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Miscellaneous - Browns Court
Date. �/. G....... . 02 �` TOWN OF NORTH ANDOVER , • PERMIT FOR GAS INSTALLATION ♦ a _y SSACHUSEtt 4 This certifies that ....�. s.....��'.. 1 . ................. i/ ' has permission for, gas installation ..j.S . of s in the buildings of ..//? s . !' �: ` .......................... at .. f1. .. (.j 1 `` . `. '... 4 ....� . , North Andover, Mass. Fee. Lic. No. l ?G ?... ::l.J ...... . GAS INSPECTOR Check # G 7� 7240 MASSACHUSETTS UNIFORMAPPUCATON FORPERMIT TO DO GAS FI'ITNG (Type or print) Date NORTH ANDOVER, MASSACHUSETTS Building Locations /7 23 'Iiy `V New ❑ Renovation Owner's Name Replacement 1:1 Plans Submitted 171 Permit # Amount $ a (Print or type) �Al P Check one: Certificate Installing Company Name �( � t✓ L G% L� LL /� ❑corp. Address ❑ Partner. as.� 3mess Te ep one irm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes © No[:3 If you have checked ,Yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy UM Other type of indemnity Bond RQML- Owner's Insurance Waiver: I am aware that the.Iicensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 0 Agent 1 hP.rehv nPrti4i1 A—f .11 nP A— A -+-:l, ..-.a :-r-- I -- -- --- -- -- _-•• . == J��•• u kvi cntereu) in aoove application are true and accurate to the best of my knowledge and that all plumbing work and in tions performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massae State Gas Code and ter 142 of the General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Signature '0f Licensed Plumber Or Gas Fitter ® Plumbed S ® Gas Fitter License Number 0 Master ® Journeyman �, c4 a H o x a w w c c z � w d � w w �. �, a a U F z b w a > W U x a w 7d F z c F U -' ° x w W o L 3 o v < o o W SUB -BASEM ENT x > o ° o BASEM ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8TH. FLOOR (Print or type) �Al P Check one: Certificate Installing Company Name �( � t✓ L G% L� LL /� ❑corp. Address ❑ Partner. as.� 3mess Te ep one irm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes © No[:3 If you have checked ,Yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy UM Other type of indemnity Bond RQML- Owner's Insurance Waiver: I am aware that the.Iicensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 0 Agent 1 hP.rehv nPrti4i1 A—f .11 nP A— A -+-:l, ..-.a :-r-- I -- -- --- -- -- _-•• . == J��•• u kvi cntereu) in aoove application are true and accurate to the best of my knowledge and that all plumbing work and in tions performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massae State Gas Code and ter 142 of the General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Signature '0f Licensed Plumber Or Gas Fitter ® Plumbed S ® Gas Fitter License Number 0 Master ® Journeyman Information an d Instructions Y 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 pe—non 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 orother 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 apartraents 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 stare 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 coxnpiiance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone nuniber(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the perzuit 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 perarits 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 Bice to -thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office ofInwest aatioas 600 Washmgton Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-8 77-MAS.SAFE Revised 5-26-05 Fax it 617-727-7749 vrvrv7 .Ill ass-- g ov/di a Date �:r �.. �. ...... . TOWN OF NORTH ANDOVER PERMIT FOR GAS -INSTALLATION ',SSAC'MU9Ett This certifies that has permission for gas installation_._..�..... in the buildings of ...% ....................... at .......•............ , North Andover, Mass. Fee. ` .. Lic. No % P), ^"GAS IN� CTOp Check # 116-0P), MASSACHUSETTS UNIFORM APPUICATON FOR PERNII'f' TO DO GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locations _ � \o g(b tatl C e mac• so^ Owner's Name New ❑ Renovation ❑ Replacement El dtis Datev� a_300q Permit# OC1 Amount $ Plans Submitted (Print or Nance_ Address 1�q pt4 t t�PtXvc Business a ep one i cAj -�Cs r- Name of Licensed Plumber'or Gas Fitter 0 (9'4-3 Check one: Certificate installing Company ❑ Corp. ❑ Partner. Firm/Co. (lINSURANCE COVERAGE If have a current liability Insurance, policy or it's substantial equivalent, Check one: Yes Liability insurance policy 13 Ifyou have checked ves, please indicate the type coverage by checking the appropriate box. ❑ Other type of Inde "Q mnrty ❑ Bond 1:3Owner's Insurance Waiver. I. am aware that the licensee does not th the insurance c Mass.. G' �rnl Laws my signature on this • ermit overage required b Ch tS P apP[ication waives this requirement. Y Chapter 142 of the Signature of Owner or Owner's Agent Check one: hereby certify that all of the details and information !have submitted Owner ❑ Agent ❑ best of my knowledge and that all plumbing work and. installations performed under Permit Issued for this application will be compliance with all pertinent provisions of the Massachusetts State G ntered) inabove application are true and accurate to the as Code and Chapter .142 of the Gen m General Laws. r X -1 _ By: Title City/Town; _ APPROVED (OFFICE USE ONLY) ❑Signature of Licensed Plumber Or Gas Fitter Plumber ❑ Gas Fitter CL ❑icense um er Master ® Journeyman a -d 4�- rA � v w ' M ,. Gn w o o a o o N F 14 i Q w ��" zx w w ck m w QQ > 11,U z w m .� SU B-BASEM ENT z z a + c J e p BENT uASEM 5. c i IST. FLOOR 2ND, FLOOR 3RD. FLOOR 4TH. FLOOR STH. FLOOR .—F, L 0 011R -7TH. FLOOR STH. FLOOR (Print or Nance_ Address 1�q pt4 t t�PtXvc Business a ep one i cAj -�Cs r- Name of Licensed Plumber'or Gas Fitter 0 (9'4-3 Check one: Certificate installing Company ❑ Corp. ❑ Partner. Firm/Co. (lINSURANCE COVERAGE If have a current liability Insurance, policy or it's substantial equivalent, Check one: Yes Liability insurance policy 13 Ifyou have checked ves, please indicate the type coverage by checking the appropriate box. ❑ Other type of Inde "Q mnrty ❑ Bond 1:3Owner's Insurance Waiver. I. am aware that the licensee does not th the insurance c Mass.. G' �rnl Laws my signature on this • ermit overage required b Ch tS P apP[ication waives this requirement. Y Chapter 142 of the Signature of Owner or Owner's Agent Check one: hereby certify that all of the details and information !have submitted Owner ❑ Agent ❑ best of my knowledge and that all plumbing work and. installations performed under Permit Issued for this application will be compliance with all pertinent provisions of the Massachusetts State G ntered) inabove application are true and accurate to the as Code and Chapter .142 of the Gen m General Laws. r X -1 _ By: Title City/Town; _ APPROVED (OFFICE USE ONLY) ❑Signature of Licensed Plumber Or Gas Fitter Plumber ❑ Gas Fitter CL ❑icense um er Master ® Journeyman a -d 4�- za tl� y I i y r; BE c,ommonwe¢lih of Massachusetts Department of IndmtriolAccidents Office of .rnvestcgataons 600 Wash- -ton Street L'oston, MA 62111 WH'•�Ft4SS.e OV/LfIQ Wormers' Compeasatiou Insurance Affidavit_ Buiilders/Contmetors/Electrici �Iicaat Information ans/°iumbers 1'�Zl1e (Business/OrganiztionMdividu,J): PI -AAV. Address: CIty/State/Zip: cvrs3 a-� -t L' «u Are yon an employer? Check the appropriate box: 1❑Lam } Phone #: c e l i+ S Sy a amp oyer with 4. ❑ I am a aenesal emp}oyees (full and/or part-time).* 2. E?_1 am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required,] 3 • ❑ 1 am a homeowner doing all work myself. [No workers' comp• insurance required.] t L_ contractor and I have hired the sub -contractors Listed On the attached sheet t These Sub -contractors have workers, comp. insurance. 5• ❑ We area corporation and its officers have exercised. their right of exemption per MGL C. 152, § 1(4), and we have no Mnploye:es. [No workers' comp in Type of project (required): -6•. ❑New construction 7• ❑ Remodeiing . g• ❑ Demolition 9• ❑ Building addition 10:❑ Elects ca.l repairs or additions i 1.❑ P}tunbing repairs or additions 12-❑ Roof repairs *,4n}, appiicut.that checks box #I .must also 6fl out the section below sho surance regwred ] 13 ❑Miter t ilGmcownera who submit.f7ris arirdavii indicaritt, ate;r ase uuir:g t:_:z swing their workers' co mPertsation poiic}r mmmtahoa. tCortuactota that el:ec}: this box must atffiched an additional sheet showittQ ---ru niter Guside eunirxciurs rnusi sabrnit a new atnciavit ine: �.irr scch, the sir of the sah-eG'_'Z=tors and their workers' comp. policy inform such. 1 ttrrt 2n. e^iployc tl:.:a is provi own no . hers ce...Ramatio oz insarance for ng, e e� irtformatiors• mP�Y -s• Below is oftCy and p joh site Insurance Company Name: the Policy # or Self -.ins. Lite. #: Expiration Date: Sob Site Address. Attach a copy of the workers' comneacafinn City/state/Zip:_ .Failure to secure coverage as required under Section 25A of a> ion pabe (showing the policy number and expi ii nora da e) fine up to 51,500.00 and/or one-year imprisonment as well MGL c. 152 can lead to the imposition of Of up to .5250.00 a day against the vio}ator. Be advised that a civil penalties in the form of a STOP W R riO 1 penalties of a Investigations of the DIA for insurance copy of this staierrrent ma , P RDER and a fine cov.;age verification. ) be forwarded to the Office of I do herehn rr. wi;, f_ _ �« r,•••« rcna pPn=M gffperlurJ' tha7 the information provided above is true =" L� and correct official use onip. Do not write in this area, to be completed hJ , city or town ofcia( City or Town: issuing Authority (circle one): Permit/License — 'N -Ad 2GC 1. Board of Health 2. Building Department 3. C' fi. Other n3�1wn Clerk 4. Electrical inspector 5. PlumbiuQ . b Inspector Contact Person: Phone 4 - iniormanon and Instructions �k_ Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their empioyees. Pursuant to this statute, an empLoyee is defined. as ".. _-ver-y 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 inclucii-n.g 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 ap z r-tlnents and who resides therein, or the occupant of the dwelling house of another who employs persons to do ma int=ance, 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 o r 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 forany applicant who has not produced acceptabie evidence mf compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither -the commonwealth nor any of its poiitical subdivisions shall enter into any contract for the performance of public worll< until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contraaEQrg authority." . Applicants Please fill out the workers' compensation affidavit compZ-etely, by checking the boxes that apply to yore situation and, if necessary, supply sub -contractors) name(s), address(es) amid phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limiter Liability Partnerships (LLP) with no employees other than the members or. partners, are not required to cant' workers' compensation insurance. If an LLC or LLP does have -_ employees, a policy is required_ Be advised that this affic -avit may .be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and dame the affidavit. Theaffidavitshouid be returned to the city or town that the application fur the permit or license is being requested., not the Department of Industrial Accidents. Should you have any questions re_,*L*T-ding the-la%a, or ifyou are rzquir-„d to obtain a workers' compensation policy, please call the Dep ar-(rnnent at the n>nber-listed below Self insured coiTiLariie� should enter their. self-insurance license number on the amsroBriate line. . City or Town Officials Please be sure that the affidavit :is complete and printed leQibiv. The Department has provided a space at the bottom of the affidavit foryou to fill out in the event the Office of Investigations has to contact you regarding the applicant: Please be sure to fill in the permitrticense number which will be used as a reference number. In addition, an applicant that must submit multiple permitliicense applications in arty given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Adm-ess" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially starinped or marked by the city or town may be provided to the appiicant as proof that a valid affidavit is on file for future: permits or Iicenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a licens= 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 and fax number. The Comnlonwea:lth of Massachusetts Department of Ldustrial Accidents. Qfflice of Lavesfigatiions 600 Wash ingtc)n Street BQston; 1A 02111 Tel. # 617-727-4900 *7t 406 c r 1 -877 -MASS 4FE Revised 5-26=05 Fay, # 617-7-7-7749 WW Vi'.rrIBSS.gov/dia N --�p? 08 Date....! ................ TOWN, OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .:..Ik has permission for gas installatio `................... in the buildiiing�s of .. �'. ........................... . at . / (-.?6-P".-�?-"' .. 41-" ..... . , North Andover, Mass. Clow Fee . '. Lic. No .. `�. ., . ........ . GAS INSPEie � Check # 6546 MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FITTIlNG (Type or print) Date NORTH ANDOVER, MASSACHUSETTS Building Locations J (n /e C1�.tJ AJ C ' P Owner's Name New Renovation1:1 Replacement rM ermrt If Amount $ C Plans Submitted SU B-BASEM ENT BASEMENT 1ST. FLOOR 2ND. 3RD. FLOOR FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. BT H. Z aa a OnV c z W < 0 W C7cc F Z E= Q x a a W W > W Z) Z C N SU B-BASEM ENT BASEMENT 1ST. FLOOR 2ND. 3RD. FLOOR FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. BT H. FLOOR FLOOR (Print or type Name Ck 0 Check one: Certificate Installing Company V c 2 E] Corp. _ -j Address 0 Q 11Partner. Busmess a ep one `'� , � � Firm/Co. Name of Licensed Plumbeior Gas Fitter (f rte' INSURANCE COVERAGE k one: I have a current liability Insurance' policy or it's substantial equivalent. Yes c13 If you have checked yes, please indicate the type coverage by checking the appropriate box. No� Liability insurance policy Other type of indemnity D Bond 0 Owner's Insurance Waiver: [.am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Signature of Owner or Owner's Agent Check one: Owner 13 Agent 13 1 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 instliations performe# under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachts State Gas Coq&iZd Chapter 142 of the General Laws. By: Title City/TowE APPROVED (OFFICE USE ONLY) SignatVe of Licensed Plumber Or Gas Fitter ® Plumber C�/ v1 d `� 2] Gas Fitter License Number 0 Master qJourneyman U c z z 0 o° z w o U D C > d (Print or type Name Ck 0 Check one: Certificate Installing Company V c 2 E] Corp. _ -j Address 0 Q 11Partner. Busmess a ep one `'� , � � Firm/Co. Name of Licensed Plumbeior Gas Fitter (f rte' INSURANCE COVERAGE k one: I have a current liability Insurance' policy or it's substantial equivalent. Yes c13 If you have checked yes, please indicate the type coverage by checking the appropriate box. No� Liability insurance policy Other type of indemnity D Bond 0 Owner's Insurance Waiver: [.am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Signature of Owner or Owner's Agent Check one: Owner 13 Agent 13 1 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 instliations performe# under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachts State Gas Coq&iZd Chapter 142 of the General Laws. By: Title City/TowE APPROVED (OFFICE USE ONLY) SignatVe of Licensed Plumber Or Gas Fitter ® Plumber C�/ v1 d `� 2] Gas Fitter License Number 0 Master qJourneyman J Office Use Only ubE Lf ofttsttttr4uEii Permit No. 5r "C �j �C}1AL21Ii¢A2 of uh11L -% feta Occupancy &Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 3i90 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All .vork to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date / ?a '�5 W� or Town of NORTH ANDOVER To the Inspector of Wires: The uders)aned acches for a permit to perform the electrical work described below. Lccation (Street 8 Owner or Tenant Owners Address Is this permit :n conjunction with a building permit: Yes No (Check Appropriate Box) Purpose of Eu icing 4011401166 --, Utility Authorization No. � 00 -1141 Exist nc Service Amos Volts Overhead 7 Undgrnd El No. of Meters Ne,v ernce 100 AmpsVolts Overhead e Undgrnd i , No. of Meters (1 1-4 WI%TG`%? 57 Number of reeeers and Amoacity Location ana Nature of Proposed Eiectrical Work Total No. _t _.^^.•rnc C -bets No. of Hot Tubs I No. of Transformers KVA �7&=fjCE CC'.FPAGE: Pursuant ;o the reau rements of %lassacnusens general Laws ve a Curren; '_:ao ty Insurance Policy including Ccmo.eteo Operations Coverage or its substantial eauivaient. YES NO I J% ^,ave sucm ttec vai d Groot of same to the Office. YES _ NO _ If you have checxea YES. please indicate the type of coverage by UI cnecxir,e 'he aocroonate cox. INSURANCE = BOND - OTHER - (Please Soeafy) (Expiration Date) Esrmatee /Vaiueof E�ctricai Work S 00/ NorK to Star, _ 13 7 Insoecuon Date Recuestea: Rouch S enec uncer :he Penaities of perjury: Final /' 1P { 715 RM NAME LIC. NO. Licensee iCiT VL N AV& SianatureG LIC. NO. 1ao �ur/4��/ iL`/� 7/ �0// ✓� Bus. TeI. No. No. TeI. o. ACciress ' O'WNER'S INSURANCE'NAIVER: I am aware that the Licensee aces not have the insurance coverage or its substantial eauivaient as re- :uirea by Massacrusetts General Laws. and that my signature on this permit application waives this reauirement. Owner \Aeent Please cnecK one) 644 /IO eleohone No. PERMIT FE=VVV Sianature of Owner or Aaent) 1-55ii:; Abover--- In - No. -., _nt:ng Flx.tures Swimming Pool 9rna ._ grnd.'..— Generators KVA ! No. of Emergency Lighting No. of Recectac:e Cutlets No. of Oil Burners Battery Units No. of Sv tcn Cut:ets No. of Gas Burners FIRE ALARMS No. of Zones Total No. of Detection and No. Of Rances No. of Air Cond. tons Initiating Devices Heat Total Total No. ::f Disposa s No.of Pumos Tons KW No. of Sounding Devices No. of Self Contained I SoaceiArea Heating_ KW Detection/Souneina Devices No --f Disnv:asners No ^f D^•ers Heating Devices KW — Municlpai —Other I Loca) i_ Connection_ No. of No. of Low Voltace No. dda;er eaters KW i Signs Baitasts Wiring No. -vcro 1.1assace iucs No. of Motors Total HP OT*HEP.. �7&=fjCE CC'.FPAGE: Pursuant ;o the reau rements of %lassacnusens general Laws ve a Curren; '_:ao ty Insurance Policy including Ccmo.eteo Operations Coverage or its substantial eauivaient. YES NO I J% ^,ave sucm ttec vai d Groot of same to the Office. YES _ NO _ If you have checxea YES. please indicate the type of coverage by UI cnecxir,e 'he aocroonate cox. INSURANCE = BOND - OTHER - (Please Soeafy) (Expiration Date) Esrmatee /Vaiueof E�ctricai Work S 00/ NorK to Star, _ 13 7 Insoecuon Date Recuestea: Rouch S enec uncer :he Penaities of perjury: Final /' 1P { 715 RM NAME LIC. NO. Licensee iCiT VL N AV& SianatureG LIC. NO. 1ao �ur/4��/ iL`/� 7/ �0// ✓� Bus. TeI. No. No. TeI. o. ACciress ' O'WNER'S INSURANCE'NAIVER: I am aware that the Licensee aces not have the insurance coverage or its substantial eauivaient as re- :uirea by Massacrusetts General Laws. and that my signature on this permit application waives this reauirement. Owner \Aeent Please cnecK one) 644 /IO eleohone No. PERMIT FE=VVV Sianature of Owner or Aaent) 1-55ii:; Of NOR71f ,� m �,SSACMuSE� Date .... rf/............ .......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ......:11.. . ......... ....... ................. ........ .....L....................... has permission to perform ...%.'............:.. F........... .....:. ..... t`........................ wiring in the building of ........................ .!......'........................................................ at ........ ......... - / ../ r.... ............. . North Andover, Mass. Fee..,-..,, ;;... Lic. No.;f ............................................................... ELECTRICAL INSPECTOR 01/31/95 09;29 35,00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File I. Say State Gas Company GAS INSTALLATION ALJTHORIZATION y bate 1e� Issued to Address For Installation BTU Input Restrictionsz2 �G Represe n t a tfiwv e PERMIT ISSUED gY INSPECTOR This Portion of Authorization To Be Returned to BSG. Inspection Has Been Made of the Following Gas Equipment: ❑ Heating System (BTU Input ) ❑ Range ❑ Water Heater . ❑ Clothes Dryer ❑ Room Heater Location All Work Has Been Done In Accordance With The Massachusetts State Gas Code And Is Ready For Use. I1N NO POSTAGE NECESSARY IF MAILED IN THE UNITED STATES BUSINESS REPLY CARD FIRSTCLASS PERMIT NO. 721 LAWRENCE, MA POSTAGE WILL BE PAID BY ADDRESSEE BAY STATE GAS COMPANY ATTN: SALES DEPT. 55 Marston Street Lawrence, MA 01840 r 5 -;' Date......: .............. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION P ♦ This certifies that ......` .. t.- t ...-: !................ ....... . 1 has permission for gas installation ........ _ .... ' .......... . �'��:..../ in the buildings of ............. ......... ........... at X". ......... , North Andover, Mass. Fee.'. Lic. No........... , ...:/.." :... ' ............ . GAS INSPECTOR J WHITE: Applicant CANARY: Building Dept. PINK: Treasurer No 4 51;. ...3.... . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING / J +This certifies that . ........ . has permission to perform '. plumbing in the-puilding ., ............. .... .. ......... at ................. ... ........... , North Andover, Mass. Fee Lic. No.....�..... ............. PLU BING INSPECTOR Check # d / WHITE: Applicant CANARY: Building Dept. PINK: Treasurer s > MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FMING �Type or print) Date r - 0� NORTH ANIZOVER, MASSACHUSETTS // /i,F �1/ i'7' Building Locations ��"/lfig Ij Owner's Name New ❑ Renovation ❑ Replacementz Plans Submitted Permit # Amount S (Print or.ype) ���/� � ������ Check one: Certificate Installing Company NameCorp. Address 162 '/ 4&1e e4zel( S �. Axe—lo L,24,4 1W LLD ❑ Parm er. Business Telephone 1;'7 — 4;7-5'— C aZ F-1 Firm/Co. Name of Licensed Plumber or Gas Fitter Ll 0 &-� INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes No ❑ If you have checked ves, please indicate the type coverage by checking the appropriate box. Liability insurance policy (j Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement_ Check one: ❑ Signature of Owner or Owner's Agent Owner ❑ Agent i hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Perm Issued for this application will be in compliance with all pertinent provisions of the tilassachusetfs !at ±s Co�d�t'ai n 2 of the General Laws. By: Title City/Town APPROVED (urr•!cF USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumberj�y� © Gas Fitter License (Numuer Master ❑ Journeyman I l (Print or.ype) ���/� � ������ Check one: Certificate Installing Company NameCorp. Address 162 '/ 4&1e e4zel( S �. Axe—lo L,24,4 1W LLD ❑ Parm er. Business Telephone 1;'7 — 4;7-5'— C aZ F-1 Firm/Co. Name of Licensed Plumber or Gas Fitter Ll 0 &-� INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes No ❑ If you have checked ves, please indicate the type coverage by checking the appropriate box. Liability insurance policy (j Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement_ Check one: ❑ Signature of Owner or Owner's Agent Owner ❑ Agent i hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Perm Issued for this application will be in compliance with all pertinent provisions of the tilassachusetfs !at ±s Co�d�t'ai n 2 of the General Laws. By: Title City/Town APPROVED (urr•!cF USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumberj�y� © Gas Fitter License (Numuer Master ❑ Journeyman N2 2482 Date ... 9./77� .......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..... .................. ................................. ........................... has permission to perform--,--. �- ............. 67 wiringin the building of................................................................................... ad.4� .... .......... -,'/ ................................... . North Andover, Mass. Fee/S...'7 . ........ Lic. No..I, M ............................... ELECTRICAL INSPECTOR Check # WHITE: Applicant CANARY: Building Dept. PINK: Treasurer �"�• Inp- L.Ulr✓11► U1VF'i'P-4W All tld"1VL4A1-"E.11'61.N—f11iJ utnce use only DEPARTALEATOPPUBLIC&4F•ETY Permit No. BOARD OFFIREPREVEMONRWULA770AS527CM12.00 � � Occupancy &Fees Checked APPUCATION FOR PERAIRT TO PERFORM ELE=CAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dat /, ` 7 - Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & NumzT;4 Owner or Tenant C f Owner's Address 7.7 47 A15 777v-7 Is this permit in conjunction with a building permit: Yes EaNo ® (Check Appropriate Box) Purpose of Building % (yU.s� " Utility Authorization No, Existing Service Amps / Volts Overhead ® Underground ® No. of Meters New Service Number of Feeders and Ampaciv Location and Nature of Proposed No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA ground El ground No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local® Municipal Other No. of Dry -4 Heating Devices KW Connections ® No. of WateigHeaters KW 'No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER Insx wCa,a-g PtmmtDthemgtmarcrisofNiasmdaseltsGataaiLaws I hmeaaxrutLiabkhwx&=Pob yutdudmgCar>p ComaWcrkssulwt Uegi abt YES NO lhavest-xr»ttedvalidpcoffifsametatheOfimt±YES ® Ifjauha%edtadcedYES,pimeetdicatL-the �9:bydrzkigthe pWaebox 1NS ICE BOND ® OTI-I1 R ® (PlmseSpefy) / JExpcatiatDt� WcdcttoStartEsti�ValuelWodc $ SigrWttrskr cRnaltiesofpejtay. FIRM NAME L e=Nn I ST��L� f" l�'I, i�-o�U� sig - o..® Li=wxb j^' ' � J✓ ' / i/� SJR - / Bt=CSs Td. Na f�i� (//l / /G-" L✓ Aj Tel Na 1?79 3 OWNER'SIN�WANER,Iamawaretha irLmme rdt $teinsurdsme truss laglriva>e8asragtmedbyM GataalIaws and�myemttrsp�,this raQtrsar�ag. (Please check one) OwnerED Agent ® pf Telephone No. PERMIT FEE $ N2 4819 Date. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .. P. �'. �./... P.�. /....................... . has permission to perform .... !:!� �' '.� `.. . plumbing in the buildings of ......!. Y at. .. f I.....%3/�. t.<. ............... , North Andover, Mass. Fee..1.�.. ~.Lic. No..�.!2..".. ........ ...� ....... PLUMBING INSPECTOR Check # WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS � Date Building Location Owners Name PWFE U U Permit # (ffig S Type of Occupancy �[I[p11 L/ N w 'O r Amount New M Renovation n Replacement ❑ Plans FIXTURES Yes r-1 No El (Print or type) Check one: Certificate Installing Company Name_ U o x- El Corp. Address / /�7i/d-Q6 60 1--/d- S-/o� L IS 4) A- Business Telephone G 4-Firm/Co. Name of.Licensed Plumber. R U A i Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policyOther 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 A Signature Owner 11 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 d ' llations perfo ed under Permit Issued for this application will be in compliance with all pertinent provisions of the M ac etts State Plum ing Code and Chapter 142 of the General Laws. By: 1 ot ns um er Title Type of Plumbing License City/Town Li rise um er Master Joumeyman APPROVED (OFFICE USE ONLY P Date.f!; Je-; ......... °� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ...i. `.. /... ............................ . has permission for gas installation ... .� ................... in the buildings of ... ......................... at ./':.! .....1 ��.�. ". `.'...�. ......, North Andover, Mass. Fee. ! Lic. No.... ...... ..... `. r. :.:.......... GASINSPECTOR1 Check # ? 363 04�A—\ MASSACHUSETTS UNVORM APPIIICATON FOR PERMIT TO DO GAS FITTING or print) PIUMIH ANDOVER, MASSACHUSETTS Building Locations ,/b – Owner's Name New ❑ Renovation 12 Replacement ❑ Date Permit 9 3 3 Amount S Plans Submitted (Print or type)` Check one: Certificate Installing Company Name— �–p4t 3 �� l ❑ Corp. Address �le/ Ll�lJ�'% �!� ��_ �" �� ❑ Partner. Business Telephone In 6 vn( �Firmico. Name of Licensed Plumber or Gas Fine.- INSURANCE itter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No❑ If you have checked ves, please indicate the type coverage by checking the appropriate bo c_ Liability insurance policy� Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Nlass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and intormadon I best of my knowledge and that all plumbing work and compliance with all pertinent provisions of the :Massa( By: Title C i tvi Tow n APPROVED iuFrv: usF !)Ni.Y) itted (or entered) in above application are true and accurate to the s performed u n a Permit Issued Cor this application will be in :e Gas Code and hapter 142 of the General Laws. Signature of Licensed Plumber Or Gas Fitter Plumber 4/ a Q 5� Gas Fitter icense ;vumoer ❑ itlaster EJourneyman r (Print or type)` Check one: Certificate Installing Company Name— �–p4t 3 �� l ❑ Corp. Address �le/ Ll�lJ�'% �!� ��_ �" �� ❑ Partner. Business Telephone In 6 vn( �Firmico. Name of Licensed Plumber or Gas Fine.- INSURANCE itter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No❑ If you have checked ves, please indicate the type coverage by checking the appropriate bo c_ Liability insurance policy� Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Nlass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and intormadon I best of my knowledge and that all plumbing work and compliance with all pertinent provisions of the :Massa( By: Title C i tvi Tow n APPROVED iuFrv: usF !)Ni.Y) itted (or entered) in above application are true and accurate to the s performed u n a Permit Issued Cor this application will be in :e Gas Code and hapter 142 of the General Laws. Signature of Licensed Plumber Or Gas Fitter Plumber 4/ a Q 5� Gas Fitter icense ;vumoer ❑ itlaster EJourneyman 10 Locatdonl —/� No. ,=t5 Z Date NORTH TOWN OF NORTH ANDOVER f � Certificate of Occupancy $ scMus `� Building/Frame Permit Fee $ X's Foundation Permit Fee $ Other Permit Fee $ ' TOTAL $ Check r �; Building Inspector l TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: to • � • �Q SIGNATURE: btuilding Commissio for of Buildings Date S • SECTION i- SITE .INFORMATIO 1.1 Property Address: 1.2 Assessors Map and Parcel 1 Map Number Number: A!J /,-7 Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Address for Service,,�, � Rear Yard Required Provide ReqWred Provided Required Provided 2.2 Oviner of Record: 1.7 Water Supply M.G.L.C.40. 54) Public ❑ Private ❑ 1.5. Flood Zone Information: Zone Outside Flood Zone ❑ 1.8 Municipal Sewerage Disposal System: 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record may---- Name (Print),., fn. Address for Service,,�, � Signature Telephone 2.2 Oviner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ zv Licensed Construction Supervisor: License Number . �ft S, y� ����y / f Address /n OIB d ,z0 7 t Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone SECTION 4 - WORKERS COMPENSATION (NLG.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 building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check au applicable) New Construction ❑ +' ` Existing Building Repair(s) Alteratio �l .. W� Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: y� s ., .SC '• CC" JiG/ �/VQwG/ +-MT's +M�°'Ir � .. SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant =, UFFICI�►L USS UNLY =s 1. Building (a) Building Permit Fee- eeMulti lier Multiplier 2 Electrical .Z (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (8) X tb> 4 Mechanical (HVAC) --- 5 Fire Protection 46 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT r fes%` as Owner/Authorized Agent of subject property Hereby authorize to act on y bel lf, in all ma �a;u=y this building pernut application. ' —Signature of Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Signature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TMERS 1ST 2ND 3 RD SPAN MIENSIONS OF SILLS DIMENSIONS OF POSTS DIN ENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING x MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE r_ Y The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations If Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Location: City Phone F7 am a homeowner performing all work myself. ;RTI am a sole proprietor and have no one working in any capacity aI am an employer providing workers' compensation for my employees working on this job. Company name: Address City Phone #: Insurance Co Policy # Company name: Address City Phone #: Insurance Co Policy # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations cf the DIA for coverage verification. I Print Official use only do not write in this area to be completed by city or town official' ❑Check if immediate response is required Building Dept Contact person: Phone A FORM WORKMAN'S COMPENSATION Phone #/� ding Dept E] Licensing Board F1 Selectman's Office C] Health Department 1] Other f k - \k§ ) �\ R B ka �§§m % to ON w C', mk ƒoZ kJ /2 § § a a k k m K = 2 x & Town of North Andover * t%ORTH q O �iLeo ,6 ti O Building Department o 27 Charles Street North Andover, Massachusetts 01845 (978) 688-9545 Fax (978) 688-9542 ,gSSACHUSti�( DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and a condition of Building permit # the debris resulting from the 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 /at: Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. 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