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HomeMy WebLinkAboutMiscellaneous - Exception (92)Date. . . . 4,, TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 40 ,SSACMUSi This certifies that �. ..lh....... l .`-'......... has permission to perform; �. ...... plumbi g ri the buildings of . 1.� ..../tf,�r!.��. . at .1.,t�L� .. , North Andover, Mass. Fee�� .Lic. No. PLUMBING INSPECTOR -1 Check � r MASSACHUSETTS UNIFORM (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location /'? J awSh Ire (�17- i New Renovation CATION FOR PERMIT TO DO PLUMBING Date 3 '—o s- )�,pers N mek/dvxi r Permit # Amount O� of cc anc icem t Plans Submitted Yes No FIXTURES l.. (Print or type) n� ) Check one: Certificate Installing Company Name IJ,114SOAJ JC.yr!'!b//?q ^ �/�(j F1 Corp. 1-3 Partner. ElFrm/Co. C Name of Licensed Plumber: -N V fa- 0UIZ-SG� Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy CIL 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 I hereby certify that all of the details and information I have sul best of my knowledge and that all plumbing work and installatii compliance with all pertinent provisions of the Massachusetts S D (OFFICE USE ONLY Agent to �red in above application are true and accurate to the erform er PeltIssupplication will be in 'Plu nde and QhapCe a General Laws. Type of Plumbing License iceum e6 r Master Journeyman Date ... !A/ ........ 0, TOWN OF NORTH AND VER 0 • PERMIT FOR GAS INSTALLATION This certifies that ................ has permission for gas installation . .............. in the buildings of . �0071....... ..... V4 North Andover, Mass. Fees ...... Lic. Y1'�� 'If�4 "OR"* GAS Check # 5744 MASSACHUSETTS UNIFORM APR ICATON FOR PERMIT TO DO GAS Ff rnNG (Type or print) Date NORTH ANDOVER, MASSACHUSETTS Building Locations �� Devi ,n.[) Permit # Owner's Name Amount $ New ❑ Renovation ❑ Replacement Plans Submitted ❑ (Print or type) Name of Licensed Plumber or Gas Fitter Check one: Certificate Installing Company Corp. Partner. ber<lco. INSURANCE COVERAGE Check one: I have a current liability Insurance policy o 't -s substantial equivalent. Yes NoO If you have checked yes, please moiele the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity rl Bond 13 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 13 I hereby certify that all of the details and information I have submitted (or enter m above application are true and accurate to the best of my knowledge and that all plumbing work and installations pe rfo er Permit Issued :KVeral pplication will be in compliance with all pertinent provisions of the Massachusetts State Ga e nd Clutter 142.0 Laws. by: Title City/Town OVER (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber ;a (0 &C Gas Fitter icenseu e �er ourneyman F � � � x a F• cW7 a � w � E✓ � x � 4w m F a o a o w H w d w F x x Nz z H w x w x x -et 00 zw SUB -BASEM ENT B A S E M ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8TH. FLOOR (Print or type) Name of Licensed Plumber or Gas Fitter Check one: Certificate Installing Company Corp. Partner. ber<lco. INSURANCE COVERAGE Check one: I have a current liability Insurance policy o 't -s substantial equivalent. Yes NoO If you have checked yes, please moiele the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity rl Bond 13 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 13 I hereby certify that all of the details and information I have submitted (or enter m above application are true and accurate to the best of my knowledge and that all plumbing work and installations pe rfo er Permit Issued :KVeral pplication will be in compliance with all pertinent provisions of the Massachusetts State Ga e nd Clutter 142.0 Laws. by: Title City/Town OVER (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber ;a (0 &C Gas Fitter icenseu e �er ourneyman F Location No. 6.3cS' Date TOWN OF NORTH ANDOVER • s • ; , Certificate of Occupancy $ Building/Frame Permit Fee $ ACMUS Foundation Permit Fee $ L' Other Permit Fee $ TOTAL $ 1& Check # 6a-9,0 1746-8 \,Bui` Iding m 4ctor Building OF The Commonwealth of Massachusetts State Board of Building Regulations and TOWN OF NORTH ANDOVER Standards BUILDING DEPARTMENT Massachusetts State Building code 780 CMR TO CONSTRUCT REPAIR, R$NOVATE, CHANGE THE USE OF OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING Date Issued: %— _ D y 107 Wats Supply 9UG.LC.40.4 S 54 11.3. Flood Zo Public 0 primo a zoo -13- 2.1 Owner of Record W ocoC R L J-,Ite 1-6yn-o5 Coo Name (Print) <6 LL.4-A-a7 2.2 Authorizeded t • Name (Print 3.1 Licensed Construction Supervisor: Licensed Construction $µpervisor: wt I Ij�ZV ib i2 3.2 Regi9ed Hoe Ir I e aril Co tractor: Company Name_ Address ` JMC a3 Outside Flood Zone I 10 W004 Telephone (v32 Address Telephone O (Q r►IS Rear Yard Not Applicable Q R09°ired Provided O -�3�(43 Q Expiration Date 3 15 1.8 Sew a Disposal System; Di M�� 013Site sposal Sysum 5n?7 (0 Isrt d i e t2 c/ e✓ 7p4 3 k� t�•. y f a vtc� vh,4 ZO / 3 THAN 35 000 CUBIC FEET OF ENCLOSED SPACE Not Applicable Q License Number O -�3�(43 Q Expiration Date 3 15 20o t- 5n?7 (0 ne q -1--I1 Not Applicable Q Registration Number O U �_ l Expiration Date SECTION 4 WORKERS' COMPENSATION INSURANCE AFFIDAVIT [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 building permit. Signed Affidavit Attached Yes' No SECTION 5 - PROFFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FOR BUILDING AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPA 5.1 Registered Architect: No Applicable Name (Registrant): Address Registration Number Signature ' Telephone Expiration Date 5.2 Repjstered 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 53 General Contractor Not Applicable C1 Company Name: Responsible in Charge of Construction Address Signature Telephone SECTION 6 - DESCRIPTION OF PROPOSED WORK check allapplicable) New Construction 0 1 Existin Building Repairs 13 Alterations Addition 0 Accessory Bldg. 0 1 Demolition Other 0 Specify Brief Description of Proposed: - T S� 1 i ✓1 S. 9 - SECTION 7 - USE GROUP AND CONSTRUCTION TYPE USE GROUP Check as applicable BUILDING AREA CONSTRUCTION TYPE A Assembly A-1 A4 A-2 A-5 A-3 IA 1B 0 0 B Business 13 Total Height ft 2A 2B 2C 0 0 0 E Educational 0 F Facto 0 F-1 F-2 H High Hazard 0 3A 3B 0 0 I Institutional O I-1 I-2 I-3 M Mercantile 13 4 13 R Residential D R-1 R-2 R-3 SA 5B 0 0 S Storage 0 S-1 S-2 U utility 0 Specify: M Mixed Use 0 Specify: S Special I 0 Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS. ADDITIONS AND/OR CHANGE IN USE Existing Use Group: Existing Hazard Index 780 CMR 34 Proposed Use Group: Proposed Hazard Index 780 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 D No SECTION 10a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I—z v - -- hereby author' 7 �'✓� my behalf, in all matters relative to work authorized 6y this building permit application. Signature of Oyf9t revised bldg form/state JMC As Owner of subject property to act on SECTION lOb - OWNER/AUTHORIZED AGENT DECLARATION 1, , 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 2-601000— (a) Building Permit Fee Multi lier 2. Electrical (b) Estimated Total Cost of Construction from 6 a (/ C) 00 3. Plumbing Building Permit Fee (a)x(b) o2 % 1 O — 4. Mechanical AC 5. Fire Protection 6. Total = 1+2+3+4+5 Check Number iOawvff6lYwi*aLut a` l/luasar�uu�eCla BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 033843 Birthdate: 0311511955 Expires: 03/15/2006 Tr. no: 18496 Restricted: 00 JOHN T HAFFEY 3 WILLIAMS ROAD w WAYLAND, MA 01778 Acting Cc mis oner k• N � � c V U vi o �c 'L• LU m 00 etiO :DF- ° v oU LO o m I r m O o'c W a) n LULLJ > LL O N LLm E '� ° O 0.. c c ° ei Q2MC: m m o W 2 O 01 X uj uj co O > iiM� c p 2 � 00 O LL Q •M M " �'• t 3 m Location: ©DdL RL jl4- e✓ City: N o rt'ln O vtct oye r MA- phone # ❑ I am a homeowner performing all work myself, ❑ 1 am sole proprietor and.tiaye no one working in any capacity I am an employer providing workers' compensation for my employees working on this Job. Company name: 44 4 Re� by i Idu- s Qi c. Address: 4 3 City: W d) t 7 Z phone Insurance co. _.A_ o - ✓''` M^ -Q policy# WCLo2'5 t 3 �O _U10 /2–lr-o � ❑ I am sole proprietor, general contractor, or homepwner(61mle one) and have hired the contractors listed below who have. the following workers' compensation policies: Company name: Address: City: phone # Insurance co. policy # Company name: " Address: " City:phone # Insurance co. - ___.,,,,,;. policy # Failure to, =ec�re coveragq—OrM. years lmpiisonment as well as;alyll;penalties in the, form of a STOi this statement maybe fonvard9d to the�Ofncc of Investigations of t I do hereby certify under the/pains and /penalties of pe#ury that the Cinnnfurw. O Jul a !!..•'�'hlev f�Ge� Print of criminal penaltles'of a fine up to $1,500.00 and/or one '$100.00 a day against ine. I understand that at copy of Ipfomiatiorl prpir�ded above is true and correct. Date phone # 50S, ca Zo R t to a or `'r :: Y , f �i, The Commonwealtot+ �,,saf usetts :.• De t3rtment of irt`dU' 1"cCldents C or.town: !tY Office 00 6;` ❑ Building Department J .600 Washlcgton`Stiieet -- ,.tr..•,�J ,.,' Boston; Miss: ' 02111 potieck K Immediate responsa'Is required : ' r {`+ ;;t r Workers' Compensation Insurance Affidavit Location: ©DdL RL jl4- e✓ City: N o rt'ln O vtct oye r MA- phone # ❑ I am a homeowner performing all work myself, ❑ 1 am sole proprietor and.tiaye no one working in any capacity I am an employer providing workers' compensation for my employees working on this Job. Company name: 44 4 Re� by i Idu- s Qi c. Address: 4 3 City: W d) t 7 Z phone Insurance co. _.A_ o - ✓''` M^ -Q policy# WCLo2'5 t 3 �O _U10 /2–lr-o � ❑ I am sole proprietor, general contractor, or homepwner(61mle one) and have hired the contractors listed below who have. the following workers' compensation policies: Company name: Address: City: phone # Insurance co. policy # Company name: " Address: " City:phone # Insurance co. - ___.,,,,,;. policy # Failure to, =ec�re coveragq—OrM. years lmpiisonment as well as;alyll;penalties in the, form of a STOi this statement maybe fonvard9d to the�Ofncc of Investigations of t I do hereby certify under the/pains and /penalties of pe#ury that the Cinnnfurw. O Jul a !!..•'�'hlev f�Ge� Print of criminal penaltles'of a fine up to $1,500.00 and/or one '$100.00 a day against ine. I understand that at copy of Ipfomiatiorl prpir�ded above is true and correct. Date phone # 50S, ca Zo R t to a or Otfidal'use only d ofwrite in this area to be compl8ted,6�'clky o te�v�m ofticlal . :.• Ott t C or.town: !tY n` i carinitlticense # ❑ Building Department -- ,.tr..•,�J ,.,' E] Licensing. Board potieck K Immediate responsa'Is required : ' r {`+ ;;t r p Selectriien's Office. - [] Health Department tadperson: ,:: ..�: :;J�;:.a. '0�@::#' •'1:'(.:.r'• �• :J• �(''7 Gj'%i", � a,: R:�• 1'!'' lr �' $ ' 1•�:^ ' h.. :'fJr . A;'r'',;i�•, ..i:%j. 5)'• ilk'.._ 1{ 7t.,•: �ii. :•.K..:.I�.in\�'t:-iiia .} . • V•f�^I�' J1+ ..... , w,l. .rte ..\%,:7�.••,�rk' .r• .1'f .,��'r�tJ. >ll";{iiyl�,, �,%h'h�rr�f/d1i::J,.' r;i'.�'r{t�,Lr:O�{J ., <y rf�.titS�.tA! �'`p »jhy�:2�b �tt�,:i,:iA .` j( i}YY''77,Ii.tii-,Lk,l•4}?KI'K. `r7r'` ati+",r�•r• :,o� r�i�{LI Irl, 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 c 11, S 150 A. The debris will be disposed of in: I a u k V-) , M G s s— 3—, Ileap c� c�, �o SQ I (Location of Facility) ignature fWefmit Applicant -7-z,wo y Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector v 0 b N W rA to a N o w a as o v ro a a Ci a w a W w a _ w O C O rA o z cn Cl) ui z T -M MM v' O 0 •Qr E Z GO h E I.L O v h 0 CL y O O C cc C40 Y/ Y/ 0 W LU 19 W N ' C O :•m C Ci •: :oo C h O C O CC LL 113 O O O• }: y Q' ECdb Q MM Ee ra • C V •0.. w�sts� c ` m r' h _l CD E O co :m �: O Z co w m•-: m co to it ? CD nv m ♦y O � Of C C_ C4'c m :1� v Z Z'•�°o o •�no o CD C m NJ C �mz3 C :CLO�0 440.211- 4or~W= S H W90 M.=• �r r... .O C++ O Z o C* a •� o� _ a o� o 1- t .0 a$m > T -M MM v' O 0 •Qr E Z GO h E I.L O v h 0 CL y O O C cc C40 Y/ Y/ 0 W LU 19 W N