HomeMy WebLinkAboutACFrOgBP18Cjrlsol2TEvYi2Wu7ysTzgvODPqEe...KT_8lg9scKxreg_aintbVR3hbhm10KQzf8tAI= 2
Location Date
No.
TOWN OF NORTO ANDOVER
o s
Certificate of ccupancy
Building/Frame Permit Fee $
C Foundation Permit Fee $
other Permit Fee
-ro'TAL
Check #
Boding Inspecior
Date ........,...
TOWN OF NORTH
PERMIT FOR WIRING
�CHUS�
I
This certifies that .................
has permission to perform ......... �
wiring in the building of.............. .... ...: .::::......................
t... ...:...:
......,Lic.NO. —,.... ... ........ ��,� r� S
r w q North
L Andover,
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ELECTRICAL 41SPECI OR
Check #
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Commonwealth of Massachusetts Official Use Only
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Department of Fire Services Permit No. _
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] {leave blank}
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC) 527 CMR ] Oo
(PLEASE PRINT IN INK OR TYPE ALL WFORMATTON) Date:
City or Town of: NORTH ANDOVU To the Inspector of Wires:
By this application the undersigned Ivesnotice ofAis or herintention to perform the electrical work described below.
Location(Street&Number) Ca CJ 4--)
Owner or Tenant ���``e
Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes ® No ❑ (Check Appropriate Box)
Purpose of Building O 1 !1\ Z _ Utility Authorization Na.
Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters
New Service Amps 1 Volts Overhead ❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
8 6�
Completion 2f the followin table may be waived by the Inspector of Wires.
No. of Recessed Luminaires No.of Ceii:Susp. (paddle)Fans No.°f otal
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above In- ❑ o.o Lighting
ig g
rnd: nd. E Battery Units
No. of Receptacle Outlets F
cer ar%.1U uU1 Ur1-b rucE ALAR1MiS INo. of Zones
No.of Switches No,of Gas Burners No. of Detection and
Total —'Initiatina Devices
No.of Ranges No.of Air Cond, Tom No. of Alerting Devices
No.of Waste Disposers eat Pump Number Tons_ KW No.of Self-Contained
Totals: Detection/Alertina Devices
No. of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other
Connection
No. of Dryers Heating Appliances KW Seeurity D Systems:*
evic or Equivalent
No.of Water No.KW Na. Sign Ballasts Data Wiring:
No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring-
OTHER:
No.of Devices or E uivalent
`
Attach additional detail ifdesired, or as required by the Inspector of Wires,
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties a perjury, that the information on this application is true and complete. f
FIRM N C' sA L LIC.NO.:
Licensee: � Signature LIC.NO,:
(If applicable, enter "exempt"in the license number line.) Bus.Tel.No.: LDS C
Address: Alt,Tel.No.:
*Per M.G.L c_ 147,s. 57-61,security work requires Department of Public 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. PERMIT FEE: , r
The Commonwealth of Al,&ssachusetts
Department of Industrial Accidents
,1_ Office of Investigations
.,• t,, 600 Ff ashington Street
`Null
Boston, MA 02111
t I www-mass govIdia
Workers' Compensation Insurance.k idavit: Builders/Contractors/Liectricians/Plulmbers
A licant Information Please Print Le6ib1
Name ($usiness/Organization/Indivi dual):
C� d C
Address:
City/State/Zip: 1 e� \
� `� � � ` Phone #: '2�_Y�6
Ayou an employer?Check the appropriate box:
l. l am a employer with� 4. ❑ I am a genera.[ contractor and 1 Type of project(required):
employees(full and/or part have hired the sub-contractors 6 ❑ New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. Demolition
working for ine in any capacity. workers' comp. insurance.
[No workers' comp. insurance 5. ❑ We are a corporation and its 9. ❑ Building addition
required.] officers have exercised their 10:❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MOL l l.❑ Plumbing repairs or additions
myself [No workers' comp, c. 152, §1.(4), and we have no
insurance required.] t employees. [No.workers' 1?'❑ Roof repairs
comp, insurance required.] 1.3.❑ Other
*Any applicant that checks box N I mast aiso fill out the section below showing(heir workers'compensation policy information.
Hun-ownors who submi his Orglavit lndicatina they art deing ai3-*0--.'a::d.then hirtnw» ;;;e„^,n":T'uci'
+Corrvactots that check this box must attached an additional sheet showing the name oft he sub contractors and heir workers, aaof i vir indicating such,
F P cy information.
I am an enipic yer that is providing workers compensation insurance,for my employees.
information Below is the policy and job site
insurance Company Name: _ 1 � —CC
Policy#or Self ins. Lie.#: c �1�_.�i� , �- Expiration Date: P_2" --p
Job Site Address:° 1 '� �15 S _ 2- 09
City/state/Zip.
Attach a copy of the workers' compensation policy declaration pace(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a
tine up to$1,500.00 andior one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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 hereh)certi y under the pains and penalties of perjury that the information provided above is true and correct
Siprtature: Date:
Phone#: C)
Official use only. Do not write in this area,to he.completed by cit)>or to wn official
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person: Phone#:
Date. . .. . . . . . .. . . . .. . . .. .
q,OWYH .."
OTOWN OF NORTH ANDOVER""
M1Q PERMIT °a l
� 5 1
�5SA 05��� f
This certifies that � � . . .
L
has permission for gas installation
in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
t . . . . . , . . . . . . . . . . . . . . ... . . . North Andover, less.
;
Fee. . . . . . . . . Lic. No., , . , . . . . . . . . . . . . . . . . . , .
GAS INSPECTOR
Check#
r-
MASSACHUSETIS UNIFORM APPUCATON FOR PERMrr TO DO GAS FITTING
(Type or print) Date y
NORTH ANDOVER, MASSACHUSETTS
Building Locations
Permit#
$
Owner's Name Amount
New El Renovation Replacement ❑ Plans Submitted ❑
Gxl '
&i Z W C x Z C dr O F
U rzt O d
a Z CF a m Z q Z �+ C
w
SiJ MEN T u rx p C6 per„ G
SASEM ENT
1ST. FLOOR
2ND . FLOOR
3RD . FLOOR
4TH . FLOOR
STH . FLOOR
6TH . FLOOR
7TH . FLOOR
8TH . FLOOR
(mint or ivuce - -
Name LL 1 ' ' , Check one: Certificate Installing Company
Corp.
Address 7 ca
C ElPartner.
Business a ep one
Firm/Co.-
Name of Licensed Plumber'or Gas Fitter
FINSURANCECOVERAGE
t liability Insurance'policy or it's substantial equivalent. YeeSck�a�ne;
ecked ves,please indicate the type coverage by checking the appropriate box. No�nce policy Other type of indemnity 0 Bond
Owner's Insurance Waiver: I am aware that the licensee does not the Insurance coverage required by Chapter 142 ofthe
Mass. General Laws,and that my signature on this permit application waives this requirement.
Signature of Owner or Owner's Agent Check one:
Owner Agent13
hereby certify that all of the details and information 1 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 Massacht
ksetts Mate Gas Cooke and Chapter.142 of the General Laws.
By: Signature of Licensed Plumber Or Gas Fitter
Title 0Plumber
City/Town,
Gas Fitter icense um er
_ APPR4vED(OFFICE USE ONLY) ❑ Journeyman
Date. . . , .. . . . . . . . �
l
TOWN NORTH
PERM
IT FOR PLUMBING
"f"his certifies than . , . . .
has permission to perform
plumbing in the buildings of , . . . . . : . .'. . .
at , . . . . . . . . . ', ,�:.. . . . . . . . . . . , North Andover, Mass.
Fee. . . Lic, Flo
. . . . . . . . .
PLUMBING INSPECTOR
Check #
r
MA.SSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER,MASSACHUSETTS
Date
Building Location— Owners Name '/� t Permit#
Amount
Type of Occu anc
New Renovation Replacement Plans Submitted Yes Na
Li
F TU S
z
z
W
Lo E� d `�C7 W W
& -
MILCM
5]HHJDM
L9M FLOCR
%gH
(Print or type) Check one: Certificate
Installing Company Name « •, 1 A° C
Corp,
Address l 'L'L "
Partner.
Business Telephone r Firm/Co.
Name of Licensed Plumber:
Insurance Coverage• Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity Band
11 Li
Insurance Waiver: 1, the undersigned,have been made aware that the licensee of this application does not have any one of the above
three insurance
Ygnature Owner 13 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 Massa uset State P umb' g Code and Chapter 142 of the General Laws,
By: 2gna ure or �.ac se um er
Type of Plumbing License
own
Title
City/'
rcense urn Ter Master ourneyman
APPROVED(OFFICE USE ONLY
BUILDING PERMIT Ole
p,ORTMitLeo r6q+o
.,Z, ya.,sd. y.,.,, •a ��
TOWN OF NORTH ANdVI=
APPLICATION FOR PLAN EXAMINATION �
Permit NO �� Date Received
Date Issued: S US
„ IMPORTANT: Applicant must complete all items on this page
;LO0AT1O"N ,?
ANE
°1 tint
PIAP 11 : AR EL: Ot llfi IC p1 TRIC T: istoric/District yes no
Machine'shop Vlllae des no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
New Building One family
Addition Two or more family Industrial
: eratioi7' No, of units: Commercial
Repair, replacement Assessory Bldg Others:
Demolition Other
Septic Well Floodplain , etlancls Watershed District
"Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
OWNER: Name; id ntificatiarn Tip rPriant Clearly) Phone: ;
Address:
CONTRACTOR Name: Phone:
Address:
Supervisors Construction, License. E p, ;Date:
"Horne improvement License: Exp. Date.
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BULDIMG PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ FEE: $ IDO
Check No.: Z" ) 2 Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner Signature of contractor
Location
Svc,. l` '` Dat
0 �
Certificate of occupancy $
3 cam# Building/FramePermit Fee ,L '
Foundation Permit Fee $
Other Permit Fee
TOTAL $
i
Check #
r
Building inspector
NORTH
Town of
0
: - � r„
No, -_
- � POO,
dover, Mass., d
T O - LAKE �. T
I� COCHICMEWICK .
7 AERATED PPS`
BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT 44'0.......�� `...........�.. .... ............................... ............................................. Foundation
has permission to erect...... buildings on .. . .........Sso.A.P.,......... .. Rough
to be Occupied as Chimney
p ....
provided that the per on accepting this permit shall in every respect conform to the terms of the application on file in Final
this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of
Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
06 -- PERM T' EXPIRES IN 6 MONTHS
ELECTRICAL INSPECTOR
UNLESS CONSTRUC AR S Rough
....................
Service
BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing, or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector, Burner
Street No.
SEE REVERSE SIDE Smoke Det.
The Commonwealth, of Massachusetts
Department of Industrial Accidents
JAL
Office of Investigations
600 Washington Street
Boston, MA 02111
-/J www-mass.zov1dia
Workers' Compensation Insurance Affida-vit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/individual):
Address:
City/State/Zip: .
Phone#:-47 7T—
Are you an employer?Check the appropriate box: Type of project(required):
1.n I an a employer with 4. ❑ 1 am a general contractor and 1 6. n New construction
employees(full and/or part-time).* have hired the sub-contractors
2.0 1 am a sole proprietor or partner- listed on the attached sheet, 7. E] Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity, workers' comp, insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. We are a corporation and its
officers have exercised their 10.n Electrical repairs or additions
3. ama homeowner doing all work right of exemption per MGL I Ln Plumbing repairs or additions
myself. [No workers' comp, c. 152, §1(4),and we have no 12.n Roofrepairs
insurance required.] t employees. [No workers' 13.❑ Other
. comp, insurance required.]
*Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information,
t Homeowners Who subniil,tbis of fidavit indicating they ajt ulaing ai'r work and then hirc,outside,contractors must submit a now affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name ofthe sub-contractors and their workers'comp,policy information,
I am an employer that is providing workers'compensation insurance for ny>emplqlvees. Below is the policy and job site
information.
Insurance Company Name,
Policy#or Self-ins. Lie.#: 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 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.
I do hereby certify under the pains andpenalties ofperjuiy that the information provided above is true and correct
Signature: Y,Aw_�Avu, Date:.
Phone#:
Official 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 Clerk 4. Electrical Inspector 5. Plumbing Inspector
G. Other
Contact Person: Phone#:
cf NonxM TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
1600 Osgood Street Building 20, Suite 2-36
°+,r.°'�,. North Andover,Massachusetts 01845
1$$�caus�
Gerald A.Brown
Telephone(978)688-9545 j
Inspector of Buildings
Fax (978)688-9542
HOMEOWNER LICENSE EXEMPTION
Flean pript
DATE: �C v u
JOB LOCATION:
Number Street Address MAP/Lot
.HOMEOWNER g�1&
Dame Home Phone Work Phone
PRESENT MAILING ADDRESS M on
City Town State Zip Code
The current exemption for"homeowners"was extended to include owner-occupied dwellings to two units or less
and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the
owner acts as supervisor). State Building (Code Section 108.3.5.1)
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended
to be,a one or two family structures. A person who constructs more that one home in a two-year period shall not
be considered a homeowner.
The undersigned"homeowner"assumes responsibility for compliances with the State Building Code and other
Applicable codes,by-laws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department
minimum.inspection procedures and requirements and that he/she will comply with said procedures and
requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Revised 10.2005 1
Fom7 Homeovm ms Exemption
1
1
110ARDOF \PPF;:V.S6$8-Q54A CONS FIZV,VIION(M-9 53 0 1 1EALTH 0"-9i40 PLANNIV3688-9535
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