HomeMy WebLinkAboutPermits - Permits - (9) Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No.
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev. U07j (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 C R 12,00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 9s
City or Town oh NORTH ANDOVER To the Inspector of Wires.
By this application the undersigned fives notes of his or her intention to perform he electrical w xk described below.
Location(Street&Number)
Owner or Tennant V/` 1;rA e- eleP hone No.
Owner's Address -
Is this permit in conjunction with a building permit? Yes Ej— No
❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Und rd
------ g ❑ No.of Meters
New Service Amps / Volts Overhead❑ Und rd
g ❑ No,of Meters
Number of feeders and Ampacity
Location and Nature of Proposed Electrical Work: r-Ctn
Completion of the follotvin table may he waived by the in eclat o Wires.
No.of Recessed Luminaires 11 No.of Ceff. Susp. (Paddle)Fans No.of Total
Transformers KVA,
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires a,7 Swimming Pool Above ❑ In- ❑ o. o Emergency Lighting
rnd, rnd. Batter Units
No.of Receptacle Outlets /.;I No. of Oil Burners FIRE ALARMS No.of Zones
No.of Switches No, of Gas Burners o. of Detection and
Initiatin Devices
No.of Ranges Na.of Air Cond. Toniota; No, of Alerting Devices
No.of Waste Disposers eat Pump Number Tons No, of Self Contained
Totals: .,............ ..................................... ...............
Detection/Alertin Devices
Faf
washers Space/Area Heating KW Local❑ Municipal
Connection ❑ Other
ers Heating Appliances K`,4r Security Systems:�
er -- of No.of Devices or E uivalent
Heaters KW Na.of Data Wiring:
Signs Ballasts No.of Devices or E uivalent 3
h No.Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring:
OTHER: No,of Devices or E uivalent .3
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: y v Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVE GE: 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 covera is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ND ❑ OTHER
❑ (Specify:)
I certify, under th a and penalt'es of perjury, that the information on this application is true and coi-»pleta
.FIRM NAME: t)m LTC.NO.:
Licensee: oma4S e ebldvc- Signature p-ar LIC.NO.: 33o-q6'
(If applicable, ente "exempt"in th�,license n tuber lime.)
Address: 7 Qto /( f �k�� �e�,r, (J (, D 34S'�3 Bus.Tel.No.:
*Per M.G.L c. I47,s. 57-61,security work requires Department of Public Safety"S"License: Alt Lec,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(cheek one) ❑owner ❑owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE. ,$'
1 E
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
i 600 * zvhington Street
,f Boston, MA 62111
t' www roxass.gov/dia .
Workers' Compensation insitirance Affidavit.- Builders/Contraetors/Electricians/Plumbers
Anplicant Information Please Print Lqibl '
Name (BusinesslOrganization/individual)c::Eo L
Address;
Citystate/Zip: 1�1 V1d.er�^ ,N t Phone#: .
Are you an employer?Cheek.the appropriate box:
Type of project(required):
1.❑ IL eLrn a employer with 4, ❑ 1 am a.general contractor and i
employees(full and/or part-time),* have bred the sub-contractors fi, ❑Now colistruction
&J-rwm a sole proprietor or partner. listed on the attached sheet.t 7. ❑ Remodeling
ship and have no employees These su&contractors have S. ❑Demolition
working for me in any capacity. workers' comp,insurance. g, ❑Building addition
[No workers'comp, insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10•0 Electrical repairs or additions
3.❑ I am a homeowner doing all worn right of exemption per MOL I l.❑ Plumbing repairs or additions
t myself. [No-workers'comp. c. 152, §1(4),'and we have no
insurance-required.]t 12•❑ Roofrepairs
employees. [No workers' ME]Other
COMP. insurance required.]
'Any nppiicant That checks bob#I roust also fill out the section below showing their workers'bomponsation poiicy information,
t Homeowuera who submit this affidavit Indicating they am doing all work and then hire outside conusctors must submit anew Affidavit indicating such,
lConnaators that cheek this box mostattsohed an additional sheetshowfng•the name of the sub-Contractors end their workers'comp,policy information.
1 am an employer that is providing:workeml compensation insuraneefor my employees. Below is the policy and job site
Information.
Insurance Company Name, '
Policy#or Self=ins. Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the warlmrs' 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
E 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 un er the pains and pen 1 s of perjury that file information provided above is rue and correct:
5i ature: 1-1-4-
Date: 9
Phone A. 603 lr3 r 633
EEOther
only. Da not write t►r this area,to be cnmpleted by city or town offietaL
Town: Permit/License#
hority(circle one):
Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5, Plumbing Inspector
son: Phone#;
PERMIT No. 1 Y✓� APPLICATION FOR PERMIT TO BUILD NORTH ANDOVER, MASS. PAGE Y
MAP "0.Zp� LOT NO. ® � 2 RECORD OF OWNERSHIP DATE BOOK PAGE
ZONE SUB DIV_ LOT NO. ^W� E
i
LOCATION PURPOSE OF SUILDING
OWNER'S NAME N&4uu —Oq
r�440 NO. OF STORIES SIZE
OWNER'S ADDRESS 1� SASrMENT OR SL-Kw
ARCHITECT'S NAME / IEZE OF FLOOR TINDERS 1ST 2ND SAD
BUILDER'S NAIVE .+�' SPAN
DISTANCE TO NEAREST [LDING / DIMENSIONS OF SILLS
DISTANCE FROM STREET - PASTS -
DISTANCE FROM LOT LINES-SIDES REAR - GIRDERS
AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS
E
IS BUILDING NEW - - SIZE OF FOOTING X
IS BUILDING ADDITION - MATERIAL OF CHIMNEY
IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM TO REOUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER
BOARD OF APPEALS ACTION. IF ANY 19 BUILDING CONNECTED TO TOWN SEWER
IS BUILDING CONNECTED TO NATURAL GAS LINE
a PROPERTY INFORMATION
INSTRUCTIONS
LAND COST
SEE BOTH SIDES EST. BLDG_ COST .,,,, ,
EST. SLOG. COST PER SQ. F'T. ++v
PAGE 1 FILL OUT SECTIONS 7 - s -
EST. ■LDG_COST P£R ROOM
PAGE 2 FILL OUT SECTIONS 1 - 12
SEPTIC PERMIT NO_
ELECTRIC METEPS MUST BE ON OUTSIDE OF 8U1LOING A APPROVED BY
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVED ■Y RUILDING IN:SPSCTOR
GATE F 11 -p 7
�� iUli�ll vm*pm rc"t
sIG RE OF OWNER OR OREZED AGENT .
DWNERTEL#
Ih L E
- !'lCRMIT aRA:rrco � - VLK ��z-43� _ _- ._.. _-_ -.�• =_��M�'=="�_,.�.
-
- _ k•
�OR7'
Town of ,_ 4Andover
No. AlL Z, * - - = --
doves, Mass., 1977
fl LAKE
�y 4�-00CMCH9wjcx ' r 1•
s R'1 Tg D AP
�G BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
• BUILDING INSPECTOR
THIS CERTIFIES THAT...N or+�T"K.!..Ni.... .�..0�'F .. � !v..�,�r.�L� 41AWt�¢ .
Foundation
has permission to aa•d.......jNC. .... .. ............. buildings on . ?,3. ° R. $ .. ..'`. .L.Ls.'�'+ ........L/. Rough
to be occupied as.........I*Vt64...... -orpm?V ...................................... Chimney
provided that the person 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
PERMtT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTI0 T TS Rough
---------------- ----- •-•---------.•--•-•-•----................-----•-----•--------•-----.... ce
BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Display in a Conspicuous Place on the Premises — Do Not Remove Rough
Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector.
Burner
�vR1`t12 • L !* r Street No.
Smoke Dec.
hoom.JohnT 9rannanJohnT.Brennan&AsocfArchilecl Fax;603-696-0092 Voice:G03893-.im ra Gina at:OR l.auretteloelGyr! Page 2 0t2 ThuAloy 15.97 11:27:11 P61
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?MUM OFFICE
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CUBE
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-- - ' - The Co►nmonivealth of Massachusetts
Departrtretil of bidustrial Accide►tts
T Office ollflyvesifty+lnns
600 Wdshittgio►t Street
Bostotl Mtiss, 02111
C Workers' Compensation Insurance Affidavit
MUM
focation:
IE
❑ I am a homeowner performing all work myself,
I am a sole proprietor and have no one working in any capacity
[) I am an employer providing workers' compensation for my employees working on this job.
c a tot Uw1 1 I"
address:
l V1
b 2
i Ceco. 0 IrCJ OICY�{
r
E] I am a sole proprietor,general contractor, or homeowner(circle one) and have hired the contractors listed below who have
the following workers' compensation polices:
comply nante:
address:-. .
1 H'
insurance co, policy h
address'
h
olio #
Failure to secure coverage as required under Section 25A of AIGL 152 can lead to the imposition of criminal penalties of aline up to$1,500.00 and/m-
one years'imprisonment as well as civil pe nail ies in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a
copy of this statement may be forwarded to the office of Investigations of the DIA for coverage verification.
I do hereby rtif ender the pains and penalties of perjury,that the information provided above is true and correct.
Signature KA
k Date
Print name 0 t� t yr Phone N
Lit
ly do not write in this area to be completed by city or town official
permit/llcense# aBuilding Department
pLlcensing Board
mediate response is required pSclectmen's Office
pllealth Department
n: phone ll; 001her
(revisrd 11%P1A)
afftt•..UfN Only
014E LOum unwealt4 of _liac4m>rtto Perm it No.
Etpartuunt of iluhllc *nfettl Occuptitiay A F"Chod(sd ' }
BOARD OF FIRE PREVENTION REGULATIONS 527 ChMR 12.00 ° Peeve blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK ':
All work to be performed In accordance with the Massacnusetts Electrical Code, 527 CMR 12,00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date
(Z* or Town of NORT14 ANDUTER To the Inspector of kris o;
The,uderaigned applies for a permit to pert ttte electrical work described below.
r Location (Street & Number) �.,� S..•- AJ A"�
G t
Owner or Tenant �no _ �� •',�••�'t
Owner's Address
Is this permit in conjunction with a building permit: Yes No C (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps _J Volts Overhead E Undgrnd No, of Meters ,
New Service Amps Volts Overnead Unagrna C' No, of Meters
Number of Feeders ana Ampacity
Location and Nature of Proposed Electrical Work
No. of Lighting Outlets I No, of Hot -cLs T No. of Transformers Total
KVA ':
No. of Lighting Fixtures I Swimming Pcoi Above.--- In.
Li grra. _ grno. Generators KVA
No. of Emergency Lighting,
No. of Racentacie Outlets No. of Oil Burners 1 Battery Units
No. of Switch Outlets No. of Gas Sufrers FIRE ALARMS No. of Zones
No. of Ranges 1 No. of Air Cana. aiai No, of Detection and
tcns Initiating Devices
No, of Dlsoosals I Na.of Heat Total Tatat
Pumcs tons KW No. of Sounding Devices
No. of Sail Contained t
No. of Oishwasnefs I SoaceiArea pleating DetectianlSounaing Devices '
--- j1w
No. of Dryers I Heating Dev,ces KW Local i Municipal
Connection Connection ' .Olher t
No. at Yo. 31 Low Voltage i
No. of Water Heaters KW Signs Sa,lasts Wiring ;1
No. Hydro Massage 1Lb3 No. of Motors Total HP r Ali`
OTHER:
INSURANCE COVERAGE. Pursuant to Ina requirements or massacni.seas general Laws
I have a current Liaoillty Insurnnco Policy incluaing C.;mciwec Operations Coverage or its substantiel equivalent E NO
have suamitleo vatic proof of same to the Office. YES NO = it you nave checxeo YES. please inaicam Ih _ty a of coverage by
checking the approortate box. /�� ( ,� p _
1/NSURANCE � BOND OTHER Z (Please Scec;�l}-c•7�C1t bAN,c-C, i, Q f�h) -rnywy
(Exotrattbn Oalet
Estimated Valur.91 Electrical WaTR `
Work to Start � ' t Inso c.tGn Gate Racuestec: Rough Final i.
Signea unoar this Pen ties of arlury:
FIRM NAME 7 - (` 1Z LtC. NO. '3-2 — !, r
Licensee �c, tM eZ2 t,fC. NO.
B
Address Vl l C �} /( Ali. Tsl. No. �r�Z `zJ)1. ).Z
f;
[�k OWNER'S tNlSURANCE WAIVER: I am aware that the t_:censee toes not have the insurance coverage or its suostantlal equivalent as (e•
011 1 qu,rea t)y Massacnusetts General Laws. aria that my signature on .nis aermo aopncauon waives this requirement. Owner Agent
(P14aaa check onrl � � ,` 1.
V Teieorone No. PERMIT FEE 3 1- U
(Signature of Owner or Agent) i i
�4
�O R
® of
- = FAndover
®
No. A1 G I.
z _ ^ � lover, Mass., �` /9 _19 e r
° I.-KE
COC HICHEwICK
S BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
• BUILDING INSPECTOR
THIS CERTIFIES THAT AW
......._ ..1 !s.. ... ....1 ... .. .. ... ..r � .. I�i1, • oun tton F da -
has permission toe t....... . .... . ............. buildings on. .0� ..�- .t�i ........L/ Rough
to be occupied as......... i. .....W.! ....4.W.0" ' _. ..................................... Chimney..................
provided that the person 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
PERMIT EMPIRES IN d MONTHS
ELECTRICAL INSPECTOR
UNLESS CONSTRUCTIO TARTS Rough
..... ................... Service
BUILDING INSPECTOR
Final.
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal
No Lathing or Dry Wall To Be Done
Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT
Burner
• Street No.
Smoke Det-
Proposal Proposal No. r
r
FROM Beaudoin Family Enterprises Sheet No.
19 Westminster Lane
Merrimack, N . A . 03054 Date
Proposal Submitted To Work To Be Performed At
Name CEK Properties , Inc . Street Andover Office Park
Street St . Suite 210 City N . Andover State M a
City Date of Plans April 12 , 1993
State Architect John Brennan
Telephone Number 5 08 6 8 b-5 2 21
We hereby propose to furnish all the materials and perform all the labor necessary for the completion of
Proposal excludes all plumbing and HVAC . Project to be completed
no later than July 1 1993 or 30 days after building permit is
issued which ever is later . 1f C/0 is not issued on the above
referred date than the contractor will forfeit $100 . O0 per day .
All material is guaranteed to be as previously specified, and completed in a substantial workmanable manner in
accordance with the drawings and specifications submitted for the above work. In the amount of
Dollars i$ - 54 , 104 . 00� ��.-� �.�.-.�------ J �+Fifty--four thousand one hundred and four, --,,, ,---,,,
with payments to be made as follows,
15% down Payment , 20% after 20 Days . Balance due upon receiving C/O
Any modification or deviation from the above specifications envolving additional charges wil be executed only
upon written orders and will become an extra cost over and above this estimate. All agreements contingent upon
strikes, accidents or delays beyond our control, Fire, tornado and all other insurance to be carried by owner on the
above work. Workmens Compensation and Public Liability Insurance on above work to be taken out by
Beaudoin FamilK Enter rises
Submitted resp tfullyprisesL
Per
Note: This proposal may be withdrawn if not accepted within 30 days.
ACCEPTANCE OF PROPOSAL
The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as
specified. Payment will be made as outlined above.
Accepted Signature
Date Signature
Formadyne Stock Form 8170 The Colonial Co. Brooklyn,N.Y. 11204.
I
nuRry
Gf .•.• Y1
OFFICES OF: . Town of 120 Main Street
APPEALS ' ; �`,t � NORTH ANDOVER North A11dover,
RUIL.ntNc; ';•. w�,: 11d;t4'iFuiltt�it:t,!i��tH4�-,,,
C ONSH.1ZVMIUN s' DIVItiION(W W1 7)GH5.477,
HEALTH '
PLANNING PLANNING & COMMUNITY DEVELOPMENT
KAREN H.P. NELSON, DIIIEC-1.011
lt3 accordance with the provisions of MGL c 40, S 54, a condition of Building permit
Number is that the dcbris resulting from this work shall be
disposed of in a properly liccnsed solid waste disposal facility as defined by MGL e 111, S
150A.
'Ile dcbris will be disposed of in:
9 Alt-0
(Location o Facility)
Signature of Fcrtiit Applicant
9
0��� `
Date
NOTE: Demolition permit from the Town of north Andover must be obtained for
this project through the Office of the Building Inspector.
I
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 sect'on* **************
APPLICANT: (/Phone J3 Z d 'z
{
LOCATION: Assessor' s Map Number Parcel
Subdivision Lot(s)
3
n
Street v 5 St. Number )
1
************************Official Use Only************************
RECOMMENDATIONS OF TOWN AGENTS:
Date Approved
Conservation Administrator Date Rejected
Comments
Date A �pproved i
Town Planner Date Rejected
Comments
i
Date Approved
Food Inspector-Health Date Rejected
Date Approved
Septic Inspector-Health Date Rejected
Comments
"Public Works - sewer/water connections
- driveway permit
Fire Department
w REc ;iYed' by Building Inspector Date
3
E
CERTIFICATE OF USE & OCCUPANCY
Town of North Andover
Building Permit Number 160 Date JUNE 30, 1993
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 203 TURNPIKE STREET Suite 115
MAY BE OCCUPIED AS FIT-UP FOR OFFICES -_ _ IN ACCORDANCE
WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND
SUCH OTITER REGULATIONS AS MAY APPLY.
KOfaTH
CERTIFICATE ISSUED TO Holy Family Hospital - OB/GYN
C/O Claude J. Beaudoin
a ADDRESS 9M 'h Trnni ka Sr- , North Andnypr, M .
F
ytg'
'Sa��uS uildrng Inspector
;`OF;TH
o ��, =off over
- "y / 19
Aox t lover, Mass.,
qpr
AERATE 0A?R\ Al
BOARD OF HEALTH
PERMIT To BUILD Food/Kitchen
Septic System
BUILDING INSPECTOR
6,�
THIS CERTIFIES THAT..... ..:.... ...�...... .4.�.. �. . ..... .. Foundation
has permission to erect.00 4. ...... buildings on.... .A .. �. 1V .S /L�T�r f Rou h C ~3"�,
� -
' g c�C'
tobe occupied as..... .... ........... .. ............... ... .......... ......... ........ .... ............................................................ y
provided that the person 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. PLLTM5ING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit.
PERMIT EXPIRES IN 6 :MONTHS F a
UNLESS) CONSTRUCTION STARTS
E C CAL INSPECTOR
Rouge t\An
�� t
---- ---" Service 1
BUILDING INSPECTOR l
n ��' Fina
Occupac�f F;nnii Required to Ocaq)y Building
OWUAS INSP CTOR
Display in a Conspicuous Place on the Premises — Do Not Remove Rough
Final
No Lathing or Dry Wall To Be Done FIRE DEPAR T
Until Inspected and Approved by the Building Inspector.
Burner
e.PLANNING FINAL j, CONSERVATION FINAL Street No.
` Smoke De[_
QMAfFQ /WATPQ FINIAI nRII/SWAY FNTRY PERMIT 6 ��
MASSACHUSETTS UtAlFORM APPLICATION:FOR.PERMIT:.TOVO #?L1UME11 .
•
(Type or Print) ;" �, ;c ..; ;•,r.; !
NORTH ANDOVER Massa f�;. . Date,
'
Building Location '. t. c) ;k, < ,b :� f,, � r ` �e ,kPermit
Owners Name
New D Renovation j Replacement [ Plans Submitted ❑ ' ` ,
FIXTURE
r;
• w � ..! tr. '.:Q h
_ v�
x
x s
N a rr v
r (� Z tYl
pa o0 W N h W I- a W0 �
o 0a' N a �- d r- 0x a a d a a
w '� a x' � o x x a o I- W ccH a w LL u w '
Y N p :1 sn h x o vs x Y to f, O 0 �
J 4 -� 4 `� VC !c sG 0 "t H y ..
SUB—USIOT.
HASEMEHT
'SST FLOOR )• 1'
2ND FLOOR f :
3RD FLOOR `j�'•
4TH FLOOR !i%t
5TH FLOOR ' ,.fir:,
6TH FLOOR
'lr
TTH FLOOR
IITH FLOORI-A
(Print or Type)
" � Check one; Certificate
Installing Company Name �'� [� Corp. F'
Address Partner. F
�TAC� Firm/Co.
Business Telephone �� 1� _ _� �ozc
Name of Licensed Plumber:
Insurance Coverage: Indicate the type of insurance coverage by checking the
appropriate box: ?
Liability insurance policy n 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 coverages.
Signature of ownertagent of property Owner [D Agen.t''\
S hereby certify Ili at all of the details and Information I have}ubinittcd(or entered)In above application are lout an4\14Curate to(lte bent of Inv
—. - knowledge wd that all plumbing work and installations perfnrnied under rcmiit i%sucd for this application will be in Compliance with all ptrlio;ept p40•.4
V4100S of[tic Mauachusetit State Piumbin Code and Chapter 142 of Me General Laws,
By ,
Title • Signature of Licensed Plumber
City/Town:
Ty a>�of plumbing License. G y
_ c`� � (y� .
APPROVED OFFICE use ONLY) License Number ❑ master Journeyman
BUILDING PERMIT 014 nT eA'bp
TOWN OF NORTH ANDOVER ?`b `'` ,,..,' •6 °
APPLICATION FOR PLAN EXAMINATION
Permit NO: S Date ReceivedAr
��SsacHuS���y
Date Issued: AZ4
IMPORTANT:Applicant must complete all items on this page
K
LOCATION C7
3
P:
PROPERTY OWNER _
Print r.
MAP NO PARCEL ZONING DISTRICT; Historic Disttict yes no
!Machine Shop Village yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
New Building One family
Addition Two or more family Industrial
Alteration No. of units: oC mercial
Repair, replacement Assessory Bldg ers�-
Demolition Other
Septip Well Floadpla�n Wetlands Watershed D' trio
U1laterlSewer
DESCRIPTION OF WORK TO BE PREFORMED:
I — t e S .�
J11 okf_.
Identification Pleas Type or Print Clearly)
OWNER: Name: i o Phone:
Address:
f
CONTRACTOR; Name Phone. ~ +
Address;:..: ,: ' . Y,; _
Supervisor's Construction License, ( (, Exp Date,
Home Improvement License Exp, Date;
ARCH ITECTIENGINEER 't all Phone:_ Sp/ft]Jj_
Address: r. . A Reg. No. �� b
FEE SCHEDULE:BULDING PER IT:$12,00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
ti Total Project Cost: $ � � FEE: U0
1 $
Check No.: Receipt_Receipt No.: ���
NOTE: Persons contracting with urzr•egister•ed contractors do not lzav ess to the zza•arzty fuzz
,3
Signature of AgentlOwner Signature flf cori actor
07/21/2009 09: 35 113-186814 507 LIRETTE 01/01
161B Harry, Brook.XV.
Groff8town, M-J 03045
Phono or Fax(603) 3,14-2076
DATE: 07-17-09
THIS 'ESTIMATE HAS BEENT PrtEPARED FOR: Dr. 1.6'Otte
W(IRK TO B'E COMPLEJED:203 Tw,npike
Permits 700.00
Demo and discard 2500.00
Carpentnj 2300.00
Supply and instal I new door 2400.00
Frame and sh-left-ock 6000,00
New Glazing 2400,00
New Counter tops MOM
Painting waM9 and trini 7800,00
Mool-ing 6000.00
In,owrance mid Materia) included in price wile,,45 otho.rwisc note) abvve,
'Foud est 1 irate flor the work described ahave.
We,thaTik you for y r r t ill loin UM eq�q-M t h u,,,. If'I can be of,any fbitfit'l,
'1 71,11
assistatloo to you 1) 8- I Ctme.
Not valid allT 60 a C, �q�i ate, and return upon atceptame of thl.9
S1 IE DATE
siwxvely, C-I a Ude J Beaudoin
The commonI-Pea t of Massirchusefis
Departmerxt of Industrial.Accidents
Office of znvesdgatkns .
606 ff rashanglan Street
Boston, AL4 #2111
www.mass.gav/dia
Workers' Compensation Fnsitrance Affidavit: gididers/Contractor,/.Eiectriciang/Plumbt;rs
A liicstnt nformation
I
Please Prins Laa7'rbI
N»e (Bu&incsslQrgaalzafiooAndividual); ��
Address: i f
3 �
• City/stste/Zi •
Are an employer?Cheep, a appropriate boz: '
Are
e employer with 4. ❑ I am $ iota Fr
t of prpject(requires:
general contractor and I ' '
employees(full and/or part-litre).* have Hired the sub-aarttracats ❑Ncw coristructiott
2.❑ I am.a.sole proprietor.or partner. listed on the attached sheet.t ]:Remedeling
ship and have no employees" These su&contraetors have
working far mein an capacity, workers' comp. insurance. Damdlition-
Y �' 9. Building aci&an
[No workers,comp, insurance 5. ❑ We are t3 carpotatiom end lts
3.❑ required,] offiam-s have exercised their la,❑'Electrical repairs or additions
I sin a homeawmer doing ail work right of expanption per NtCiL I I.❑Pfumtbingrcpairs oradditions
myself. [Tio workers' comp, a, 15 , §l(4)!'ttrtd we have no
insurance,recluired.11 ,amployees. [No workers! 12.n Roof rapairs
comp. insuranccrequirod.J 13•0.0thbr
'Any appjjmown am that cb=alibmI box a l must also MI out the saaflm boiow chow.ing their.warketi'4ornpenwdion potiey information
t Homeowners who submit this of ii avi!kndloating t1'ey arz doing of i wo*end(ham hire mnsida nantmciom rnuat submit a new affidavit indias' su
Cuntraatuts that Check this box mustatteoyted an artditioaal ahextshow hag such:
inig t he rramm dithe sub-�antrapfors and tlmir work—I camp•potiap infnr=Uon,
I ara e►rplayer that ispanv ug worker:'aurrperxsai ensurmrreforrrD'enrplaye=- Briowv is-the poltcy'wedJob site .
infar»urtiort
lnsuranot Company NameAe
;
policy#or Self ins, laic.#:
Expiration Date:
Jab Site Ad&ass; .
. •CitylStatelZip:
Attach a copy of the workers'�campeuseifan policy declaration page(showing the policy number and expiration date. .
I+aiiure to secure coverage as required under Section 25A of MOL c. 152 can lead to tim imposition of
criminal pemaldes of a
tine uA to$45(I0M and/or one-year imprisonmemt;as well as civil penalties in the form of a 57Y7P WORK ORDER Of up to 5250.pE7 a dV agairist.the violator. Be advised that a Copy of this statement may be forwarded to the,Office of d a fire
Investigations of the IA for insurance coverage verification.
I do 1ere6J' f nder the pains and pcnnnfipr afP.e '
r!w'that the iaformafion provided above is true ana'trarretx
Si tare: \
]'hone#: i
tjcial use only. Da not ware its thb area,to he con ple4ed n5y city or town afficia�
City or Town: Perneit/1 aicAuse#
Is6uing Authority(circle one):
I. ward of Health 2. Building Department 3.City/' O"InClerk 4. Electrical Inspector 5. Plumbing Inspector
6.Oth6r
Contact person:
Phone#•
NORTH
Town of
� s
0
No.k�
, o dover, Mass., 7 ' .31
COC IC r.CK
,q Ao'4areo
`S BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
BUILDING INSPECTOR
�
THIS CERTIFIES THAT.......... ... ..................................................................... ........................................................... Foundation
Us°�/ r �� Srt. ��r to
has petmission to erect---------------------------------------- buildings on.�.�'.-�-.......�.....---�-----------------------................---...--- .� Rough
ik 'rya .�:A"f t /—/.�,�,_r ey
t0 be occupied as �.�
provided that the person 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
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION STARTS Rough
��' —............................. ................ service
` BUII.DING 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.
OFFICE OF BUILDING INSPECTOR
TOWN OF ANDOVER MASSACHUSETTS
CONSTRUCTION CONTROL AFFIDAVIT
PROJECT TITLE: RENOVATION TO EXISTING MEDICAL OFFICE SPACE
PROJECT LOCATION: ANDOVER OFFICE PARK
NATURE OF PROJECT: RENOVATION TO EXISTING 2417 SF MEDICAL OFFICE SPACE,
i
IN ACCORDANCE WITH ARTICLE 116 OF THL MASSACHUSETTS STATE BUILDING COMP,
I John T. Brennan _REGISTRATION NO. 4808
BEING A REGISTERED PROFESSIONAL ARCHITECT DO HEREBY CERTIFY THAT I HAVE
PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS,
COMPUTATIONS AND SPECIFICATIONS CONCERNING:
ENTIRE PROJECT \/ ARCHITECTURAL STRUCTURAL MECHANICAL.
FIRE PROTECTION ELECTRICAL OTHER(SPECIFY)
FOR THE ABOVE NAMED PROJECT AND THAT,TO THE BEST OF MY KNOWLEGE,SUCH PLANS,
COMPUTATONS AND SPECIFICATIONS MEET THE APPLICABLE' PROVISION OF THE MASSACHUSETTS
STATE BUILDING CODE,ALL ACCEPTABLE ENGINEERING PRATICES.
AND APPLICABLE LAWS AND ORDINANCES FOR THE PROPOSED USE AND OCCUPANCY.
I FURTHER CERTIFY THAT I SHALL PERFORM THE NECESSARY PROFESSIONAL SERVICES AND BE
PRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND PERIODIC.BASIS TO DETERMINE THAT
THE WORK IS PROCEEEDING IN ACCORDANCE WTH THE DOCUMENTS APPROVED FOR THE BUILDING
PERMIT AND SHALL BE RESPONSIBLE FOR THE FOLLOWING AS SPECIFIED IN SECTION 116.0
1. Review.for conformance to the design concept,shop drawings,samples and other submittals
which are submitted by the contractor in accordance with the requirements of the wnstruc6on
dacumants.
2. Review and approval of the quality control procedures for all code-required controlled materials.
3. Be present at intervals appropriate to the stage of construction to become,generally familiar
Wth the progress and quality of the work and to determine, in general, if the worts 1s boing
performed in a manner consistent with the construction documents.
PURSUANT TO SECTION 116.2 .2 1 SHALL SUBMIT BI-WEEKLY, A PROGRESS REPORT
TOGETHER WITH PERTINENT COMMENTS TO THE TOWN OF ANDOVER, BUILDING INSPECT R
UPON COMPLETION OF THE WORK, I SHALL SUBMIT A FINAL REPORT S THE
SATISFACtTQRV09jyf LETION AND READINESS OF THE PROJECT FOR ANC
"o per q
�RII SINORM TO B1=FORE ME THIS _ AY OF �_ZU
PH1L 2;
NDTA Y ' LI Q.: '�>�� MY COMMISSION EXPIRES 6