL (J I SERVICE 1 MOP SINK J I I f _-J I 1 .. . _._f I I ( -J TOILET URINAL WASHING MACHINE CONNECTION + E t WATER HEATER ALL TYPES WATtR PIPING OTHER ._. ___---- _=� = f I -- -- - J -- ! - ---- -f --- I --J I -+ E-7 U INSURANCE COVERAGE: have a current liability insurance or its substantial equivalent which meets the requirements of MGL Ch. 142. YES 0-90---o policy IF YOU CHECKED YES, PLEASE INDICATE THE TYP OVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY�OTHER TYPE OF INDEMNITY BOND QI OWNER'S INSURANCE WAIVER: lam 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 I hereby certify that all of the details and information I have submitted or entered regarding this application are true a a rate t e best of wled e and that all plumbing work and installations performed under the permit issued for this application will be in compli c ith a + nt o ' of th Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAMEc! ,��R LICENSE # /�j SIGNATURE MP CORPORATION Fjl# PARTNERSHIP# LLC aF= COMPANY NAME - it ADDRESS c-' ' CITY - ..__....._...._� STATE �I ZIP�- TEL EE 04 FAX—CELL � - _ .._ _ _ _ I i EMAIL H O z FH w w o z a r� d WE W LU O W CL Z U = H✓ 5 o a LLU Pro 0 w o a � W a � U J a a a � w z w F- a W E+ O z O H U a C7 a a o The Commonwealth of Massachusetts Department ofIndustrial Accidents Office q fInvestigations 600 Washington Street .Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/.Plumbers Address: 1 Phone #: q ? 3 � City/State/Zip: �'l l l� FA, Are you an employer? Check the appropriate box: Type of project (required): LEI I am a ployer with 4.ElI am a general contractor and I 6. F1 Now construction P oyees (full andloxpart time).* havehvredthe sub -contractors on the attached sheet. 7• ❑ Remodeling 2. 1 am a sole proprietor or Partner . ship and'have no employees These sub -contractors have These 8. Demolition working for me in any capacity. woxkers' comp. insurance. 9, El Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10. F1 Elecixical repairs or additions required.] 3. ❑ 1 am a homeowner doing all work officers have exercised their right of exemption per MGL 11. ❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), andwehave no 12.❑ Roofrepairs insurancere �ed. ] i employees. [No workers' 13.❑ Other 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 submit this affidavit indicating they ge doing all work and then hire outside contractors must submit a new affidavit indicating such. tCoatractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. X am an employer that is providing workers' compensation insurance for my employees .Below is the policy and job site information. Insurance Company Name:, Policy # or Self -ins. Lic- Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A ofMGL o. 152 can lead to the imposition of criminal penalties of a fine up to $1,5 0 0.6 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. Bo advised that a copy of this statement may be forwarded to the Office of investigations ofthe DIA for ins3aarp coverage vexi?ati .I do Hereby certify Phone If: the information provided ove is rue and correct. n;tP. �3 . l q Of.fccial use only..Do not write in this area, to be completed by city or town official. City or Town: PermitUcense Issuing Authority (circle ane): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - Contact Pers 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 orimplied, oral or written.,, An employeY 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 ortrustee 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 an 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapterhave beenpresented to the contracting authority." Applicants Please till 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 phonenumber(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, 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 filll 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 permiWicense applications in any given year, need only submit one affidavit indicating current Policy information (ifnecessary) 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. Anew affidavit must be filled out each year. Where a home owner or citizen is obtaining a license o 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 and fax number: Tho CommonwoalthofMassarlivsP s Depad ent ofIndustrial ,A.cddmts Office allaveatigat om 600 Wasb ugtoz2 meet Boston, NA 02111 Tel # 617-727.4900 est 406 or 1-M-MMSAFE Revised 5-26-05 Fax # 617-727-7749 _WWW.MmS.gQ-VMa Date........ ................. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION -,;:::: �W— Thi% certifies that u� Vutv S ............................... V .......... .......................................... has permission for gas installation ............................ in the buildings of T. vv- at !..5... . !!Ng -:7 ............ ;I ................... North Andover, Mass. e-2 Fe . . ...... Lic. No. I ....... w .. ...... ....M . . . .......................................... GAS INSPECTOR Check #32-% ,G' TYPE OR PRINT CLEARLY MASSACHUSETTSUNIFORMAPPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE PERMIT # JOBSITE ADDRESS , ,is;�a.��OWNER'S NAME© OWNER ADDRESS ' OCCUPANCY TYPE COMMERCIAL EDUCATIONAL NEW; ._ j RENOVATION: El REPLACEMENT: APPLIANCES 1 FLOORS- BSM BOILER --TF-- BOOSTER - BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE RESIDENTIAL PLANS SUBMITTED: YES 0 NO M0 w 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES I 1 IF YOUNECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE Y CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ® BOND R 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: OWNERIj AGENT LjI 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 e b st of my know ge and that all plumbing work and installations performed under the permit issued for this application will be in complit i anth erti isio • o e Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 10 PLUMBER-GASFITTER NAME/( -+-� j! LICENSE # SIG T E MPGF 0 JP -® JGF [] LPGI © CORPORATION []# PARTNERSHIP Dt= LLC E]#= COMPANY NAME: II ADDRESS CITYSTATE ZIP TELMIN F441 4 FAXE= CELL >yQMAIL 1) 1% 1/2212015 Division of Professional Licensure: License Search The Official Website of the Office of Consumer Affairs and Business Regulation (OCABR) Division of Professional Licensure Y y. Mass.Gov Home State Agencies A -Z Topics Home > Division of Professional Licensure Check A Professional License By the Division of Professional Licensure LICENSEE Name: ADAM C. HOLMES HAVERHILL, MA NEW SEARCH "This Licensee has additional Licenses, click here to view them." Licensing Board: PLUMBERS fit GASFITTERS License Type: MASTER PLUMBER License Number: 15685 Status: CURRENT Expiration p 5!1/.2 016 Issue Date: 3/18/2010 Exam Date: 3/18/2010 School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Thursday, January 22, 2015 at 11:34:28 AM. © 2007-2011 Commonwealth of Massachusetts Mass.Gov ONLINE SERVICES Check a License Locate a Licensed Professional Online Address Change Contact the Agency More... REFERENCES& RELATED INFO Disclaimer Regarding Website License Searches Glossary of License Status Codes More... http://license.reg.state.ma.uslpublic/pubLicenseQ.asp?board code=PL&type_class=_M&license_number=000015685&color=&Ib=PL Site Policies Contact Us 09757 Date) (t? X77.... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that`' �(-))IvnP. S . ,R•t , .. . /` has permission to perform plumbing in the buildings of. j� at . %O. .. EYzk `: !Wk ,00cl 64 ,North Andover, Mass. Fee . h Lie. No.H ................. ... PLUMBING INSPECTOR Check #oZ � 1� rAa-J. 1'6 J MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE -_. PERMIT # - JOBSITE ADDRESS OWNER'S NAME ._. _.._ TEL FAX OWNER ADDRESSI i TYPE OR OCCUPANCY TYPE COMMERCIAL' EDUCATIONAL [ RESIDENTIAL PRINT CLEARLY NEW: ) RENOVATION: El REPLACEMENT: PLANS SUBMITTED: YESjI NO[] FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE _ € ....__.- I _..,.I _ - . €._......... DEDICATED SPECIAL WASTE SYSTEM _ € ------ DEDICATED GAStOIUSAND SYSTEM DEDICATED GREASE SYSTEM -----.,... I . -._. _( .__ ! € ° _ f ..__....€ .---•_-€ - J _.. 1 .. DEDICATED GRAY WATER SYSTEM _-j DEDICATED WATER RECYCLE SYSTEM - DISHWASHER F DRINKING FOUNTAIN — - - - ------ FOOD DISPOSER - _-- FLOOR/ AREA DRAIN _.1.._1 ..._.._.._. ._.- _i ..-..,...__I ..__.__..(!... __..i �r INTERCEPTOR INTERIOR __._ ._ €�- -.--'•-----__ . _. ._, �r ._. -.---I ---.-- € __...Y.w€ _,.__ ._.. €TCHEN SINK LAVATORY _ ROOF DRAIN_..._.. SHOWER STALL _... 1117 __... _. _ _.__ .._. .._ _.__..._ _' SERVICE! MOP SINK F -Ji TOILET _rJ _,-_€ ^._I .___...J _ -- I I .-.'--1 ._-.�. .: - - € . `_ _ _.i _ . _I _-------I URINAL WASHING MACHINE CONNECTION 4E -Ji WATER HEATER ALL TYPES WATER PIPING OTHER -� _ ._...._..-.1 :,-...1 ........_I ._ _ I .._ ._.1 ,- r. __._.....i ____ _ .__ _.J 711.1 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YE&UN4 [j - IF IF YOU CHECKED YES, PLEASE INDICATE THE E Of COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY -.._ ` OTHER TYPE OF INDEMNITY E] 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 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are tru and accurate to the best of my knowledge and that all plumbing work and Installations performed under the pemiit issued for this application will be In co pl nce with all Pertinent 4roviflon of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAMEM� LICENSE # l 'SIGN RE 4�� MP ._ JP E-3 CORPORATION PAR!NER,3HIPDJ#=LLG __[-tel'`# COMPANY NAME ADDRESS CITYTE ZIP TEL �� FAXwr- 'tjv®rhIHI gSu�-_ttEMAIL� rAa-J. 1'6 J U r a 1 I Date D 0 TOWN OF NO A ANDOVER PERMIT OR PLUMBING �SSACHUS This certifies that ? t ... -74 ................. has permission to perform ...... ......................... plumbing in the buildings of . . 4.r'. 1'.c r.%- . Alf-.�.-. — . . . . . at .16. 14... 1-3. P ! ( t4.4-. . I . . A -'N ............ North Andover, Mass. Fee. .30 Lic. No.. .2 K. ?f'3 ....... Y UUMBING INSPECTOR Check # 7541 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date Building Location //y ifa!'i r —is Xg,2&0/1-Owners Name � ,h r, �� Permit # r' Amount 70 7' / Type of Occuvancv /_rico New 1-1 Renovation 1:1 Replacement Plans Submitted Yes E—] No ❑ (Print or type) Check one: Certificate Installing Company Name ,, % ❑ Corp. Address !� Partner. Business Te ephone 30. Name of Licensed Plumber:�1!/L, Insurance Coverage: Indicate the type of insurance coverage byy c'heeckiinng the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ 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 Owner ❑ Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations perfo ed up4prPermit Issued for this ap ' A on will be in compliance with all pertinent provisions of the Massachusetts State b' de a ter 42 eneral Laws. By: Signature 517-1-c-ensea Fluinver Title Type of PJumbing License � City/Town icense NumDer Master ❑ Journeyman APPROVED (OFFICE USE ONLY F i 'F I • ' • , ------------------------- 4PUMMMnommmmm MWMWWWW0WM WMM ;,nnnnnnnnnn�nnnnnnnnnnnnMW -e,'MMMMMMMMM WMMWMWMWWM W��� nnnnnnnnnnMnnnnnnnnnnnnnWMMMMMMMMWWWMWMMMMWWMMWMMW �i :",o'nnnnnnnnnmmmmnmmnnnnnnMMME (Print or type) Check one: Certificate Installing Company Name ,, % ❑ Corp. Address !� Partner. Business Te ephone 30. Name of Licensed Plumber:�1!/L, Insurance Coverage: Indicate the type of insurance coverage byy c'heeckiinng the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ 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 Owner ❑ Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations perfo ed up4prPermit Issued for this ap ' A on will be in compliance with all pertinent provisions of the Massachusetts State b' de a ter 42 eneral Laws. By: Signature 517-1-c-ensea Fluinver Title Type of PJumbing License � City/Town icense NumDer Master ❑ Journeyman APPROVED (OFFICE USE ONLY Date ,0:12. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACMUS� This certifies that.t!:. has permission to perform plu1m�b/ing n the buildings of .li•�!!%��! .. mac.. . T,!�� . . at/..1/. .�tL�%�/.�.� 1%.. .(-�` �C��'/._/. /. , North Andover, Mass. Fee. ,. Lic. No.,.Js���!? ./�(,IAA2..... . PLUMBING INSPECTOR Check 6381 MASSACHUSETTS UNIFO (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location/),J �/d &aqw ze�D New M Renovation of APPLICATION FOR PERMIT TO DO PLUMBING Date ame n,eOP. d Permit # Amount ancy Replacement F FIXTURES Plans Submitted Yes No (Print or type)Check one: Certificate Installing Company Name /i� ?2.c,inr i mQy Corp. Partner. Firm/Co. Name of Licensed Plumber: '27)Vyl'o �tj/e-sqn Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy I Other type of indemnity Bond ❑ 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 Owner 0 Agent 11 I hereby certify that all of the details and information I ubmitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work install 'ons rformed under P 't Issued for this application will be in compliance with all pertinent provisions of the sachuse s Spff Plu ng o d Chapter 142 of the General Laws. By Signature or MEMO PiumBer Type of Plumbing License Title 2?3/ 3 City/Town ` is n um er Master Journeyman i APPROVED (OFFICE USE ONLY L..Y 1-4 Of ,NORTH �� O P tr Date... Ilb 5 . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING J' SS us . .. ... .. .. . This certifies that , has permission to perform "".`►-.� r 40� P plumbing inIthe buildings of . - j .. .....North Andover; Mass. Fee 1.. Lic. No..�/..... ,! �1/.1.(l/ / PLUMBING INSPECTOR f Check +! 6479 MASSACHUSETTS UNIFORM APPLICA (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location of New 1-1 Renovation 1:1 Replacement ea 0a FOR PERMIT TO DO PLUMBING Date L " g Name hR\4e- Permit# Amount anc 61�TU-1��vTS Plans Submitted YesNoEl (Print or type)/ //� Check one: Certificate Installing Company Name //��/ .�% �G(/J97� /0, Corp. ElPartner. EFirmlCo. F GrsName of Licensed Plumber: v req- Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: y Liability insurance policy E21� Other type of indemnity ❑ Bond ❑ 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 Owner Agent 11 I hereby certify that all of the details and information I have mitte (or entered) in above appli ion are true and accurate to the best of my knowledge and that all plumbing work and ins ations p o d un4d Permit Is for this application will be in compliance with all pertinent provisions of the Massac etts St Pivaing d n of the General Laws. By: SignaEureTt Licensecium er Type of Plumbing License Title 3 `� City/Town License MOW Master ❑ Journeyman APPROVED (OFFICE USE ONLY L_I Location % /0 •' �Jt! C ',. No. e5 Date N0MTM TOWN OF NORTH ANDOVER FO 9 Certificate of Occupancy $ s'•••' E,�' Building/Frame Permit Fee $ ncNus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ AM, 7' Check # 4,3 7 .. F 17466 /Building Inspect . The Commonwealth of Massachusetts State Board of Building Regulations and TOWN OF NORTH ANDOVER Standards Massachusetts State Building code BUILDING DEPARTMENT APPLICATION TO CON 780 CMR AIR, RENOVATE. Cw�Ncv muv ■rc.n ........�_ . __ BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING urAA4UY VF, OR DR] Date Issued; —/ 91d ev SECTION 4 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (14LG.L. c 152 25C(6)j Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached ye'li No SECTIONS- PROFFESSIONAL DESIGN AND CONSTRUMON SERVICES -FOR BUILDING AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 CONTAINING MORE THAN X000 C.F.OF ENCLOSED SPACE 5.1 Registered Architect: No Applicable Name (Registrant): Address Registration Number Signature Telephone Expiration Date 5.2 Registered professional Engineer(s) Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name): Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 5.3 General Contractor Not Applicable 13 Company Name: Responsible in Charge of Construction Address Signature Telephone SECTION 6 - DESCRIPTION OF PROPOSED WORK check allapplicable) New Constructioa O 1 Existing Building Repairs U Alterations Addition Q Accessory Bld . Q I Demolition Other Q Specify Brief Description of Proposed: ✓� Cl S o -r S s r rt S. 9- �l SECTION 7 - USE GROTIP AND roNCTRTirnov TVPR USE GROUP Check as applicable Independent Structural Engineering Structural Peer Review Required Yes O No O CONSTRUCTION TYPE A Assembly A-1 A-4 A-2 A-5 A-3 lA IB O Q B Business 2A 2B 2C 3A 3B Q Q Q Q O E Educational O F Facto O F-1 F-2 H 11igh Hazard O I Institutional O I-1 1-2 1-3 M Mercantile 4 13 R Residential R-1 R-2 R-3 5A 5B O Q S Storage O S-1 S-2 U utility Q Specify: M Mixed Use O S i : S Special O Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS. ADDITIONS AND/OR CHANGE IN USE Existing Use Group: Existing Hazard Index 780 CMR 34 O Proposed Use Group: ; n Proposed Hazard Index (7 80 CMR 34 SECTION 8 - Building Height and Area BUILDING AREA Existing ifapplicable) Proposed Number of Floors or stories include basement levels Floor Area per Floor Total Area Total Height ft SECTION 9 - STRUCTURAL PEER REVIEW 780 CMR 110.11 Independent Structural Engineering Structural Peer Review Required Yes O No O SECTION I Oa - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, G a-4 As Owner of subject property hereby authori 7 �� to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date luvis uiug lorrmsraie m1- SECTION l Ob - OWNER/AUTHORIZ$D AGENT DECLARATION I Ji h n T PO iC a , as Owner/Authorized Agent hereby declare that the statements and information on the foregoi g application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Name Date SECTION 11 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be completed b permit applicant Official Use Only 1. Building Q 1 / ZDV (a) Building Permit Fee Multiplier 2. Electrical (b) Estimated Total Cost of Construction from 6 �7 lo�j 3. Plumbing Building Permit Fee (a)x(b) qao 4. Mechanical AC 5. Fire Protection 6. Total = 1+2+3+4+5 Check Number Jite VOnvn2(Yn!lI�L2LL2 a� �lcw�cuiuu3eCld BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 033843 r.' r� Birthdate: 03/15/1955 ' Expires: 03115/2006 Tr. no: 18496 Restricted: 00 JOHN T HAFFEY 3 WILLIAMS ROAD w WAYLAND, MA 01778 Acting Cc mis oner /[ § �§§ \|� %]] 3 �\ j�cc , ��@2 - § § 2 § ) \ \ ��.� �\ • l �\ �- ]]]� k\\§� � (} \�A}� § $ - , � / i \ \ \) ( \� (} Lo . E I C) X UJ CL }/ \ k 3 m q w LU _ ) ? ) \ w0 U. < me 4C;v - �\\\\ / \ \ } / . J�� City: h1 o r to (� v)d.o ue r rM phone # ❑ 1 am a homeowner performing all work myself. ❑ 1 am sole proprietor and, have no one working In any capacity I am an employer providing workers' compensation for my, employees working on this Job. Company name:_j- I o1.13U r (dus Tn C -- Address: { 3 u , rr City: W LL4 (-C4 'moi (MA d) t `7 Z phone # SZ) S- Co 2d `1 t e 8 Insurance co. A o � r.rv�Q policy # W C(92 �5 r 3 86 -Ue 2 12 - {r -o ❑ I am sole proprietor, general contractor, or homeowner, (chola one) and have hired the contractors listed below who have the following workers' compensation policies: Company name: Address: City: phone # Insurance co. Dolicy # Company name: Address: �+ City: phone # Insurance co. ,__ policy # Failure. fo sacirre covera�p a41, gkad uiidof 3ection';z.SA:of MOL` 1 2 Ga.R`�e�e to thq (ry.p Itlon of criminal penalties'`of a Me up to $1,500.00 and/or one MVI(, - \ f,r me. I understand that at copy of this statement may be forward@d WAN; Office of Investigatlons of th4 OIA fgrcoverage 4erificatlon. a 7f I} r y 1 kl �Iir (`SV .The Commonwealt�ia� � sa�l{usetts I do hereby certify under the ,. , ,Jt r °c`cldents Department of hW' Signature Moe of ►nvQsfl a#lQns b 600 st l l0 8 Boston, Miss 02111 Workers' Compensation Insurance Affidavit City: h1 o r to (� v)d.o ue r rM phone # ❑ 1 am a homeowner performing all work myself. ❑ 1 am sole proprietor and, have no one working In any capacity I am an employer providing workers' compensation for my, employees working on this Job. Company name:_j- I o1.13U r (dus Tn C -- Address: { 3 u , rr City: W LL4 (-C4 'moi (MA d) t `7 Z phone # SZ) S- Co 2d `1 t e 8 Insurance co. A o � r.rv�Q policy # W C(92 �5 r 3 86 -Ue 2 12 - {r -o ❑ I am sole proprietor, general contractor, or homeowner, (chola one) and have hired the contractors listed below who have the following workers' compensation policies: Company name: Address: City: phone # Insurance co. Dolicy # Company name: Address: �+ City: phone # Insurance co. ,__ policy # Failure. fo sacirre covera�p a41, gkad uiidof 3ection';z.SA:of MOL` 1 2 Ga.R`�e�e to thq (ry.p Itlon of criminal penalties'`of a Me up to $1,500.00 and/or one year's imprisonment as well as.civil penBlue$ in the form of a $TOR, ORK OPEE ' and,; title,of;100.00 q day against me. I understand that at copy of this statement may be forward@d WAN; Office of Investigatlons of th4 OIA fgrcoverage 4erificatlon. that the infonnatlon above is true and correct, I do hereby certify under the pains and penalties of perjury pro"deo Signature Date Print name i10l1e # 50S Z� l l0 8 d this to be completed;tiy�cl�y o'{dvyrt official Offctal use only of writeiri area . ..•..I"OT.,V;,11 11ift •... .. Gity or:toWn: .r i, rmit/UCense # ❑ Building Department .:. `:. Ilc IYI f �IS;M 11 '' (] Ucerising Board •: r �. : J , , � +t�vw.�. ; ., &c ck f. immediate response is requlred ,� Selectmen'sOffice. 0 Health *etrnent coptact person + at ,' r18 #: ❑ Other •. N s y . {J FJ' S 1 iii " r M,f�I 1 j x tFir 74, ' -• s. .�.cV�•}!?:`MY,,rr '.• /`, �1• ...r�„it,",, J�(K ,3AiJJ :�..�x. Y.� e... K...-4it•A.SM.�1 ':,v.V r•r;:; ..•r{y .,:. .:r'... ;, .,:. .:., ' .tifi•.!ik�tl(��tJl i°=.ii•'�I.w7Y '.:1.:/.ljJ[iS `+i 11 .:r''(�,ratM•p. lil� IeL.ltrj• - v'A'Hi, r�J% t 1. ' yy�� ty1 i J •.y}} L�3t '�i1J/I,1; 1 1- 1 ' '':! i�lx7Ld�i1 J :`7 IJV i �,•.1P.h�!r0,'.I'! .. 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 of Facility) ig,nature f 6Pefmit Applicant --z^Z°oy Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector CA m m m co m m v y C � — d CA O n Z y CL =• o CL y aCc '0o go OCD v CD O CL— CD O O cD w w 1• C• O N CD �O H C I � v CA10 O P a 74 CDO CD c 010 C = -4 ma m = M0 SL mCL 44 y G Nod j i m _ �� - 0 0, =-CL o ir CD �H a m 0 S' 1 f m a > > RV m � CC �,� o . � ii cr C >0�CDa► ?moo . aC49����ia r'd hnCLm CL l J o 0; :s. aD :b ►' v' CL ��� Q 0 W _* Aft C a �� a JE CD: 0 n•FO Qo". -D � z mom z m .�.. ?. txfir ; m :dp C/).Q too!, 'b O o _�iL a os: MVIO CP co'fi om• r v 0. ftp y� b a O CO rl X x p O o M "I