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HomeMy WebLinkAboutMiscellaneous - 640 Great Pond Road rn D �` Z f7 /-U CJ 09789 Date . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . �-!� has permission to perform ..2 plumbing i the buildings f. . Are�-�-pv`.A. . 2. . .;! �PS 4r (� oj at . . .Q . . . . . . . . . .� . . . . . . . . . . ,North Andover, Mass. 8� Fee .Y . . . .��. ."- . . . Lic. No. M I.cj?��3. . . . . . . . . . . . . . . . . . 'x' PLUMBING INSPECTOR Check# ���� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY _ { MA DATE 1 30j PERMIT# 11 JOBSITE ADDRESS r P OWNER'S NAME � � � P OWNER ADDRESS I re g4- o,4 l TEL FAX j TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIAL®� PRINT CLEARLY NEW: RENOVATION:Q REPLACEMENT: PLANS SUBMITTED: YES NOEI FIXTURES 7 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/OILISAND SYSTEM -- DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL ! SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES 1 --- - WATER PIPING OTHER I _ ( 1 .__._..._.1 .__._._� _—( —( -._---( 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 T PE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY I BOND Q 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: OWNEREI 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 compl' nee with 2rtinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE# �- `Id3. SIGNATURE MPzJPQ CORPORATION # EPARTNERSHIPD#r LLC --- COMPANY NAME ,.} pLvM ;aC�' 11 ADDRESS OCo lv i 1 +—AAq,.. CITYn t/_- - -.... .... STATE ZIP TEL FAX L �__ i CELL��EMAIL -- ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# f PLAN REVIEW NOTES z The Commonwealth of Massachusetts Department of IndustriqlAccidints Office of Investigations ip 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/individual): SSSS (,.e��eytQ _ / PAr,qrw:�,••k �l•�M�` �+�P�►�'` '� Address: Q.Ob Nor + AAA,: S*rec_ City/State/Zip:���,,,u , MA . O t S (C) Phone#: `��-�— CA& S Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction loyees(full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet 1 7• RRemodcling ship and'have no employees These sub-contractors have 8. ❑Demolition comp.'coin working forme in any capacity. workers9. ❑ g Buildin addition [No workers'comp.insurance 5. ElWe are a corporation and its required.] officers have exercised their 10.E]Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 13.[i Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew 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. I am an employer that is r idin workers' p ov g workers compensation assurance for my employees. Below as the policy andjob site information. Insurance Company Name:. 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 requiredunder 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 cert der the pai and penalties of perjury that the information provided above is true and correct - Signature: 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 6.Other - - - Contact Person: Phone#: Information and 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 apartments 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 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 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 town 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 thepermit/license number which will be used as a reference number. 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 permits 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 burn 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 Massachvsetts Department of lndustrial Accidents Office of Investigations 600 Washington Street Boston,MA.02111 Tek,#61.7-727-4900 ext 406 or 1-877rMASSAFE Revised 5-26-05 k`ax#61.7-727.7749 www.wass.gov/dia J. COMMONWEALTH OF MASSACHUSETTS �J • • • 1 • • • •.. t^ .-P 'UMBERS A1'+ID GASFITTFRS LICENSED AS A MASTER PLUIIABER: ISSUES THE ABOVE LICENSE TO JESSE D`. LELIEVRE N 'MAIN ST : AN'L10VE`R MA 0 18 To` 3113 15423 05/01/14 18315:1 I • Date//7,d: TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ItIA-Alw . . . .Ala !; . } has permission for gas installation . -I4ei 44-PA... . . . . . . . . . . . in the buildings of. ./�4. . ,?If� . . . .Af (I J-41. . . . . . . . . . . . /v v at . �`. . . . � �./! /P! .. . . . . . . .North A over, Mass. Fee . . . Lic. No. .n.. .I. .. . . .O . GAS INSPECTOR Check# �i� 8430 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY -�?Or �4�' %�� - m�� MA DATEI ADo i ll ;� PERMIT#. JOBSITE ADDRESS 64,-4 f04_ A, OWNER'S NAME I�}/►�I� lv Irx _ GOWNER ADDRESS U KO 6-4noted _ TELF_ _ _� FAX — TYPE OR OCCUPANCY TYPE COMMERCIAL-J EDUCATIONAL © RESIDENTIAL PRINT CLEARLY NEW:[RENOVATION:® REPLACEMENT:��11 PLANS SUBMITTED: YESF--] NDE] APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE �. i 1 _.._I ... ... h .._. .� DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS ( 1 _ _�( isj.=_-{-=l J --_-I MAKEUPAIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT -- 1[ - ..._ �-T TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER L ._ _I - _ tr_ INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 9f0 El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY � OTHER TYPE INDEMNITY [j 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 0 AGENT SIGNATURE OF OWNER OR AGENT 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 GASFITTER NAMEY: �1Py ^�r9 IVICrJ _ LICENSE# /7 � SIGNATOR MP I MGF JP JGF LPGI CORPORATION FJ# PARTNERSHIP D#=LLC F COMPANY NAME: _ +t Clea 1 ..,.►b -� ADDRESS CITY ✓'�1C/,+'n,r}c ... _ STATE .r► ZIP9TEL 1—977 3t1G �ao6 y FAX CELL �`r 7�3�i=`!l? EMAIL '2 ROUGH GAS INSPECTION NOTES THIS PAGE FOR,INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES G� 31:2a//3 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 Applicant InformationPlease Print Legibly Iff Name (Business/Organization/Individual): v i G kic y It,, Address: U a 1C C,rc lc City/State/Zip: P'1 C1nyyA_- ,w►f} DA00 Phone#: Cr4779-- 37r— y/?4 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction en,�ployees(full and/or part-time).* have hired the sub-contractors 2. am a sole proprietor or partner- listed on the attached sheet.t ? 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 required.] officers have exercised their 10.F1Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' i 13.❑ Other comp.insurance required.] .%n541ll 9aJ (r,, *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. fi Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: --C7 Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: U yd Poll A. City/State/Zip: t10.4 4AJ,),>`t.•X­A 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. T do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: 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 6.Other Contact Person: Phone#: r Information and 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 apartments 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 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 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-contractor(s)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 town 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 permit/license number which will be used as a reference number. 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 permits 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 burn 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 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax# 617-727-7749 I www.mass.gov/dia i e GENERATOR APPLIC DATE: LOCATION: �b �'� '� P� ��• OWNERS NAME: 4f7rle lbyI CS GENERATOR kw NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR: EDO Lniellhec+,^4 aKd /x'11- PHONE NUMBER: l - q-7K- joy S-6,0 y ELECTRICAL GAS RESIDENTIAL COMMERCIAL TEMPORARY LOCATION OF GENERATOR: *ZONING DISTRICT: *CONSERVATION APPROVAL i _ ` t, ,� f l . ..� X�+ ,_ `�.c �6 � of � f� Date •,sk'�r.�arcos'�. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies thatG` . . . . . . . . . . . . . . . . . . . has permission to perform . . . . . . . . . . . wiring in the building of - . . . . . . . . . . . . . . . . Pte-&.Q . . . . . . . . .North Andover, Mass. 5 � QM . . . . �-. . Fee . . . . . Lic. No. .► ', EL CTRICAL INSPEC OR Check 922-S4 , 186 , y Commonwealth of Massachusetts Official Use Only Department t of Fire Services Permit No. G e p Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev-1/071 (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN HK OR TYPE ALL INFORMATION) Date: fl 30(Z-b I;;� City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigns4 gi es notice f his or her in tion to per RD the electrical work described below. Location(Street& ber) -r n() Owner or Tenant l C, Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes.�q No ❑ (Check Appropriate Box) Purpose of Building e3 l , n°1 M(MOCOL, 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 ar#kNature of Proposed Electrical Work: Twop Completion of the following table may be waived y the Inspector of Wires. ` No.of Recessed Luminaires No.of Cell:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ No.o mergency ig ting rnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No, of Zones No.of SwitchesNo.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices g Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained P Totals: � Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other P g Connection No.of Dryers Dr Heating Appliances KW Security Systems:* y No.of Devices or E uivalent No.of Water KW No.of No.of Data Wiring: Heaters SignsBallasts of Devices or Equivalent . 1 Bathtubs No.of Motors M10a1hp Telecommunications Wiring: No.Hydromassage No.of Devices or Ea uivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value o Electrical Work: ` (When required by municipal policy.) Work to Start Insl3ections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: nless 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 thpAgins and enalties of perjury,that the infor tion o this application is true and complete. FIRM NAME: . LIC.NO.: Licens Signature LTC.NO.: (If applica enter "e empt"in the 'tens ber line.) Bus.Tel.No.: Address: (�Y�p� �'' �2 Alt.Tel.No.: e *Per M.G.L c. 147,s.57-61,security work requires De artment of Public Safety' 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 PERMIT FEE:$ 55-,"v Signature Telephone No. r ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c.143,§3L,the , permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§ 32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: P L&I ROUGH INSPECTION: Pass Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: 5� Inspectors Signature: Date: Q ROUGH INSPECTION: Pass 0 Faile4 Re-Inspection Required($.) ❑ Inspectors Comments: ' Inspectors Signature: Date: FINAL INSPECTION: Pass M Failed Re-Inspection Required($.) ❑ Inspectors Comments: l ; 0Ile_ olt) Inspectors Signature: Da DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department ofIndustrirtl Accidents Office of Investigations qu 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legib Name(Business/Organization/Individual). c Address: S- City/State/Zip , Phone#: Are yo employer?Check the appropriate box: Type of project(required): 1. a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. E]Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g, Building addition [No workers'comp.insurance 5. El are a corporation and its required.] officers have exercised their 10 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11. Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 13.[i Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors 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. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name:. Policy#or Self-ins.Lic. vy Expiration Date: T3 I Job Site Address C>k VP City/State/Zip: V)o � Attach a copy of the worke 'co pensationpolicy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder 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. IdoIzere ert�Fdermth pas andpenalties ofperjury that the information provided above is true and correct Si ature: Date: Phone#: 72 © ` 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 6.Other - - Contact Person: Phone#: Information and Instruction Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation employees.for their p 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 apartments and who resides therein,or the occupant of the dwelling house of another who employs person 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 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 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 return ed to the city or town 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 permit/license number which will be used as a reference number. 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 permits 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 burn 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 ladustrial Accidents Office o£Investigations 600 Washington Street Boston.,MA,02111 Tel.#61.7-727-4900 ext 406 or 1-877rMASSAFB Revised 5-26-05 Fax#617-727-7749 www.zxmass,govldia - t '•. 1 Fold,Then Detach Along All Perforation. COMMONWEALTH OF MASSACHUSMS, i BOARDELECTRICIANS EL AS AREG JOURNEYMAN ELECTRICIAN. ISSUE TO J {I L EVSE Ti TYPE JARRET. TT -� -E 33 MAR`�� St. ,` RANQ(J.LH ,•,9,, M ^ 0�365 �4 m121S1�11' 871280 25T t E 01/31/13 LICENSE • . EXPIRArION DATE SERIAL NO. Fold Than Detach.Alorq AN Pedw dan F old,Then DafaM Abrp Ag Perfontlona f . .COMM WEALTH OF MASSLIASEFF9;:;.::;':1 • _ _-- BOAR-O i ` ELECTRICIANS = State of Rhode island and Providence Plantations E L �tEGISETERED AISTER ELEG7RICIAN.: Rhode Island Depsrtiment of Labor and Training ISSUE E' L tF(4SE W- r ��• �� i —0 3306 \ BLBCTRICAL CO 0 TYPE Jd[ RE s TTO ELECT1ElIC JOtJRREi SLB P �` s 0 0147 -A � JA►i'RE�{E' TTOGz ;''; ��� - M/ EtIO JARRE? L LOTT MAf 02365 2436 33 MARION ST RADIDOLPB MA 0� .w./ 871279f02 A 07/31/13 871274 LICENSENO. EXPIRATION , SERIAL Na. DAT-FOTT.. Detad;Alortg A- . -� 0 6 L 3 0 i 2 , M Perforations Administrator _- Expiration Date. Fold.Then Detach Along All Perforations CONTROL# H 0 6 6 2 0 8 IMPORTANT If this license is lost or destroyed, notify your Board at the: Division of Professional Licensure, 1000 Washington St., Suite 710,Boston,MA 02118-6100. If your name or address shown is changed, notity your board of correct name or address to insure proper mailing of next Renewal Application. Always refer to your license number. This license is subject to the provisions of the General Laws as amended.It is a personal privilege,and must not be loaned or assigned to any other person. Keep this license on your person or posted as required by law. Date.... NORTH 0 TOWN OF NORTH ANDOVER 0 $ p PERMIT FOR WIRING 4L CHUS This certifies that . has permission to perform ....... wiring in the building of.................... ...... ..... ............................. ............ .......... ......... ..... . . . ... ... . North Andover,Mass. Fee .................... Lic.No.......... ... ......... .. . ....... ... ... ... . ELECTRICAL I PE Check # "" �a °' GSL- � o� / `� r fl\ Commonwealth of Massachusetts Official Use Only Q 66 Department of Fire Services Permit No. �� Occupancy and Fee Checked�0 , 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 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of. NORTH ANDOVER To the Insp ctor of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 690 [� l`t O ®p h d20-1y Owner or Tenant A wA `. -1�, r", Telephone No. Owner's Address �lf�1�,eL��(/ / /fj",, X-'A"L, lq4 Is this permit in conjunction with a building permit? Yes ❑ No g (Check Appropriate Box) Purpose of Building /2X14 C,4- 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 ,6�0-e- 0--JA /ap d, ll-e-� Location and Nature of Proposed Electrical Work: IWA60 u4���",-J G?i✓c� f�JJ AAf—oct �'/o ad� -I Completion o the ollowin table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets a No.of Hot Tubs Generators KVA ' No.of Luminaires Swimming Pool Above ❑ In- El o Emergency Lighting rnd. rnd. Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat PumpNumber Tons KW No.of Self-Contained Totals: ......................' Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent OTHER: Attach additional detail i desired,or as required b the Inspector o Wires. T f 9 Y p .f Estimated Value of Electrical Work: S'-//O. W (When required by municipal policy.) Work to Start: /1h f Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE OVERAGE: 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 F+ BOND ❑ OTHER ❑ (Specify:) I certify,under thepains andpenalties of perju ,that the information on this application is true and complete. FIRM NAME: LIC.NO.: Licensee: J(�A b-f-14 fdt IT Signature �� LIC.NO.: (If applicable,enter "e mpt"in the license number line.) Bus.Tel.No.: f Address: 9? C �/W- A /)I1f,- "-C 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 PERMIT FEE: °, Signature Telephone No. $,?o, Date TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that . . . . has permission to perform . . . rll�.. . . . . . . . . wiring in the building of 'e( ID Cy- . . . . . . . . . . . . . . . . . . at . . . . . . ,North Andover, Mass. Fee 4, --Q--Lic. No. (c.1.�Z� . . . . 41,. }Q ELECTRICALINSRECTOR Check# 7 ' 11223 1 J (forremonweaCtla of Plaijackasetta Official Use Only l 2c� Permit No. ! �� epartment of gire Servicee Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INF RMA, 0 Date: //—1-?�I.: City or Town of: 4 , � To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perforrn the electrical work described b.low. Location(Street&Number�Q" l/it/17 /,3 4"-? Owner or Tenant nn pp � J l�.t4 CL-i.� 7 /L�[r Telephode No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) 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: Completion of the,161lowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA /V No.of Luminaires Swimming Pool Above ❑ In- E] No.o Emergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: `"' ' Detection/Alerting Devices No.of DishwashersSpace/Area Heating KW Local❑ Municipal El Other Connection No.of Dryers Heating Appliances KW Security Systems.* No.of Devices or Equivalent No.of Water Kms, No.of . No.of Data Wiring: e Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent j OTHER: / Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: / r� (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 coverag:,•is in force,and has exhibited proof of same to the permit issuing offic:; CHECK ONE: INSURANCE 0' BOND ❑ OTHER ❑ (Specify:) I certify,under the pains nd enalties of perjury,that the information on this application is true and complete. FIRM NAME: AB viv (5�'L /c LIC.NO.: Licensee: l u"/I) R , , X10 Signature LIC.NO.:�� (If applicab; ente "exe{�pt"i the license runt er ne.)q ,n/ Bus.Tel.No.— Address: OW U E «i ��/�(f 14A t// �� Alt.Tel.No.: '9 7��9 *Per M.G. .c. 147,s. 57-61, ecurity work requires Department of Public Safety"S"License: Lie.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 oris requirement. I am the(check one)❑owner ❑ow'ner's agent. Owner/Agent .-7 PERMIT FEE: $ Signature Telephone No. r ,w a J i Y The �`omrrionilJen:fth o."14 r,s,�r�c r�za,.,sett,s Department of IndustrialAcc°dents ' Office of investigations 600 Washington Street x' Boston, AIM 02111 Y\ \ <. ly ` 1Nwiv.mass.gov1d is Workers" Compensation Insurance Affidavit Please pirin t Name(BusinesslOrgani�ation/Individual): ` (/� 'd `2/� Address*. C' C ,/-SLge/ya° �v 7Erho)ine iso . Are yot^ ata.employer?Check the appropriate lbox.: ll ype of project(required): 1.C7 I am a employer with 4. ❑I ani a general contractor and I 6. [New construction emplo ees(full and/or part-time). " have hired the sub-contractors 2. a sole proprietor or partrrei- listed on the attached sheet. 7. ❑Remodeling ship and have no•employees These sub-contractors have 8. []Demolition working for me in any,eapacity. employees and have workers' 9. ❑Building addition N) o workers'compo insurance compo insurance.t required.]. 5.0 We are a corporation and its 10.0 Electrical repairs or .additions 3. I am a homeowner doing all work officers have exercised their. 1 L[I Plumbing repairs or additions myself..[No workers'compo right of exemption per MCI,c. 12.0 Roofrepairs insurance required,] or I have hired 152, §1(4),and we have no 11[]0ther the contract/,:listed on the attached employees;[No workers,sheet compo insurance requtred.� Any al,,licant that chec„s box#1 must also fill out the section below showing their worken,'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. iContractors 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 thesub-contractors have employees,they must provide their workers'compo policy number. tam aapw.employer haat is providing workers°compeca$c don ivasura pice for my empipyges.Below is the picy apid job site in,0ormca&on. Insur-auce..Co>rrmpany Name: Polity 4 or Sel&ins.Lie: Expiration Date: Job Site Address:a�._a � �._. .� . wcity/state/zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).Failure to secure ;overage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fineup to$1,500,00 and/or one-yeas imprisonment,as well as civil penalties in the form of a STOP WORD 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. Ido hereby certifY er the pains andpenalties ofperjury that the information provided above is true and correct.. Signature: date: Phone: ��� 3�D GENERATOR APPLICATION DATE: LOCATION: OWNERS NAME: GENERATOR kw NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR: PHONE NUMBER: �q-1-7r ELECTRICAL GAS RESIDENTIAL COMMERCIAL TEMPORARY LOCATION OF GENERATOR: *ZONING DISTRICT: *CONSERVATION APPROVAL v`v �- '� Date./P/'?�A . . .. .... ,aORTM 3? TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION SA US 10�/ This certifies that . 1�`!4'!..-r. . . (41.4!r' . . . . . . . . . . . . o . H has permission for gas installation . 4A. ./ f in the buildings of . . . . . .�. . Q. . . j ���! �! . . . . . . . at . l�a. / � t� . . . . . . . . Nortthh,,Andover, Mass. Fee. . ca? Lic. No.Z�/�!1 . . �Jl ?�4!'. �►f?�/'?r?`t. . . GASINSPECTOR Check# 7860 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: }lo.-„ A✓►c u"— , MA. Date: Q r Permit# Building Location: Owners Name:_i0jim �a Type of Occupancy: Commercial❑ Educational ❑ Industrial ❑ Institutional❑ Residential❑ New: U Alteration:❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes❑ No❑ FIXTURES re ui LU w co co Z x � W 0 0 H ui O w x U m x W � F- � O W w C7 J Z F- _ >- � '— co O IM Lu W � i 0 z z 0 W W W W 0 � Y W U) W m 0 F- W 0 Q X Lu W ~ W Q W W W ? 0 x W W 1— a x U: Z V W Z O J 1— F-O Z J C7 li x Z W W R O R W Q a' W W m > O z O N F Z x V o o LL C� 0 x x 0 a. H > > > O SUB BSMT. BASEMENT ) ' 1 FLOOR i 2 FLOOR 3 FLOOR 4 FLOOR 5 FLOOR 6 FLOOR 7 FLOOR 8 FLOOR Installing Company Name:_ Ali i.A5 Check One Only Certificate# El Corporation Address:—10A—as L rc City/Town:_rnP�'i iv,b4r State: IMb Business Tel: 1`x(76'--3"7 J'- L//16 Fax: El Partnership Name of Licensed Plumber/Gas Fitter: k4l.2 El Firm/Company [Allability SURANCE COVERAGE: ave a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes❑ No❑ ou have checked Yes,please indicate the type of coverage by checking the appropriate box below. insurance policy ❑ Other type of indemnity ❑ Bond ❑NER'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 Signature of Owner or Owner's Agent Owner ❑ Agent ❑ By checking this box❑;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. =(OFFICE Type of License: ❑Plumber �. Title ❑Gas Fitter Signature Licensed Plumber/Gas Fitter ❑Master City/Town ❑Journeyman License Number: (� ❑LP Installer 9 1 5 9 Date.,/P`/ —k. . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING -TS HUS /' ll'' This certifies that 4,!y� , . Al,.; . . . . . . . . . . . . . . . . . . . has permission to perform . .1761.4'4 . . )?` plumbing in the buildings of .�41f. !. . C'TQ4G'�.��I• P �/l; g .f.44j'... r 6� �� at. .lv. .G. . . . . . . .aK �./. . . ., North /And/over, Mass. Fee.� ,dC?.Lic. No.ZS/.7�. . ./. 4Sr/ v-.f?. . . . . . . . . PLUMBING INSPECTOR Check # �✓ Do MASSACHUSETTS UNIFORM APPLICATION FOR PER TO DO PLUMBING City/Town: A dl j p`v rv- MA. Date: G C� _ 11 Permit# Building Location: t Irey[ -%� 4 1� Owners Name:I�cl�i�S /�dye o,^,�- »rn��bo�� C�li Type of Occupancy: Commercial[] Educational[❑ Industrial❑ Institutional[] Residential New:�" Alteration: ❑ ❑ Renovation:❑ Replacement: ❑ Plans Submitted: Yes❑ No[] FIXTURES ^/ cr DEDICATED �lJ ? SYSTEMS 1` > z �' y a Q cn _ iii O Y ¢ U � t- w z = z cr �„ Z Q Q w (D cr z w F w p m vxi rr LU 13 in Q htn h O } Q Q rr w ¢ Yx O cr w ❑❑ ° w w `� Z " a U LL x Q ¢ F- v_xi v`ai O F- u Q 0 0 a Y ¢ x w w o'J O w L Q ¢ Z v� F- cu LLJ Q m m ❑ ❑ LL-SUB BSMT. "' x 3 O ¢ BASEMENT 1 11T FLOOR 2ND FLOOR 3RD FLOOR 4'FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR 8'FLOOR p Installing t;rii-ript&fly Name: VIA!; Check Qne Carl:, Address: -3 oQ k EJ Corporation City/Town: 11'�C'sr;i'►� c State• M 6 Business Tel: �`y jlY' ��`� V/7( Fax: ElPartnership Name of Licensed Plumber: B El Firm/Company INSURANCE COVERAGE: 1 have a current liability,Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.942 Yes El If you have checked Yes,please indicate the-type of coverage by checking the appropriate box below. No E]A liability insurance olic policy.❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does the insurance coverage required b Chapter Massachusetts General Laws,and that mysignature on this permit application waives this requirement. Y p r 942 of the Check One Only Signature-of Owner or Owner's A entOwner ElAgent E] 1 hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and „r - , Knowledge and that all p[��mbing work and instalfatior,s performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 742 of the General Laws. a afe to t� of my 3y Type of License: 'itle ❑Plumber Signature o Licensed Plumber :ityn,own ❑Master PPROVED(OFFICE USE ONLY) (Journeyman License Number: (� Q 7 The Commonwealth ofMassachusetts Department oflndustrialAccidents Office of Investigations, 600 Washington Street Boston,MA 02111 5� www assgovldia Workers' Compensation Insurance Affidavit: /E Bui tiers/Contractorslectricia A licant Information ns[Plumbers Please Print Le ibI Name(Business/organizatiolAndividual): Address: 3 v g It C;rc (c .City/State/Zip: iN�C rr,'v%►✓,fie v9 Phone#: c// F.EII an employer?Check the appropriate box: a employer with f7 0 4. Type of project(required):loyees(full and/or part-time).• ❑hae hired the ub-hcontrac orrs* 6. ❑New construction a sole proprietor or partner- listed on the attached shgaet.t 7. ❑Remodeling and have no employees These sub-contractors haveing for me in any capacity, workers'comp,insurance8. Demolitionworkers'comp.insurance 5. ❑ We aie a corporation and its9 ❑Building addition red.] .officers have exercised their 10.❑Electrical repairs or additions a homeowner doing all work right of exemption per MGL 11 [❑Plumbingrepairs or additions lf. [No workers'comp. c. 152,§1(4),and we have no ance required.]i employees. 12.❑Roof repairs [No workers' comp,insurance required.] 13.❑Other Homeowners *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. who submit this affidavit indicating they are doing all work and then hire outside contractors 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. -ram an employer that is providing workers'compensation insurance for my information. employees Below is thepolicy andjob site Insurance Company Name: �U<�,rnti_ ��u✓ ,�.. Policy#or Self-ins.Lic.#: f Expiration Date: Job Site Address:_ o 116 U ✓C� City/State/Zi : v Attach a copy of the workers'compensation policy declaration page(showing the policy number d expirationr-- 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 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. r do hereby cerci y under the pains andPenalties of PerJurthat the information provided above is true and correct. ii nature: � �..w,,, 6 r Date: av G/ one#: (' �� � 8 7S `'Il � 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 S.Plumbing Inspector 6.Other Contact Person: ' Phone#: Information and 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 apartinents and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work o p n 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 compliance with the insuranc6 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 acceptable of public work until . P p ble evidence of coin-fiance with the insuranc requirements of this chapter have been presented to the contracting authority." e P 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 town 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 permit/license number which will be used as a referencd number. In addition an applicant that � pp must submit multiple permit/liceuse applications in any given year,need onlysubmit one affidavit indicating current policy information(ifnecessary)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 a applicant as proof that a valid affidavit is on file for future permits 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 burn 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 COnruonwealth o,i Massaejusetts Depaftent of Industrial Accidents Office of Investigations. _ 600 Washington Street Boston}MA 02111 Tel-#617-727-4900 ext 406 or 1-877 MASSA � Fax#61.7,727-774.9 Revised 5-26-OS - Www.mtass.govfdia Date. I..... TOWN OF NORTH ANDOVER PERMIT 'FOR WIRING This certifies that .....& .....Q':UI ............................ has permission to perform ....Ale.... ................... wiring in the building of...Iveo..els],A-ew...aov ............ at -FA4.......&.... North Andover,Mass. Fee. ............ Lic.No..I�?�';.....-116........ . .... . . .. . ....... ECMTRI� INSPE QQ Check 1 10413 r . � ,� t . .�. . .. �' a :�� tjf + ` ' \ � .-. ..-,i,. s (fommonwea&of)&JachWetfi Official Use Only cc�� cc77 Permit No. vlJeparfinenf ol.}ire�eruices Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (ieave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),5277 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: City ci r Town of: t/0/e/ 69 d l"F?L— To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 9'—//o Owner or Tenant Al Z7(/&N/e� �OGd,¢ Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No E (Check Appropri.ae Box) 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 Naturt of Proposed Electrical Work: Completion of thefiollowing table may be,waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Mot Tubs Generators KVA No.of Luminaires Swimming Pool Above ® n- E] o.o ' mem rgency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners. FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners / No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total g Tons No.of Alerting Devices No.of Waste Disposers eat PFemp umber TonsW No.o Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection Security S stems:* No.of Dryers Heating Appliances KW t's' y No.of Devices or Equivalent No.of Water K`,1, No.of `" t' No.o Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.J Devices or E uivalent OTHER: ,) Attach additional detail if desired,or as required by the Inspector c.:'Wires.. Estimated Value of Electrical Work: V(J (When required by municipal policy.) Work to Start: 10' -- / Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVLRAGE: 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;nr its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibite4roof of same to the}mriit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: 1)44/t Z� 7/�? r _ LIC.NO.: Licensee: '7 ,3iv/ Signature LIC.NO.: (If applicabl tern VXe int a li ense number line. Bus.Tel.No.: Address(p-%% (�5� G ,f� � f�l d��t Alt.Tel.No.: *Per M. 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. B,,, my signature below,I hereby waive this requirement. I am the(check,)Pe' ❑owner ❑owner's agent. Owner/Agent �'E�21►1j7 FEE: $ Signature Telephone No. �+ The Commonwealth of Massachusetts Department of Industrial Accidents pari Office of Investigations 4 t 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information f _ Please Print Legibly Name(BusinessIOrganization/Individual): ✓�l/G �i�C/u/� �Z �i� Address: City/State/Zip: l /�f���/�,'�l�g d�9 Ph®ne#: . �7e Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 4. I am a general contractor and I 6. ❑New construction employees(full and/or part-time). * have hired the sub-contractors 2. am aassole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity, employees and have workers' 9, Fj Building addition [No workers'compo insurance compo insurar.;.e.t I0.❑ Electrical repairs or additions required.]. 5.0 We are a corporation and its 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself.[No workers'compo right of exemption per MGL c. 12.❑Roofrepairs insurance required.] or I have hired 152, §1(4),and we have no 13.00ther the contractor listed on the attached employees. [No workers' sheet compo insurance repuired.l Any applicant that checks box#1 must also fill out the section below showing their v,orkers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hit it outside contractor&must submit a new affidavit indicating such. ;ontractors 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. the sub-contractors have employees,they must provide their workers'compo policy number. am an.employer that is providing workers'compensation insurance for my employees.Below is the policy and job site iformadon. rsurance Company Name: olicy#or Self-ins.Lie: Expiration Date: ob Site Address: City/State/Zip: ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).Failure to secure Overage 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 ie-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 relator.Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage -iftcation. to hereby certifY under the pains and penalties of perjury that the information provided above is true and correct. piature: Ae���� Date: one: a Date.." ` a' f NORTI{, 3?�°`�``�• "�o� TOWN OF NORTH ANDOVER PERMIT FOR WIRING r �,SSACNUSEt This certifies that ~ has permission to perform ..69d 0 4"' e.... (f°�9�� . ................. wiring in the building of... .... at.......... i ........... ........... ,North Andover,Mass. ..5 Fee ' ' : ................... ............. .......... . ...... .. ELECTRICAL INSPECTOR Q Check # 7442 Cormnw¢ah o�Ma9ac�� Oficial Use Only 2eParowd of- ire Service4 Permit No. BOARD OF FIRE PREVENTION REGULATIONS [Rev]p/07j y and Fee Checked (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC) 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: b City or Town of: rll - ,Aol).e . To the Inspector of W res: By this application the undersigned gives notice of his or her 7",:; tioperform the electrical work described below. Location(Street&Number) Q Mq� Owner or Tenant ��`��v j ,�� �tz{ Cwt; Telephone No.G'j 7j�P r� Owner's Address v Is this permit in conjunction with a building permit? Yesv❑ No (Check Appropriate Box) Purpose of Building l3e.S/ Le- Utility Authorization No. Existing Service /U* Amps ,l,�,,o Volts Overhead ❑ Undgrd No.of Meters _L New Service cPG v Amps f /d v Volts Overhead Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion o the followingtable may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- El Battery o Emergency Lighting rnd. rnd. Batte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No.of Zones No.of Switches No.of Gas Burners o.of Detection an Initiating Devices No.of Ranges No.of Air.Cond. Total No.of AlertingDevices Tons No.of Waste Disposers Heat Pump umber Tons KW No.of Self Contained Totals: ".'."""""""""""'""""""""'"' Detection/Alerting Devices No.of DishwashersSpace/Area Heating KW Local❑ Municipal [I Other Connection No.of Dryers Heating Appliances KW Security No Systems:* f Devices or E uivalent No.of Water Kms, No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Eq uivalent No. Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent OTHER: 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: 616lu 7 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 cove age is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 0 BOND ❑ OTHER ❑ (Specify:) I eerti fy,under the pains and enalties of perjury,that the information.on this application is true and complete. FIRM NAME: r24,6 f/pq Z��� C/4,// ' C LIC.NO.:J;L cFG 1 Licensee: Li ' .J.- �f?' j' Signature LIC.NO.: (If applicable,enter"exempt"in the license umber line.) 61W4 Bus.Tel.No.•r'7 /oo- �'`�? Address: �77 L-</4/,4' AA C /i,aa 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:$ S� I \ Location V No. 1 � `� Date 4 " d t10RTM TOWN OF NORTH ANDOVER p Certificate of Occupancy $ Building/Frame Permit Fee $ AcMuse� Foundation Permit Fee $ _Other Permit`eek $ S J 0 pmt)'Sy � ALL connection Fee $ -- `- NORTHWater Connection Fee $ �— TOTAL $ � 992 { 'DEC 1 6 Building Inspector Div. Public Works PER31IT NO. 3 Gc�! �,� APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 AMAO. LOT NO. 2 RECORD OF OWNERSHIP ;DATE BOOK ;PAGE SUB DIV. LOT NO. ION, v 6 fLCRT' =PQN- K-D._ _,pV p �ULk1�krt URPOSE OF BUILDING D P-51 DE�CE � ,-) 0�S 'NAME �1 NO. OF STORIES l SIZE !/l/�VMkt:S ADDRESS J1 p� BASEMENT OR SLAB J 1 - ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD S NAME —tO5 PAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES-SIDES REAR " " GIRDERS AREA OF LOT _ FRONTAGE HEIGHT OF FOUNDATION THICKNESS 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 REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES EST. BLDG. COST PAGE 1 FILL OUT SECTIONS 1 . 3 EST. BLDG. COST PER SQ. FT. PAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER ROOM , SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY 1 ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DAT FIL D BOARD OF HEALTH SIG T E OF OWNER OR AUTHORIZED AGENT FEE 00 PLANNING BOARD PERMIT GRANTED r 6 19 BOARD OF SELECTMEN BUILDING NSPECTOR 7�� WHITE: Building Dept. CREAM: Assessors CANARY: Treasurer 1 BUILDING RECORD 1 j OCCUPANCY 12 , SINGLE FAMILY I STORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- APARTMENTS I RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE d 1 2 13 CONCRETE BL'K. PINE BRICK OR STONE HARDW D PIERS PLASTER DRY WALL UNFIN. 3 BASEMENT AREA FULL �I FIN. AREA y, = �/1 �/, FIN. ATTIC ATTIC AREA NO B M'T FIRE PLACES HEAD ROOM - 1_II MODERN KITCHEN WALLS I 9 FLOORS gAPBOARDS 8 1 2 3 DROP SIDING CONCRETE �_ WOOD SHINGLES EARTH AlM*irT SIDING HARDV✓'D _ ASBESTOS SIDING _ COMMON VERT. SIDING ASPH. TILE _ STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. & FLOOR _ BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING I STONE ON FRAME _ SUPERIOR I� POOR _ ADEQUATE NONE j ROOF 10 PLUMBING - GABLE I HIP BATH 13 = GAMBREL MANSARD TOILET RM.M. 12 FIX.I FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR "- — TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE _ FORCED HOT AIR FURN. TIMBER BMS. &COLS. _ STEAM STEEL BMS. & COLS. _ HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING RADIANT H'T'G UNIT HEATERS GAS 7 NO. OF ROOMS -OIL B'M'T 2nd _ ELECTRIC 1st 13rd I NO HEATING r t Georgetown Chimney Sweep 218 Andover Street Georgetown, MA 01833 352-2222 Date c, l 'Z._+ 1t 2— Name TO dA ajo U,�Cpy&-�4t CLU" Address pAb-c.6 Lt Yla.L�Quv� � o184s' vv"d o l �s m iG. nnAc t ` cQ .c,vli L QIA 01 *AI.c 8 � � � t - o Wit., 314 a sv` Uj CLL m '-A ry", 4-j-d-L4 4i;:L i LO, 1 WOOD STOVE INSTALLA110N CHECKLIST �� ►.)i�' II�):�,3 -(�l' Permit A building permit is required for the installation of any solid fuel burning appliance. The building permit and installation inspection are limited to the stove installation and not to the stove construction. Stove n A. New Used x B. Type/radiant . Circulating C. Manufacturer keo _Lab. No. UOZ)r-_feW(C.tTEP-5 L -% Name/Model No. SNF KWW-0 Collar size 4o, 9'J! Dimensions/Height 1 le It Length VOL Width 1 Chimney x A. New Existing B. Size(flue area) 1(O"'Ll�a•'' _ ______ C. Other appliances attached to flue(Number and flue size) __t�S2NE D. Prefab(Manufacturer—name and type) N►IA _� _ E. Masonry/Lined Unlined _ Type 3 manulacturerr F. Height(refer to diagrams) ftd_.la` cap S TA lrJLIES E STEEL OVER ICr -fie, MIN. 3 M1410'10175 35 Alta. \ 1z -�- MIN. Ig"MIN. -- (F1)EL,:4 1 n HEARTH CHIMNEY HEIGHT Hearth(non-combustible) A. Materials S61.VE STO Q& t" 3:OSOLATED "E AA�N E.Yt1LWS16-J B. Sub-floor construction C. Minimum dimensions(refer to diagram) 18" IN r-(Z.o,,) of sTavC) 1d '` ot') SLOES cy( StaJE Clearances and Wail Protection(see stove installation learances chart) A. Type of wall protection provided �`-; '1 i�R �0 116 B. Clearances(refer to diagrams) Asa ftff t FIREPLACE CORNER WALL/CENTER 13 + �s F� i , pl," s'. .`s;{i,.{�Tv 1i •e, a.� " 1.$4F•`. ..� '4�•t`. � '11ex;��r,�r7 �a e-1e may:{..t�• iS► r t . . .�,�� s��..` �,?• ye. f.'1 "L rl�i •;a.�3ditt{i�i,i1 n.,<f.s,_,;.e...-.._... s.• a114LGSS P.19G GoEs T-o FiKST' existing fireplace Damper removed 171 LG i. and chimney 1 ~ non-combustible seal shield protects mantel connector w/cleanout Note:Condensation may build up resulting woodburnin in connector pipe.dete- 9 rioration. Frequent stove inspection should be. performed--18"---I Figure 9.3 TYPICAL STOVE CONNECTED INTO FIREPLACE DAMPER 4 existing fireplace damper removed and chimney shield protects mantel non-combustible fireplace closure w/access for cleaning i woodburning stove clean-out door Note:An excessive •_18" build-up of creosote /Z 11117771111A may occur in the 7l'. . • •D v •d •a fire- Place. Frequent ins e c- ca tion and cleaning may be required. Figure 9.4 TYPICAL STOVE CONNECTED INTO A FIREPLACE CLOSURE 11 a i HomuuEr VTib , UL LISTED HOMESAVER" OVALFLEXT* OVAL FLEXIBLE STAINLESS STEEL f , �4RRt�ME RELINING PIPE 4 4pp%I�oj vrh n The first oval.relining system appropriate Adaptors, Boots, oohs 9 " UL Listed to the 1777 Standard, and hardware pieces,and you' �-HomeSaver OvalFlex is the done. " superior oval pipe on today's In fact,the whole system of ;. market. It is manufactured_to OvalFlex,RoundFlex, `y the sam"e.018"4-ply certified)' RectangleFlex(pages 42–48). 304-stainless specs that have j and Adaptors,Insert Boots,an,made UL Listed RoundFlex hardware pieces allows you to (pages 42 and 43)unsurpassed build whatever type of direct o in both quality and popularity. positive connect system you It also comes with a lifetime need.lust mix and match—it warranty for woodburning modular in nature. N' + applications.See page 41 for We also carry OvalFlex in iN_. warranty details. tE�1S 316-stainless alloy.You'll find i With HomeSaver's V2"-wide featured on page 48.(22) to sero OvalFlex you don't have to tear �`gptahca out damper frames when �Stp11t1pr relining most flues.lust run 4 the OvalFlex through the damper,hook up the