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HomeMy WebLinkAboutMiscellaneous - Exception (100)90 mm moorw ". 9 a If 5 �� � _ti yid �• :o°� .o Vi/loge . Lond Co. Iry e•r i?� Py e� g PD _b � a o C V m Date.. .................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that lv...,,.,., /� .................................................................................... has permission to perform ., % ��; �/ - .......... ��. ,0::.. A - A wiring in the building of ........ Q..,��,.!. j.�: V /................................................................ at ... ..... /..!- .L...(^r...... �. `S?,Qr: ............ . orthAndover, M ss. - ` Fee ............................. Lic. No... LECTRICALINSPECTO Check # ,2 0 31 lnomnlonroaa& o f Mailaclruiatt-i gOfficial Use Only 2aparjmenf of �7iro Sorvite9 Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code , 527 CMR 12.00 (PLEASE PRWflV VK OR TYP A INTOI&LI TIOM Date: f City or Town of: d To the -Tnspfk ctor of Wires: By this application the undersigned gives notice of his or her intention t erform ctrical work described below. Location (Street & Number) W�p� Owner or Tenant _ .�o Telephone No. Owner's Address Is this permit in. conjunction iv' h a building permit? YesNa ❑ (Check Appropriate I3ox) Purpose of Building (� Utility 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: ! P A e"s Com lelian o tl f 11 bl No. of Recessed Luminaires t--,, re a oIMIg No. of Ceil.-Susp. (Paddle) Fans to a maU be tivatved by the In ec r of tre No. of otal Transformers KVA, No. of Luminaire Outlets No. of Hot Tubs Generators ICVA- No. ofLuminnires Swimming Pool Above ❑ In- ❑ o. o mergency tg trng , rnd. r-nd. Battery Units No. of Receptacle Outlets 2, No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiatine Devices No. of Ranges No. of Air Cond. Tonsl No. of Alerting Devices No. of Waste Disposers Heat Pump Number Tons I W No. of Self=Contained Totals: Detection/Alertin Devices No. of Dishwasli ers Space/Area Pleating ICW Local ❑ Municipal EJ Other Connection No. ofDryers l Pleating Appliances ICW Security Systems:* No. of Water No. of No. of No. of Devices or Equivalent )`seaters ICW f. signs Ballasts Data Wiring: No. of Devices or E uivalent No. Hydromassage BathtubsNo. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHIC, R: " Estimated Value of Elecj��.Attach additional detail ifdesired or as required bn the Inspector of !-tire - �— (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with NEC Rule 10. and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unles the licensee provides proof of liability i urance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cov ,e;zge is in Force, and has exhibited rooFaF am to�ti p �permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) // 1 certify, under the pains ties ofgefju'ry tltat the inforntrt r t !is applicati n is trite and connplelq� FIRM NAME: lJ �C r(//r]� Cf4`,/(f rv� Licensee:(_ In CJ 4 Signature LIC.NO- (Ifapplic. able, eni empt' ' he lice a number line_) Bus. Tei. No.- Address: �5 �S 1 C f' i Alt.'li"eI. No.: *Per M.G.L. c. 117, s. 57-61, security work re uires Department of Pu tic Safety "S" License: Lic. No. OWNER'S INSURANCE, WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law; By my signature below, I hereby waive this requirement. I am the (check one) [] owner ❑ owner's agent _ Owner/Agent Signature _ Telephone No. PERI 7T FEE: $ cn Z O V -Lti7 � � Z ..d w d V H V w ..2 w 6� � O v �a w 0 w �Ep H ca - c a cT� as � tsa .. pa w w w I" ©k' Town of Andover /OFA "`�` Massachusetts 36 Bartlet Street Andover, MA 01810 Electrical Inspector Pau! Kennedy (978)-623-8306 ELECTRICAL PE+ RAUT FEES Fax Number. (978) 623-8320 (revised September, 2012) Office Hours: 8:00 am. -10:00 am. Commercial Base Fee $50+ $1 each device Residential NewDwelling Up to 200 amp service $225 Each add. 100 amp's $20 Multi -Family New Condo/Multi-Dwelling (per unit) $225 Residential - Service/chan e/ alterations 1 phase - 200 ara $60 3 phase - 200 am $110 Multi -Family/ Single Family Each add. 100 amp's $20 Additions/Renovations/Replacements (Maximum Fee $225) $50 (min. fee) + Outlets, switches, plugs, luminaires, etc. $1 each device Residential I Commercial Appliances $50 (min. fee) + $10 each appliance Air Conditioning and Heat Pumps $50 Temporary service $50 Residential Generators/Solar Panels (service additional cost) $100 (base fee) + Additional Equipment $25 each Commercial Generators/SoIar Panels (service additional cost) $100 (base fee) + Per KVA $1 + Additional Equipment $25 each Residential Audio/video/data/phone-systems/ $5o " Fire alarm/security systems Commercial Audio/video/data/phone-systems/ $60 Fire alarm/security systems Commercial New Construction and Alterations Base fee S50+ Per 1,000 sq. ft of Construction Space $100 Service/Change up to 200 amp $150 See Electrical Ins ector for price above 200 aT Maintenance Permit/Repair Blanket Permit (up to two electricians) $200 Over two electricians(per air) $50 Office Furnishings/ Partition Relocations $50.00 (base fee) + Per Circuit $10 Transformers (non-utility owned) $50 Mis ellaneous Carnival rides $50 ` Demolition $50 Feeders or sub -feeders and panels $30 LA (each 100 amp. capacitor fraction thereof) Motors, per hp or fractional part thereof $4 Siding (re -securing service, light, plugs) $50 Si $50 Meters $20 Swimming Pools In -ground $100 Above -ground $50 Commercial $200 General Fees Re -Inspection Fee $50 Inspection after hours (minimum fee) lWorldng $200 without a permit Double Permit fee The Coiinmon:svealth..of M.assachrtsetts Departtnetit'of liidiisiPial-A'ccideiit,t Office o f'Investigations 600 Washington Street_ Boston, MA 02111 ivulm inass.g'ovIdia Workers' Compensation Insurance -Af iidavit: Builders/Contracto Name (Business/Organization/Individual)64 elecllvc W Address: 16T I 0 /kt Phone #: Are yo employer? Cheek the appropriate box: 17 man 1. I.aa employer with q_ 4. 0 I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.1 required.] 5.E] We are a corporation and its 3. ❑ 1 am a homeowner doing all work officers have exercised their myself_ [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § l (4), and we have no employees. [No workers' comp. insurance required.] Type -of project :(required):.:.. 6. �FlN construction '- 7. emodeling 8. [] Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.0 Plumbing repairs, or additions 12.0 Roof repairs 13.❑ Other *Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit tris affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. 1' am an employer that is provid' g workers' compensation insurance for my employees. Below is the policy and job site I11f01'IilQtloll. i I� Insurance Company Name: Policy # or Self -ins. Lic. #: � (�� y/D -1 Expiration Date; Job Site Address: / k 1`�� y/j/�/1'( 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 required under Section 25A of MGL c. 152 can lead to the imposition of criminal -penalties of a ',fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER -and a- fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby certlfy enth s and-penaltles of perjury that the information provided above is true and correct. Phone #: Oficial use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Cleric 4. Eleetrieal.Inspeetor S. Plumbing Inspector 6. Other .�..:,, Contact Person: Phone #: I " 0 1 7 Date .... 11. �. ...... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ?. -7 , This certifies that . .....1 ( has permission to perform plumbingin the buildings of ..................................................................... ....................... at ..... s4......................=..............f., orth Andover, Mass. Fee.4 ..... Y: ............ Lic. No:,:�O.:,3-6 .... ..... 1>1 .............. f PLUMBING INSPECTOR Check # MASSACHUSETTSUNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK P TYPE OR PRINT CLEARLY j CITY ✓��L �'/� Ae h VT4 MA DATE "� .S PERMIT # l6 1 JOBSITE ADDRESS IDP/� 1t?'2 OWNER'S NAME OWNER ADDRESS �'•�E�J GyR �f� �-J TEL FAX OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL14 NEW:4 RENOVATION: ❑ REPLACEMENT: ❑ 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 GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY f ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION 1 WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES © NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHERTYPE 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 Massachusetts General Laws, and that my signature on this permit application waives this requirement. ,CHECK ONE ONLY: OWNER ❑ 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 and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME �a 41eI'"`e LICENSE # X36 � /SIGG NATURE MP,0 JP ❑ CORPORATION V i PARTNERSHIP ❑ # LLC ❑ # COMPANY NAME C/�r�ni )tea ADDRESS 52'l )Jb PO CITY V6AZA# STATE ZIP 0) S'Yf TEL 4f-0'3cA-0 FAX CELL 545 ``7 3 SC EMAIL 60► r`l'L_Ah Ae>e- Ca ?n 0 Date 7 �!�/.5........ O TOWN OF -NORTH ANDOVER Seg • - PERMIT FOR GAS INSTALLATION r s This certifies that ..f _17-1—se /.Q `?? !?^-... `,._ 1_/ has permission for gas installation.. E'4 !:.... c�'�-"�..... . in the buildings of .. .e11'f.�!�.�.'�` .......................... at ....T.. !�!!�` ..`.... ,North Andover, Mass. uV Fee. -?-.,!F. Lic. No...go.3 e... %.... V GAS INSPECTOR Check # / C���S Date .. 3. ). z .� . /i b... . jlo ,°.'ryO ° TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 1 This certifies that . .��..'... ...................... has permission for gas installation in the buildings of .. SA �� f !.'� .................... . at ....�North Andover, Mass. Fee P...... Lic. No..:5—A to ...�� , -# GAS INSPECTOR Check # S 7163 I MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FfrnNG (Type or print) NORTH ANDOVER, MASSACHUSETTS Date JA- y /`d Building Locations Permit # Amount $ —Owner's Name / /� !c eL- New 0. Renovation ❑ Replacement 13-- Plans Submitted ❑ G SUB-BASEM ENT IBASEM ENT IST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. 8.TH. FLOOR FLOOR (Print or type) Name .J ! Address i 94 w x w rA z U w a x a �2 w > > w �d a w o w z c x o x w3 Q v ° a > c o ltm Name of Licensed Plumber or Gas Fitter e Check one: Certificate Installing Company .El Corp. FlPartner. [3-Firm/Co. ve-024 /fir -P INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes No 13 If you have checked yes, please indicate the type coverage by checking the appropriate box Liability insurance policy �� Other type of indemnity ri 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 0 Agent 0 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 Derformed under Pe t Issued for this application will be in compliance with all pertinent provisions of the Massach ss Gas Cod and Cha r 142 of General Laws. ICity/Town OVER (OFFICE USE ONLY) Signature of LicVnnsed Plumber Or G& r [ 'Plumber Y�t3 Gas Fitter icense -umber v �4aster Journeyman R The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Dolicant infnrmatinn Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Type .of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roof repairs 13. [1 Other omeowners who submit this affidavit indicating they are doing all work andthen hire outside ontra ors must submit a new affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp policy information. lam an employer that isproviding workers' compensation insurance for my employees. Below is the pokey and job site information. Insurance Company Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can Iead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains andpenalties of perjury that the information provided above is true and correct. Phone #: Official use only. Do not write in this area, to be completed by city or town official City or Town: 1 ermit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Are you an employer? Check the appropriaii 1. ❑ I am a employer with 4. eneral contractor and I employees (full and/or part-time).* 2. ❑ I am a sole proprietor or ed the sub -contractors partner- the attached sheet I ship and have no employees ese sub -contractors have working for me in any capacity. workers' comp. insuranceinsurance. [No workers' comp. incnce 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing officers have exercised their all work myself. [No workers' comp. right of exemption per MGL c. 152, § 1(4), and we have no in required.] t employees. [No workers' comp. insurance required.] `. wy applicant that check-- box #i mus-, also fiII out the sectioy beio�, shove^^ .a �' fri v H Type .of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roof repairs 13. [1 Other omeowners who submit this affidavit indicating they are doing all work andthen hire outside ontra ors must submit a new affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp policy information. lam an employer that isproviding workers' compensation insurance for my employees. Below is the pokey and job site information. Insurance Company Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can Iead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains andpenalties of perjury that the information provided above is true and correct. Phone #: Official use only. Do not write in this area, to be completed by city or town official City or Town: 1 ermit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: AL Information an d Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartaxents and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of coxnpliance 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 number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners,. are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit 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 to-zu that the application for the permit or license is being requested, not the department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a- space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permittlicense number which will be used as a reference comber. 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 perznits 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 bum 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 Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 0.2111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-72.7-7749 www.mass.-gov/dia ih MASSACHUSE M UNIFORM APPLICA-YON FOR PERNU TO DO GAS ffr,IN (T G I ype or pnnt) . NORTH ANDOVER, MASSACHUSETTS l� Building Loqations Fid- Lt-, .% Owner's Name New ❑ Renovation Replacement Daft �7�`d Permit # Amount $ P -e ffe Plans Submitted ❑ (Print or type) —• - "�' /'p c�Li. "i"- Check one: Certificate installing Company Y Address ( � �� U k �C 1erle n�nP l�'✓t/ Jv� i,.i,� �¢ 0 / �Lte Partner. usmess r � Name of Licensed Plumber'or Gas FitterFirm/Co. (30,� Z, ._/_ INSURANCE COVERAGE I have a current liability Insurance,. policy or it's substantial equivalent, Check one: If you have checked ves, please indicate the type coverage by checiLin the Yes [a Liability insurance policy � Oth g appropriate box NOD er type of indemnity j"1 Owner's Insurance Waiver I am aware that the licensee does n— have the Insurance Bond Mass. GenED eral Laws, and that my signature on this permit application waives this requirement. coverage required by Chaps 142 of the Signature of Owner or Owner's Agent Check one: 7 hereby certify that all of the details and information have submitted 13 Agent ■ best of my knowledge and that all plumbing work and installations (or entered) in above a compliance with all pertinent provisions of the Mass h pe�O�� under P application are true and accurate to the tate Gas C e and C Issued for this application will be in .142o the General Laws. By: Signature of r r:*io g Licensed PI City/Town. _ APPROVED (oFFIcE USE ONLY) umber O Gas as Fitter (� Plumber Cj GFitter License er C� Master 0 Journeyman Z. �. a a o o m +- 196.rO� a d W C x a: W A W Z c s0 " z w iU B-BASEM ENT L� ,-zr > + C o Q 4 G o y , E• 3 A S E M ENT u ST. FLOO R N D. FLOOR RD. FLOOR TH. FLOOR TH. FLOOR TH. FLOOR TH, F_LOOR. T_H. FLOOR (Print or type) —• - "�' /'p c�Li. "i"- Check one: Certificate installing Company Y Address ( � �� U k �C 1erle n�nP l�'✓t/ Jv� i,.i,� �¢ 0 / �Lte Partner. usmess r � Name of Licensed Plumber'or Gas FitterFirm/Co. (30,� Z, ._/_ INSURANCE COVERAGE I have a current liability Insurance,. policy or it's substantial equivalent, Check one: If you have checked ves, please indicate the type coverage by checiLin the Yes [a Liability insurance policy � Oth g appropriate box NOD er type of indemnity j"1 Owner's Insurance Waiver I am aware that the licensee does n— have the Insurance Bond Mass. GenED eral Laws, and that my signature on this permit application waives this requirement. coverage required by Chaps 142 of the Signature of Owner or Owner's Agent Check one: 7 hereby certify that all of the details and information have submitted 13 Agent ■ best of my knowledge and that all plumbing work and installations (or entered) in above a compliance with all pertinent provisions of the Mass h pe�O�� under P application are true and accurate to the tate Gas C e and C Issued for this application will be in .142o the General Laws. By: Signature of r r:*io g Licensed PI City/Town. _ APPROVED (oFFIcE USE ONLY) umber O Gas as Fitter (� Plumber Cj GFitter License er C� Master 0 Journeyman .�..•,,�w�acrn o� j Massachusetts Departrnerct of Industrial Accident, Of. f'tce of Investigations 600 Washin-ton Street Bastosz, MA (12111 Workers' Compensation Insurance A"�l.�`ss'ov/cam 3Iica.nt Information it- $ceders/Contractors/Eiectricisns/Piumbera Name (Business/OrganizatioNlndividual): Address: City/State/Zip: Phone #: Are :yon an employer? Check the appropriate boz: 1. ❑ I am a erne }oyer with emPloyees (full and/or p .* ?. ❑ .1 am a sole proprietor or partner_ ship and have no employees working for Mein any capacity. [*,workers'. comp. insurance required.] 3 ❑ l an a homeowner doing ELI] work myself. [No workers' comp. insurance required.] t 4. ❑ I am a renem, contractor and I have hired the sub -contractors listed oti the attached sheet I These Sub -contractors have workers' comp. insurance.. 5 ❑ We are a corporation and its ofF'cen have exercised.their rigs t of exemption per MGL c. IS2, § 1(4) and we have no MPloyees. [No .workers' con TYPe of project (required): -6•. ❑ New construction 7. ❑ Remodeling . 8. ❑ Demolition 9. ❑ Building addition 10:❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12,❑ Roof repairs H. Insurance required) 13 ❑ Other *Any appli�nt.that checks box # I .must also fill out the section be{ow sho t r iomcowoers who subnut •this aiidavh indicating tisey are u'ulF:� �'ng th-ir workers' compensation policy inrotmation. iCona$cmrs that checl: this box moist atr. error Eisen hire outside cunirus lure rnus( suimsii n ncu g^A^hod an additions! sheet showireQ the �me.of the tsi&or n"Oi s and their work=, atndanit indicsing I rim art employe, the is provuan.- wori:e s, co., rkers' °OMP. Policy infbM tion. tnfnrmaPion. "� "2 LMU,0.nce for n!' employees Below is the o Insurance Company Name: p job site Policy # or Self .ins. Lic. #: Expiration Dat~: Sob Sii~ Address: Attach a copy of the workers' con City/St/Zip: peusation policy tlecia�tion Q .Failure to secure coverage as required under Section 25A of Face (showin- the policy number and expimtian crate}. fine up to 51,500.00 and/or one-year imprisonment as well MGL c. 152 p as civil penalties in the orme of a STOP WORK p criminal p-nahtes of a Of up to .5250.00 a day against the violator. Be advised that a Investigations ofthe DIA for insurance coverage verification, copy of this statement ma , RDER and a fine be forwarded to the Office of .«, •«. cuy ce-ruJJ' under the pairzc andPe�es oJperjurj, llxar the information provided above er ince :01n are: and correct Dfcial USE on1p. Do not write in this are¢, to be complezt Qd.b3, or town offxial City or Town: Issuing Authority (circle one): Perm it/Li cease # I. Board of Health 2. Buildiin. 6. Other �pa>�eent 3. City/Town Clerk 4. Electrical Inspector 5. A Piumbinp inspector Contact Person: Phone #: .1.111Vl LuQLiV11 i=W j,jU JL11S1LI uC-U1O]1S ; Massachusetts General.Laws chapter 152 requires all em -;D loyers 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 ofhire, express or implied oral or writtmL" 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 includz 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 s dwelling house.having not more than .three ap; artments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state 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 for -any applicant who has Dot produced acceptable evidence o f compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public wor7Fc until acceptable evidence ofcompliance with the insurance requirements of this chapter have beam presented to the contracting authority." . Applicants Please fill out the workers' compensation affidavit compZ•etely, by checking the boxes that apply to yotn- siivatim and, if necessary, supply sub-contractor(s) name(s), address(es) amid phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or. partners, are not required to carryworkerscompensation insurance. if an LLC or LLP does have . employees, a policy is required. Be advised that this affidLavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Ain be sure to sign and .late the .affidavit Theaffida.vitshouid be; retuned to the city or town that the application for the permit or license is beim requested, not the D� arttnent of Industrial Accidents. Should you.have ani � estions reu g vp qu -ding the -IMM, or. if you are required to obtain a workers' .compensation policy, please call the Department at the TnX'J_rnber.Iisf.ed 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 IeL—zrbty. The Department has provided a space at the bottom of the affidavit for you to fill but in theevent the Office o: Investigations has to contact you regarding the applicant Please be sure to fill in the pennitliicense number which will be used as a reference number. In addition, an applicant that must submit multiple permit/iicanse applications in any given yam, need only submit one affidavit indiratino current policy information (if necessary) and under "Job Site Adatress" the applicant should write "all locations in o (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 Iicenses. A new affidavit must be filled out each year. 'Arhm a home owner or citizen is obtaining a licem-- or permit not related to any business or commercial vcntur e (i.e. a. dog license or permit to burn Izaves 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 Cominonwtal. th of lvfassa.chirsatts Dtpartment of lmdmtrial Accidents Office of LIIvestiptions 600 Wasl�on Street Boston; MA (12111 Tel. # 617-727-4900 Wrt 406 ar 1-87 Mp,SSAFE Revised 5-26=05 Fax # 61 7-72.7-7749 wvm,-Mass.Dov/ata LoBation / G, No. Date �ORTM TOWN OF NORTH ANDOVER O?O•,t`1O _I•,�OO? p Certificate of Occupancy $ Building/Frame Permit Fee $ ��b',•°'''tom Foundation Permit Fee Ss�cHusE $ fr Permit Fee � $ ` Sewer Connection Fee $ Water Connection Fee $ ` TOTAL $ B61ding Inspedtor 3 08;39 45.50 ,� PAID iv. Public Works W O a Y 0 0 m W F- _a I N I W Z 3 0 li 0 0 K 0 W N W N N I N K J NO N L 0 LL 0 N z 0 N z < E N W K O O N a Z N 1 F- � O O W i 0 Z , D 4 x g u / VY 1 K KC 6 L J UA W i , 0 f x � LU 3 Z 0 i m r u uu ^ j N 1 Ir 2 rc d a z 1 p u J m W J m d u O F u u W W N N c F p W Z J W W 1 0Z Z Z Z Z u 0 u u 0 O Z Z Z U. LL < p O O N < m m m K a WO O r Z K O 0 W r K Z O o w u D J t7 < < Z Z Z � J O O j � 7 m m m J Z LL Z 0 P u < N J W L L < W 0 O K 0 m 0 a Z 1 F- � O O F. i 0 , D 4 z g m / VY 1 K KC 6 L J UA W i , 0 r � LU 3 Z 0 i m r u uu ^ j N 1 u 2 rc d a z 1 p u J m O m J m d u u u W W ; N Z 1 0 F. i u , D , H I In Z J UA V i , N � LU 3 2 0 P1 i O Q ^ N ^ j N 1 Z z 1 O O , u u W W ; N N r { r , 0 0 0 N J_ J_ 0 N 1 0w W { W 3 t7 1 N iL d 1 t J UA J UA V � LU 3 2 0 0 O Q U = 3 V $^ �m 7+ w O tII 0 O,�f* rm> -I i OD S�� m00 D (JI NN()wCD mznnp zf1 f1 mD cmw fl -� D�On SooD S Ov A x2� DIO D R W D �mnn mr)z p00 z N D;N v�IO D ~ O A Q p P• ^I p D m m T m n A A, f1 y D o v¢ O �� N 7[ n m y -y T p3 D N; � O 00 O m N � = N r 0000000(�O-+NNCCDJJ z z p Z z O O O N N 2 p O 0- C ,, m m w m Z D y z C m N y z G>Gzi m; (� p 3 z z Z 1A O Z z CA O 1 W O N mN t'n°f10- Om N N O DDzD 3 N m mo pT�G10zG10 D Z T 0 z O < < a s O w O 0 N x m D v T m z m Z m 0 N ^ T y O NN Op '�� j N z < Zn _ N C 0 ISI TTT _ I I I I I I I LL I I I I I I_► L11 I MLI_ z Z^'OOCDD2yTv Or r DZ 0 p0 Om m .. r;yZ7CD ODOR �-+m yOD _ DC O D H Df1x NODDO f1 A t0 3TTT 0mzz _ c0 Z ° D I IM W •� C ON "o n x p N Z y C O< D v A r r m O m m T r rvx ^ D m r T A ti S O 1^ m Op C f1 =; A S Z x f1 O p� y m Z { N p COC i m n n Z H x O A O Z S 3 z A (� A W y A m n r Z O T Z D _� D p C Z N N m O p O O O r p 0 g N_ j 3 X m 7 N , m n -� �0j 0 21-0 NO - Op DZ A% 5C < p Z O C ? r 1A D mm s 0 z I l l l� a �> pm" C m .yN T a—LZIM m 00 S z DD " N X p Zm l l l l i z I � III !I � � IIIII� IIII IIIII" � DOx Nry Zm 14 D0 z Ovc MXN D-1 n 0 0 ND:E mim mx -4zD x(An u►o-1 Mzv mU)3 TOM �N m 0 Wsz!1 OF v0 -�c)r ANO ?�z =v v 0 nz sn mm ar C v_ z a m m n 0 v P7, LLJt �1CL R It-� m c o � :c« ;-= 0 •cam CL c to t o o m : N � Ea m c :... w o a N E � :gym :ate C.3 *r, Cf C2 O F. J Via.. 'O C m •O�O'fl � = c H U a U aw. WV a a�� m; 0 a � msr f0.1•NZ W O d0 W CC/)v a co G Ar m W u m O w 2 0 ID d t C!.s .E c�° oz �o z� o�C3ca ca C2 C aq cn cn LLJt �1CL R It-� m c o � :c« ;-= 0 •cam CL c to t o o m : N � Ea m c :... w o a N E � :gym :ate C.3 *r, Cf C2 F. J Via.. 'O C m •O�O'fl � = c H t0 m 'C .df, O a�� m; 0 `ams msr f0.1•NZ W O d0 It S ca N w ~ m •colH ID d t C!.s .E oz �o z� o�C3ca ca C2 C CL W v t . Q a a.M.. m r s O F. • • N w P4 E a. co O E O O V Z a3 C. O H � C O CM I O ,O O A O O mm CD C3 w 3 .o O CD Q L cc O a CL cma ca C cc C3 CL c Z � V y c C c CO)CL D F :W C/) oz �o z� W O U W a W • N w P4 E a. co O E O O V Z a3 C. O H � C O CM I O ,O O A O O mm CD C3 w 3 .o O CD Q L cc O a CL cma ca C cc C3 CL c Z � V y c C c CO)CL D d.ocation No. Date 4 A W TOTAL (::Kll� �> Y() 9646 4e $ uilding Inspector Div. Public Works Q TOWN OF NORTH H ANDOVER 8 Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ —8t Mr Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ Ln0 TOTAL (::Kll� �> Y() 9646 4e $ uilding Inspector Div. Public Works W EMM v p O z z_ Z t o ci O J f m S _ O Z U W m 0 a 0. UN 0 IL a a rc 0 m pN C1 It zm o 0 _Z O J_ 7 m r a W W E < ( W W z < Z z 0 Ua W W W Z = O � � � m m a O x V z I- 0 0 O LL W 0 W N a z W Z 0 f u a J W IL L < IL 0 O C t 0 m Z O t L $� s a a O 4` W W�' r ; z O 0u U U� d O 6 dgm��Ut z M S W W W m Z 0 r U Ix 1- N Z ^ M Z 0 r U W a U) r W O O J J = 4 0 m w W 13 0 d LU LU ci f J W F m C1 3 o o O V U 2 S H CI D;+0G) p p D O o D D D �Ox�3m P°mOD moT A O m = v T D x Z < O Z R U U 3 x 0 = D v 0 U O Z A 0 > 0 II-! mwv�u+mDD*On n p c C n m v 0 0 D A mZ rl0 -D m W vmnn ci z 0 N D3'^ D c z nn�a x0v� D vm D n v Ann ptilc� p z z 00 O O p O N N U 0 x a A p Q, T 3- v O p T Z D m 3 z Z o o 0 3 y - 0 3 3 30DN Z, c << T z 3:o O u m 9 < T m N y Z n N M Q 1 IIIIIIIII I III I111JI :2 Iw z{ p z l y+ oil T y H; ynx A n A Z _ Oo m z _ z n x'so=m N mF z U Vin` r z O Zy_3 7C m n H 0 1 N T J 1—L O O Z N IIIIIIIW �" ���� nON N NrN zLm1 � yo yZZ 'U �XN D� n 0�0 (n o3m mx -qza IN_n N00 �z_ mm3 �-nN M 0 mcz m F �v_O 0c)11r 9U)0 r • -+ >gs z_z v 0Nj ;aa nz =n mm N� �m D0 3 R VA �l CC LLI c L -L zu L,-) Au L] to �L:E co Of -'4 �4 E z 4 cu CD CL w2C$�)' cz W4 CO WE or cvro CO�, ca CD U co to mm —C U co CD CD =5 cis C3 >. >CD CD CD 1 C.) cc CD fl �l CC LLI c L -L zu L,-) Au L] to �L:E co Of -'4 �4 E CD *-a C.3 CD CL w2C$�)' cz W4 WE E CD *-a C.3 CD CL cm coo CO�, ca CD co M co E mm co CD CD C3 >. >CD CD CD 1 C.) cc CD fl Cl - ca C) Cc Cc IL FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section******�*7********** APPLICANT: -0 Phone / 6,3 q LOCATION: Assessor's Map Number - L - 'Parcel Subdivision Lot(s) Street St. Number Use Only************************ RECOM4ENDATI7 OF AGENTS: i!G� Date Approved Conservation Adminli traptoo, Date Rejected Comments �r4e o f 97 Town Planner Comments Food Ins ctor-Health S _t'c nspector-Health Comments /o, S�n,_ Date Approved Date Rejected Date Approved Date Rejected Date Approved Date Rejected Public Works - sewer/water connections - driveway permit Fire Department Received by Building Inspector Date W wa a W o 0 m z O W 3 z 5 ) 0 Z Q oz a 0 V o J m J W i r N J N = O Z I D OLL a. 0 m N � m O Q d N W o 4 0W Z N r 1 m 0 o H N 0 o z Z W < E H O J J LU V m z H N Wft 3 o o 0 U Q N Z LL N N z z z a } m O ! uu OW a a 6 L W Z z O 0 3 z 5 ) 0 Z Q oz a 0 V o J m J W i r N J N = O Z I D OLL a. 0 m N � m O Q d N W o 4 0W Z N r 1 m 0 o H N 0 o z Z W < E H O W N1 C 0 Ir 4 W C W a r Z 0 CK LL 0 Z 0 O LL W O W N N > i W I U L 0 < i K W z � p z O 0 a`� z 5 ) V V J J LU V m z H J Wft 3 o o 0 U Q Q Z LL N N z z z a } m O ! uu OW a a 6 L r W It 0 0 WFN F z 0 J J F iL 4 ! 0 u Mw a r 0 0 l a d tl) 6 l < u6 Y6 � p z ! 0 a`� z 5 ) V V J J LU V z H J Wft 3 o o 0 U Q Q Z N N z z a O O ! uu a a r r It 0 0 0 N J J F iL 4 ! 0 N F Mw W W 0 0 l d tl) 6 l Y6 � p z o a`� z 5 ) V V J J LU V !- H J Wft 3 o o 0 U Q Q Z f ' 3 V z Z 03.: Hp. 00 Ol O � p z y DD y� N m 'z OOnngmwmoo¢¢C, >� ` p Opp � Tl I I w: O mO D> Z D m D 3:p N m„ ZZO00 pZZ00oNNx2x I I f I lU 0CN I I I III I W Z 0 w > m_ Z= Z A T Dz>�,3: %3: Z Z )OZ(,�C) Vr Z �= as a Non Or N�? O ,;„O^ n; DN �G1N HO N inm Dv O +� Z1O Amo 3 O _ N II IIIIIIIIII IIIIIIIIIIIIII Z m O r Oy 0 C m D= p pm _ D y ZO2 p nn D TTOO�DO-On m �Z m D Z Oo= y;r 0 D C2;Njnp O Z -26M N C z; , p 'm N m y 0A ZC m m Z 0 m=y -'0m OC om 0 qm m N m H Z C DZ p> r=ig y m M p 7c mN y T C O �p f p Q' T I I I JJJIIIII.. 9 C ^' 2 O N x Z z O 0 C� S I_III'_ILIII'LLIIIIILLL I Z I �� I � III II I I IIIII� IA1!l- IC D N V C Z m ID O A m z Z Z{ y m D Z p p z y N m Tl I I w: O Dm o Z D w I I f I lU l I I I I I I III I W aON N (mjyrN zm y0 NZZ °c mX� 3> O�0 Nvg o3m mx -iza IN_ fl NO -1 �Z0 mN3 TOZ �N m�0 O -Z11 0F 0 0 -+ a r 'O Ul 0 Z�Z -10 x0 0> �z I0 mm m m 00 3 m M d z ON w W M S� U a L or. w co v w cn w° a U w ° ° or. o c E c a �: 04 cii w a w co cn v LU am a cs ` V V dC .� O "2 W co ma ms c om ` E c o m �1 dO (i y ce - H 3 � 0 m O vJ cm ca � z �HCc O 'E w U mo = go CD c :mowc '� c w c .mom m 0-4 H Z ` o � o c o CD ClC O.•" C W O =. �H O La 'C .B ._ Z Lu ,E C3,0 o O tm C2 O p m C F- CL g _ ccO C-: = S`.=m� F. Q E Q r Q v V Z CD CL O y O c CD o; cm CO2 O� .CO2— m m L- 1- .c CL C .c CS ?-ft cD CD Q Q Q C. CL Q o CA *-� c CIO V 'fl CL 0 CD CO2C Z CD CL v h � C C Q — y 0 Town. of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES 146 Main Street 11.1IAM J. SCOTT North Andover, Massachusetts 01845 Director In accordance with the provisions of MGL c40, 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 111, S 150A. The debris will be disposed of :,--1: (Location Facility) Signature of Permit Applicant -/a c ; 2� Date NOTE: Demolition permzi from the Town gfNorth Andover must be obtained for this project through the 61fice of the Bufilding Inspector. AORT" Ott��ao ,e'�tiO • OL FO A • y x i y wr10 •r G��S BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535