HomeMy WebLinkAboutMiscellaneous - Lot 12 191 Carter Field Road�_�
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Location
No. Date 5-7-09
TOWN OF NORTH
ANDOVER
0
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Certificate of Occupancy
$
CHU
Building/Frame Permit Fee
$
Foundation Permit Fee
$ 0
Other Permit Fee
$
TOTAL
$
Check # /019 q
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17 2, 6 0"
building Inspector
' TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIJ RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
idd Uk.� v
BUILDING PERMIT NUMBER: DATE ISSUED:
SIGNATURE:
Buil7nCommissioner/In for of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
, /� n
(�T 12 / I fit r4 r ri e (�t
6Z z
Map Number Parcel Number
1.3 Zoning Information:
1.4 Property Dimensions:
(P
22,5(03 t03
Zoning District Proposed Use
Lot Areas Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Required Provide RegWred Provided
Required Provided
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—Q[ 7;-
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information:
1.8 Sewerage Disposal System:
Municipal On Site Disposal System ❑
Public Private ❑ Zone Outside Flood Zone
SECTION 2 - PROPERTY OWNERSHW/AUTHORIZED AGENT
2.1 Owner of Record
7h m ZA 12 I C a At , i e • AA" M
.�TN
NNa rte (Print) Address for Service
Sign a Telephone
2 Owner of Record:
F Name Print Address for Service:
'Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: //
Not Applicable ❑
7—�7.11YA S
OF
Liens Construction Supervisor:AJ
License Number
1 r
m
Address
v(�
Expiration/Date/
Sig re Telephone
3.2 Registered Home Improvement Contractor
Not Applicable
Company Name
Registration Nu r
Address
iration Date
Signature Telephone 4116
Ma
M
Z
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SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
-Signed affidavit Attached Yes ..... X No ....... ❑
SECTION 5 Description of Proposed Work check aB applicable
New Construction X.., Existing Building ❑ 1 Repair(s) ❑ Alterations(s) ❑ Addition ❑
Accessory Bldg. ❑ I Demolition ❑ I Other ❑ Specify
Brief Description of Proposed Work: l
q $(;P\ -3i
I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I
Item
Estimated Cost (Dollar) to be
Com leted by permit applicant
�` O>E I�L'USE�ONLY-
-
1. Building(a)
/ 1
Building Permit Fee
Multiplier
SIZE OF FLOOR TIMBERS 1 '-2dr
2 Electrical
Z Ll� d `
(b) Estimated Total Cost of
Construction
DIMENSIONS OF SILLS
3 Plumbing
DIMENSIONS OF POSTS 3 L L
Building Permit fee (a) X (b)
_
4 Mechanical HVAC
SIZE OF FOOTING
5 Fire Protection
MATERIAL OF CHIMNEY k1
6 Total 1+2+3+4+5
IS BUILDING ON SOLID OR FILLED LAND St/2 /Jj
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR PLIES FOR BUILDING PERMIT
I, % ` as Owner/Authorized Agent of subject property
Hereby authorize. to act on
My behal in al tatters relative to wor horized by this building permit apply '
S�e of Owner Date
TION 7b OWNER/AUTHORIZED AGENT DECLARATION
_/ / 1
Z_eJge/YLI X4 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��
SigOwne ent
Date
NO. OF STORIES
SIZE
BASEMENT OR SLAB $
SIZE OF FLOOR TIMBERS 1 '-2dr
2 ND
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS 3 L L
DIMENSIONS OF GIRDERS
IMIGHT OF FOUNDATION S l
THICKNESS
SIZE OF FOOTING
' n X J�
MATERIAL OF CHIMNEY k1
IS BUILDING ON SOLID OR FILLED LAND St/2 /Jj
IS BUILDING CONNECTED TO NATURAL GAS LINE tiles
If
12
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 or requirements.
*****************************APPLICANT FILLS OUT THIS SECTION
APPLICANT -; Q eM �Lj ,Q� /eZM&
LOCATION: Assessor's/ _Map Num/ber/ % 2
SUBDIVISION DIC' I-)2tQU
STREET C4 r�-e (- f, e,/ j��s
PHONE'? 79- 697-676 3..5"
PARCEL 2—
LOT
LOT (S)
ST. NUMBER
**********************************OFFICIAL USE ONLY**********************kk**********
REC,9!MMENDATIONS OF TOWN AGENTS:
CONSERVATION ADMINiS hATOR DATE APPROVED p
DATE REJECTED
FOOD
TH
TH
COMMENTS
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
PUBLIC WORKS - SEWER/WATER CONNECTIONS
��-
DRIVEW.4Y PERMIT
RECEIVED BY BUILDING INSPE
Revised 9\97 jm
DATE
L oT i2 G ),,"O\ FAE LD
pp
Opose.D s tri 9 AO
s
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Name Please Print
Location: 66-T / Z
City b• AIAJOe C. AA ✓j Phone # 3S"
I am a homeownef performing all work myself.
I am a sole proprietor and have no one working in any capacity
P
I 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 _wellas_civiLpenaltiesin.SheformDfa_STOP WORK_ORDER..and_a fine of.(.$1.DO.OD)_a day against -me. I
understand that a copy of this statement may be forwagW to the Office of Investigations of the DIA for coverage verification.
l do hereby certify under the pgAs and penalties of,
Print
that the information provided above is true and correct._
Date , $(]�/4
Official use only do not write in this area to be completed by city or town official'
#°['�-6i� 2631✓
City or Town Permit/Licensing
El Building Dept
❑Check if immediate response is required Licensing Board
❑ Selectman's Office
Contact persona Phone #: ❑ Health Department
R Other
GROWTH MANAGEMENT BYLAW EXEMPTION STATEMENT
TOWN OF NORTH ANDOVER BUILDING DEPARTMENT
This form shall be used to assist the Building Department in their determination of exemption under section
8.7.6 of the Town of North Andover Growth Management Bylaw. The applicant shall provide all of the
necessary information as requested below.
Permit Applicant �— Property address Map / Parcel
Applicant's Phone Number Single Family Two Family
I the undersigned applicant for the above property attest that the attached building permit for which this form is completed
does comply with the EXEMPTION section 8.7.6 of the Growth Management Bylaw. I also understand providing this form does not
absolve me or any. party to this permit from the requirements of obtaining other permits required prior to the issuance of the building
permit. Further 1 understand that my interpretation of the exemption status is subject to review by the Building Department and is only
officially accepted when the building permit is issued.
Based on section 8.7.6 of the North Andover Growth Bylaw the above lot and the work as applied for on the above lot, in the building
permit application and associated attachments, complies with one or more of the following sections as indicated by a check mark.
This is an application for a building permit for the enlargement, restoration or reconstruction of a dwelling in
existence as of the effective date of this bylaw, provided that no additional residential unit is created.
The lot(s) was / were created prior to May 6, 1996 and are exempt from the provisions of section 8.7 of the
Zoning Bylaw.
This application is for dwelling units for low and or moderate income families or individuals, where all of
the conditions of 8.7.6 are met and or represents dwelling units for senior residents, where occupancy of the units is
restricted to senior citizens through a properly executed and recorded deed restriction running with the land. For
purposes of this section "senior" shall mean persons over the age of 55.
This application is part of a development project which voluntarily agreed to a minimum 40 % permanent
reduction in density (buildable lots) below the density permitted under zoning and feasible given the environmental
conditions of the tract, with the surplus land equal to at least ten buildable acres and permanently designated as open
space or farmland The land to bepreserved shall be protected from development by an Agricultural Preservation
Restriction, Conservation Restriction, dedication to the Town, or other similar mechanism approved by the planning .
board that will ensure its protection
This application represents a tract of land existing and not held by a Developer in common ownership with
an adjacent parcel on the effective date of this Section 8.7 and shall receive a one time exemption from the Planned
Growth Rate and Development Scheduling provisions for the purpose of constructing one single family dwelling unit
on the parcel.
_ This application represents a lot which is ready fora building permit ( all other permits from all other boards
and commissions have been received and the project is in compliance with those permits), and the Development
Schedule does not accommodate issuing a building permit in that year. One building permit will be issued per year per
Development until such time as the development schedule accommodates issuing building permits. Applicant must
submit an approved FORM U with this EXEMPTION.
PLEASE PROVIDE ANY AND ALL INFORMATION THAT WOULD ASSIST THE BUILDING DEPARTMENT IN MAKING A
DETERMINATION THAT THIS APPLICATION IS ALLOWED UNDER ONE OR MORE OF THE ABOVE EXEMPTIONS.
BY SIGNING BELOW I ATTEST TO THE ACCURACY OF THE INFORMATION PROVIDED AND THAT THE ATTACHED
BUILDING PERMIT 1S ALLOWED AN EXEMPTION AS CITED ABOVE.
FURTHER I UNDERSTAND THAT THE MITTAL OF MISLEADING OR INACCURATE INFORMATION OR THE
CHECKING OFF OF A ABOVE EXE N WHICH DOES NOT COMPLY, WHETHER DONE TO MY KNOWLEDGE OR
NOT IS GRO FOR REFUSAL B T BUILDING DEPARTMENT TO ISSUE A BUI�� G PERMIT.
CANTS SIGNATURE DATE
S FORM TO BE ATTACHED TO THE BUILDING PERMIT APPLICATION
rM
Toof North Andover Planning Board��
N is t rm represents the schedule for allowing the following lots to be considered as eligible for i „Y
Fermi 'a under the Town of North Andover Management by-law Section 8.7 of the Zoning by-law.
t 8.7 t is Development Schedule must be filed in the Registry of Deeds and be referenced on the deed of
e �h of e lots below and be filed with the Planning Board prior to the issuance of any build ] VO t" !JOVE"�;
pe it ; construction.
Name and Address of Applicant for Lots:
Name of Development:
A9,,k LLC
18S H\(yc)kYHILL PoAD
NORTh %'JDovt�, I MA O igJ s -
L kRT t; EZ �1£L1�S
(oFF QRADFbRbSTKVVl
Map, and Parcel of Original:
M Pr P 6 2 L o7 ?
Date of Application for Lot(s) Division:
flU G UST 9 20,02
Lots Covered by this Schedule
1 — \ -4
The Planning Board by the signature below, or a signature of a duly authorized representative, do hereby
establish for the above named development the following Development Schedule for the purpose of Section
8.7 of the Growth management By -Law. The applicant, their assignees, successors and or subsequent
property owners shall conform to the following schedule that limits the eligibility of the following lots for
building permits. This form must be filed in the Registry of Deeds by the property owner or representative
and be referenced on each deed for each of the following lots. Such deed reference for the deed of each lot
shall at minimum reference the book and page in which this Development Schedule is filed and contain the.
language; "This lot is subject :o a Development Schedule pursuant to the Town of 'North Andover Zoning
By Law all owners, representatives, and future purchasers should avail themselves of said restriction by
reviewing the approved Development Schedule as filed in Book insert here and Pace insert here. The fact
that a lot is eligible for a building permit is subject to the limitation of the number of building permits per
year pursuant to section 8.7.2d of the Zoning By -Law."
the Planning Board hereby schedule the lot(s) for the above development as follows:
Year Elisibie
Number of Lots Buildin Ot tce Use BuiIdin, Office Use
Elibc-ble Date Lot Eiic--ibiliNotes
COmDletely Utilized
j ,=Y 2 oo3
FY 2ooy
20oS
S
I
t
I
I
I
PI ' giBoard member or Authorized Representative
Date
Si�rrftirre of Property Owner or Auth
Date
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MECcheck Compliance Report
Massachusetts Energy Code
MECcheck Software Version 3.3 Release lb
Data filename: C:\Program Files\Check\MECcheck\Lot 12 Carter Fields.cck
TITLE: Carter Field Lot 12
CITY: North Andover
STATE: Massachusetts
HDD: 6322
CONSTRUCTION TYPE: 1 or 2 Family, Detached
HEATING SYSTEM TYPE: Other (Non -Electric Resistance)
DATE: 05/04/04
DATE OF PLANS: May 4, 2004
PROJECT INFORMATION:
Carter Fields
COMPANY INFORMATION:
Tara Leigh Development LLC
COMPLIANCE: Passes
Maximum UA = 590
Your Home = 576
2.4% Better Than Code
Ceiling 1: Flat Ceiling or Scissor Truss
Wall 1: Wood Frame, 16" o.c.
Window 1: Vinyl Frame, Double Pane with Low -E
Door 1: Solid
Floor 1: All -Wood Joist/Truss, Over Unconditioned Space
Furnace 1: Forced Hot Air, 90 AFUE
Air Conditioner 1: Electric Central Air, 11 SEER
Furnace 2: Forced Hot Air, 80 AFUE
Permit Number
Checked By/Date
Gross
Glazing
Area or
Cavity
Cont.
or Door
Perimeter R -Value
R -Value
U -Factor
UA
1996
0.0
30.0
62
3492
0.0
19.0
245
504
0.340
171
35
0.340
12
1996
0.0
19.0
86
COMPLIANCE STATEMENT: The proposed building design described here is consistent with the building
plans, specifications, and other calculations submitted with the permit application. The proposed building has
been designed to meet the Massachusetts Energy Code requirements in MECcheck Version 3.3 Release lb and to
comply with the mandatory requirements listed in the MECcheck Inspection Checklist.
The heating load for this building, and the cooling load if appropriate, has been determined using the applicable
Standard Design Conditions found in the Code. TIOWAC equipment selected to heat or cool the building shall
be no greater than 125% of the desi load as s ed in Sections 780CMR 1310 and J4.,.V /
Builder/Designer Date l/
MECcheck Inspection Checklist
Massachusetts Energy Code
MECcheck Software Version 3.3 Release Ib
DATE: 05/04/04
TITLE: Carter Field Lot 12
Bldg.
Dept.
Use
[ l
[ l
[ l
[ l
L l
L l
[l
Ceilings:
1. Ceiling 1: Flat Ceiling or Scissor Truss, R-30.0 continuous insulation
Comments:
Above -Grade Walls:
1. Wall 1: Wood Frame, 16" o.c., R-19.0 continuous insulation
Comments:
Windows:
1. Window 1: Vinyl Frame, Double Pane with Low -E, U -factor: 0.340
For windows without labeled U -factors, describe features:
# Panes Frame Type Thermal Break? [ ] Yes [ ] No
Comments:
Doors:
1. Door 1: Solid, U -factor: 0.340
Comments:
Floors:
1. Floor 1: All -Wood Joist/Truss, Over Unconditioned Space, R-19.0 continuous insulation
Comments:
Heating and Cooling Equipment:
1. Furnace 1: Forced Hot Air, 90 AFUE or higher
Make and Model Number
2. Air Conditioner 1: Electric Central Air, 11 SEER or higher
Make and Model Number
3. Furnace 2: Forced Hot Air, 80 AFUE or higher
Make and Model Number
Air Leakage:
Joints, penetrations, and all other such openings in the building envelope that are sources of air
leakage must be sealed.
When installed in the building envelope, recessed lighting fixtures
shall meet one of the following requirements:
1. Type IC rated, manufactured with no penetrations between the inside of the recessed fixture
and ceiling cavity and sealed or gasketed to prevent air leakage into the unconditioned space.
2. Type IC rated, in accordance with Standard ASTM E 283, with no more than 2.0 cfin (0.944
L/s) air movement from the the conditioned space to the ceiling cavity. The lighting fixture
shall have been tested at 75 PA or 1.57 lbs/ft2 pressure difference and shall be labeled.
Vapor Retarder:
[ ] I Required on the warm -in -winter side of all non vented framed ceilings, walls, and floors.
Materials Identification:
[ ] I Materials and equipment must be identified so that compliance can be determined.
L l I Manufacturer manuals for all installed heating and cooling equipment and service water heating
I equipment must be provided.
[ ] I Insulation R -values, glazing U -factors, and heating and cooling equipment efficiency must be clearly
marked on the building plans or specifications.
I
Duct Insulation:
[ ] I Ducts shall be insulated per Table J4.4.7.1.
I
Duct Construction:
[ ] I All accessible joints, seams, and connections of supply and return ductwork located outside
I conditioned space, including stud bays or joist cavities/spaces used to transport air, shall be sealed
I using mastic and fibrous backing tape installed according to the manufacturer's installation
I instructions. Mesh tape may be omitted where gaps are less than 1/8 inch. Duct tape is not permitted.
[ ] I The HVAC system must provide a means for balancing air and water systems.
I
Temperature Controls:
[ ] I Thermostats are required for each separate HVAC system. A manual or automatic means to
partially restrict or shut off the heating and/or cooling input to each zone or floor shall be provided.
I
Heating and Cooling Equipment Sizing:
[ ] I Rated output capacity of the heating/cooling system is not greater than 125% of the design load as
specified in Sections 780CMR 1310 and AA
I
Circulating Hot Water Systems:
[ ] I Insulate circulating hot water pipes to the levels in Table 1.
I
Swimming Pools:
[ ] I All heated swimming pools must have an on/off heater switch and require a cover unless over 20%
of the heating energy is from non-depletable sources. Pool pumps require a time clock.
I
Heating and Cooling Piping Insulation:
[ J I HVAC piping conveying fluids above 120 °F or chilled fluids below 55 °F must be insulated to the
levels in Table 2.
Table 1: Minimum Insulation Thickness for Circulating Hot Water Pipes.
Table 2: Minimum Insulation Thickness for HIVAC Pipes.
Fluid Temp. Insulation Thickness in Inches by Pipe Sizes
Piping System Types Range ( F) 2" Runouts 1" and Less 1.25" to 2" 2.5" to 4"
Heating Systems
Low Pressure/Temperature
201-250
Insulation Thickness in Inches by Pipe
Sizes
Heated Water
Non -Circulating Runouts
Circulating
Mains and Runouts
Temperature ( F)
Up to 1„
Un to 1.25"
1.5" to 2.0"
Over 2"
170-180
0.5
1.0
1.5
2.0
140-160
0.5
0.5
1.0
1.5
100-130
0.5
0.5
0.5
1.0
Table 2: Minimum Insulation Thickness for HIVAC Pipes.
Fluid Temp. Insulation Thickness in Inches by Pipe Sizes
Piping System Types Range ( F) 2" Runouts 1" and Less 1.25" to 2" 2.5" to 4"
Heating Systems
Low Pressure/Temperature
201-250
1.0
1.5
1.5
2.0
Low Temperature
120-200
0.5
1.0
1.0
1.5
Steam Condensate (for feed water)
Any
1.0
1.0
1.5
2.0
Cooling Systems
Chilled Water, Refrigerant,
40-55
0.5
0.5
0.75
1.0
and Brine
Below 40
1.0
1.0
1.5
1.5
NOTES TO FIELD (Building Department Use Only)
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No. Date &
40RTPI TOWN OF NORTH ANDOVER
Certificate of Occupancy $
k436
14U Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
TOTAL
10
I.Check #
A
17393
$ Lt q 30
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Date..... . .......... .......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
Pow.
This certifies that 44 - C ..........
has permission to perform ......... .............
wiri%g in the building of ......... .............. ..............
at ... : ............... ........................................ orth Andover 4das
Fee.AW* ...... Lic. NoW . ..................
Check # AL NSP ECTOR
5301
THE COMMONWEALTH OF
DEPARTNIEWOFPUBI
BOARD OFFIREPREVE W0N1
APPLICATIONFOR PERMET TO
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE P
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION)
Town of North Andover
ISSACHUSETTS Office Use only /�
SAFELY Permit No. V 36 1
�UTAHONS52.7GURI2.-
Occupancy & Fees Checked k
TORMELECTRICAL WORK
HUSSTS ELECTRICAL CODE, 527 CMR I2:00
Date 2
To the Inspector of fres:
The undersigned applies for a permit to perform the electrical wory described below.
Location (Street & Number) CIA
Owner or Tenant ( tJ Cts P -A-Q;,- tt. ,- P,
Owner's Address Z �% ►` ��- til r
Is this permit in conjunction with a building permit: Yes r7�,Ko (Check Appropriate Box)
Purpose of Building s (--(�>C,- t vt-L Utility Authorization No.��
Existing Service Amps/ Volts Overhead = Underground No. of Meters
New Service %+ Amps )'w / vVolts Overhead Underground No. of Meters
Number of Feeders and Ampacity
I Location and Nature of Proposed Electrical Work (1 1 L I/l 0,)s
No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total
f
No. of Lightint Fixtures
No. of Recept4le Outlet
No. of Switch Outlets
No. of Ranges
No. of Disposals
No. of Dishwashers
No. of Dryers
No. of Water Heaters
No. Hydro Massage Tubs
Y
THER-
Swimming Pool Above . r—n Below r1 I Generators
No. of Oil Burners
No. of Gas Burners
No. of Air Cond.
Total
Ton:
No. of Heat
Pumps
Total
Tons
Space Area Heating
Heating Devices
No. of
Signs
No. of
Bailasis
leo. of Motors
Total HP
ivo. or t;mergency i igntmg tsattery units
KVA
KVA
FIRE ALARMS No. of Zones
Total No. of Detection and
KW Initiating Devices
KW NQ, of Sounding Devices
N4'-bf'Self Contained
Detebtion/Sounding Devices
K-1 LocatF1 Municipal Other
Connections
wancet-overages tlualarx>nm mquffu lentsorlvla%a=>se»svax7mt.aws EK
NO Atyh>nummPblicyinchwamgComple� vaa�Oritswostantialegt Aer,t YES NO
avEsubrrritledvafidproofofsametothe0l YESIfyouhavndrcl®dYFSpleareiridirthetypeofcovetageby
R ANCEBOND r7 MHR F-1 (PaseSpecify)
ExpiratkmDate
xktoStart b Z� V)h�onDateRequested Rough ���_EstarlamdVahleofE ralWoiic$
Final
nedmdern 'esofpajuty.
:MNAME C cA-L.- V a LiceMNo.
n,ee J� �C hit- �.t�/`-�,igr>a4n1 Li.No t
Busul Tel No. -
pS AItTe1 No.
I wN R'S INSURANCEWAIVER,iama thattheL mwdoesnothavedrffmmrmcovaageoriNsulastazllialegttivaleM2Sre mu byMassachuserisCff r Laws
that my sigrmkmon this prrtit application waives this mgtmmient „1
:ase check one) Owner ® Agent 1O
Telephone No. PERMIT FEE $ `
Igna ure oT Owner or Tgent
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston; Mass. 02191
Workers' Compensation insurance Affidavit
Name Please Print
Name:
Location:
CityPhone #
I am a homeowner performing all work myself.
a- I 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. Policv #
Company name:
Address 1.
'.H •
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 w
and/or one years' imprisonment_as_we➢_as_ci%il,penattiesin-theformof-a..STOP WORK ORDER.and..a.fine_of.(.$1D0.oD)_adayagaft st_me. 1 r�
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature Date
Print name Phone.#
Official use only do not write in this area to be completed by city or town official'
City or Town Permit/Licensing
❑Check if immediate response is required
Contact
0
Building Dept
p
Licensing Board
R
Selectman's Office
0
Health Department
R
Other
This certifies that ....... ..........
has permission for gas installation ..... .... .........
in the buildings of . ....... . ...........
at North Andover, Mass.
Feek).-.7"�!. Lic. No ........... .. ...... . ......
GkS�INSPE � 0
Check #
4812
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ....... ..........
has permission for gas installation ..... .... .........
in the buildings of . ....... . ...........
at North Andover, Mass.
Feek).-.7"�!. Lic. No ........... .. ...... . ......
GkS�INSPE � 0
Check #
4812
MASSACHUSETTS UNIFORM APPLIC.ATON FOR PERMIT TO DO GAS FITTING
(Type or print)
1ST.
FLOOR
2ND.
FLOOR
Date
8/11/04
NORTH ANDOVER, MASSACHUSE S
FLOOR
5TH.
FLOOR
6TH.
FLOOR
Building Locations 191 Carter
Field d
of 12
Permit#
Tara Leigh Develo ment
1
ner's Name Thomas
Zahoruiko
Amount
New ❑ Renovation ❑
Replacelent
Plans Submitted
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SUB-BASEM ENT
BASEMENT
1ST.
FLOOR
2ND.
FLOOR
3RD.
FLOOR
4TH.
FLOOR
5TH.
FLOOR
6TH.
FLOOR
7TH.
BTH.
FLOOR
FLOOR
i
(Print or type) Check one: Certificate Installing Company
Name EASTERN PROPANE GAS
❑ Corp.
Address 131 WATER ST. , DANVERS MA- 01923
❑Partner.
Business Telephone 1 800 -322 6628 ❑ FinT /Co.
Name of Licensed Plumber or Gas Fitter Brian Kimball
INSURANCE COVERAGE Check
I have a current liability Insurance policy or it's substantial equivalent. Yes ff No ❑
Ifyou have checked Yes, pleasdicate the type coverage by checking the appropriate box.
Liability insurance policy 0Other 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 Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Gas Code and Cutter 42,General Laws.
ity/Town I
OVER (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
Plumber X1210
Gas Fitter License Number
❑ Master
❑ Journeyman
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