HomeMy WebLinkAboutMiscellaneous - 8 Bixby AvenueL
Location
No.'S��>-1
Check # 1 �L
%/663
w� cQ
Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $'
Foundation Permit Fee $ k
Other Permit Fee $
TOTAL
Building Inspector
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATIO
2 lrz ��1
Permit NO: l (� Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on this page
P
LOCATIO
PROPERTY OWNER flUy�_ IC-'�$
Print 100 Year Old Structure
MAP NO: PARCEL:%2- ZONING DISTRICT: Historic District
Machine Shop Villa
yes no
yes no
yes I no
.TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
❑ One family
❑ Addition
El Two or more family
El Industrial
❑ Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
Demolition
❑ Other
❑ eptic ❑ Well ;.
❑ Floodplain El Wetlands
❑ Watershed District
❑ Water/Sewer
OWNER: Name: �
DESCRIPTION OF WORK TO tat F t:M1 uEtmtu:
44,4d
Please Type or Print Clearly)
D
r
Ph
Address: P3 7 CN xJolenf
CONTRACTOR Name:QW-41 yE _CdiJ. ,• Phone: (P/ 7, 510 • F 3 Z
Address:
Supervisor's Construction License: Exp: Date:
Home Improvement License: Exp. Date: -
ARCHITECT/ENGINEER A/ / • Phone:
Address: Reg. No. ,
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ y�^� FEE: $
Check No.: 1L+2- Receipt No.: a 7513
NOTE: Persons contracting with unregistered contractors do not have access t he and
Signature of Agent/Owner. 1 mature of contracfor
Plans Submitted LJ Plans Waived ❑ Certified Plot Plan ❑ Stampede lans ❑
Plans Submitted ❑ Plans Waived ❑: Certified Plot Plan ❑ Stamped Plans ❑
_TYPE O1':S] WERAGEDISPQSAL" `
Public Sewer
Tanning/Massage/Body Art ❑ . -
Swimming Pools ❑
Well ❑
Tobacco.Sales ❑
-Food PackaginglSales ❑
Private (septic tank, etc:_ ❑ . :.
Permanent impster on:Site ❑
THE- FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED
PLANNING & DEVELOPMENT ❑
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE:APPROVED
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: :Comments
c
Water & Sewer Connection/Si_gnature & Date Driveway Permit
DPW 'Tow -0 Fngineer: Signature:
Located 384 Osgood Street
FIRE DEPARTItf E" - Terhp Dump;s�.er on site yes no
Located7bt 124 Mair Street
-Fire Departm&it signatureldate °w
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The Commonwealth of.Massachusetts -
Department of Industrial Accielents
Office of Investigations
6#0 Washington Street
.Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Ynsurance Affidavit: Builders/Cont°actors/Blectricians/Pliiinbers
Applicant Wormation Please Prim Ledbly
Name (BusinesslOrganization&dividual): C.L/ — %
City/State/Zip: X- Phone #• 6217, J5fy ' �' 3 Z S/
Are you an employer? Check the appropriate' box:
:1� am. a employer with 4. El am a general contractor and I
employees (faff and/or part time) * have nedthe sub -contractors
2.0 I am a sole proprietor or partner-
_ ship and`haveno.employees
working forme in any capacity.
[No workers' comp. insurance
required.]
3. [1 1 am a homeowner doing all work
myself. [No workers' comp.
insurancerequired.] i
listed on the attached sheet. 4
These sub -contractors have
workers' comp. insurance.
5. ❑ We area corporation and its
officers have exercised.their
right of exemption per MGL
c. 152, §1(4), andwehaveno
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. [] Remodeling
8. [[ Demolition
9. ❑ Building addition
1011 Electrical repairs or additions
11.[] Plumbing repairs or additions
12.[] Roofrepairs
ME] Other
xAny applicant that checks box must also fill out the section below showingtheirvrorkers' compensationpolicy u>tormanon.
t Homeowners who submit this affidavit indicatingthey Are doing all work and then hire outside contractors must submit a new affidavit indicating such.
TContractors that checkthis box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
X am an employer that is vYoviding worker s' eompeizsation insurance fo.-my employees Below is thepolicy andlob site
information.
Insurance Company
Policy 4 or Sol£ -ins. Lic.
Expiration Date:
lob Site Address: 1 3 Z —64 A"T VAs"%S� ` V City/State/Zip:—Ar—I/—/t
Attach, a copy o#the workers' compensation -policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requiredunder Section 25A ofMGL o.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
ofup to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of.
Investigations ofthe DIA- for iinsurance coverage verification.
Massachusetts - Department of ubiic Safety
Board of Building Regulations and Standards
Construction Supenisor
License: CS-049896
NHCHAELJ CRO IN •�
211 BOXFORD ST M`
N ANDOVER Mk 018 1{-'.
�✓ l )1"1 i1 \\
Expiration
Commissioner 10/20/2014
Dimension -
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
-Total land area, sq. ft.:
ELECTRICAL: Movornent of.Meter locat on,'niast or service drop requires approval of
Electrical Inspector Yes No
DANGER.Z®NE LITERATURE:. Yes No
MGL -Chapter 166.Section 21A. -F and G min.$100=$1000..fine
NO 1 ES and DA I A — II -or deoartrnent use
LJ Notified for pickup - Date
Doc.Building Permit Revised 2010
Building Department
-- 'T -he folliwing is a list of the required.forms to be filled out'for:the.appropriate.permit tube obtained.
Roofir g. , Siding, Interior Rehabilitation Permits
❑ ' Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or G.S.L Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the apw• al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submAted with the building application
Doc: Doc.Buhding permit Revised 2012
Date ...... —�
...........................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ...................... /�G-��
...............................................................................................
has permission to perform .M f1. . , `4' /-71 L
....................................................................................
wiring in the building of .............. �eE...... ..............
,# at ..........��............/.� / X g / ......................: ,North Andover, Mass.
�'ee ... � Q .g!v�--
ELECTRICAL INSPECTOR
Check #
12309
At
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. I
Occupancy and Fee Checked
[Rev. 1/071 (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code C), 527 CMR 12.00
(PLEASE PRINT INNK OR TYPE ALL INFORMATION) Date: c
City or Town of: NORTH ANDOVER To the Inspector of yYires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) 5�' h \,N�S
Owner or Tenant
Owner's Address
Telephone No.
Is this permit in conjunction with a building permit? Yes [jj' No ❑ (Check Appropriate Box)
Purpose of Building 9,.0 t� ,,�jZ A'C-- 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:
k6LAA
Completion of the following 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 q,/
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑In- Elo.
rnd. rnd.
o mergency Lighting
Battery Units
No. of Receptacle Outletsl
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burgers
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Dis posers
p
Heat Pump
Totals:
Number
Tons
KW
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal E] other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
,No. of Devices or E uivalent
No. of Water KW
Heaters
No. of No. of
Signs Ballasts
Data Wiring:
o. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
T lecommunications Wiring:
No. of Devices or Equivalent
OTHER:
8S?
CD Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: IS -00 , (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE C E: 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 covert is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
I certify, tinder the pains and penalties ofperjury, that the information on this application is true and complete.
FIRM NAME:. h,�, A4 ytr,— LIC. NO.:
Licensee: AI SignaturA LIC. NO.:
(If us
applicable, ent "exempt" in the license numbe ne.) B. Tel. No. • % t6 L
Address: �_� 0 3 Alt. Tel. No.:
*Per 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.
❑ 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 M
Failed 1fl
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass 0
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSP TION:
Pass IN K,
Failed
Re- Inspection Required ($.) ❑
Inspectors Comm ts:
e'
l
Inspectors Signature:
Date:
FINAL INSPECTION:
Pass
Failed (]
Re- Inspection Required ($.) ❑
Inspectors Comment
Inspectors Signature:
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com
The Commonwealth ofliMassachusetts
Department oflndustriglAccidents
Office of Investigations
600 Washington Street
Boston, MA. 02111
www.massgov/clia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/fndividual):
Address: nn t
`n �
City/State/Zip: FQ %,% c S71V!Q OA a3 Phone #: 01 7 6"Z ----
Are y an employer? Check the appropriate box: -
Typo of project (required):
1. I am a employer with k2
❑ I am a general contractor and I
6. ❑ New construction
employees (full and/or part-time) *
have hired the sub -contractors
�
7• modeling
2. El am a sole proprietor or partner-
listed on the attached sheet.
ship and'have no employees
working for me in any capacity.
These sub -contractors have
workers' comp. insurance.
8. ❑ Demolition
g, ❑ Building addition
[No workers' comp. insurance
5. ❑ We are a corporation and its
10.❑Electrical repairs or additions
required.]
3. ❑ 1 am a homeowner, doing all work
officers have exercised their
right of exemption per MGL
11.❑ Plumbing repairs or additions
myself. [No workers' comp.
c.152, § 1(4), and we have no
12.Q Roof repairs
required.]
insurance . re uired
employees. [No workers'
1311 other
comp. insurance required.)
'Any applicant that checks box#1 must also fill out the section below showingtheir workers' compensation policy information.
Homeowners who submit this affidavit indicating they gie doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is thepolicy and job site
information.
Insurance Company Name: �Ai,) UJ 06L91S
Policy # or Self -ins. Lic.
Expiration Date:
Job Site Address: Z City/State/Zip: /Vn , A
"Attach a copy of the workers' compe sation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as xequired.under Section 25A ofMGL o. 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 maybe forwarded to the Office of
'Investigations of the DIA for insurance coverage verification.
I do hereby cert under the pains and penalties ofperjury that file information provided alove is true and correct.
")s o
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
PermffMcense 0
Yiz".tI(H
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 Instructiolm"s
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 ofpublic 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 maybe submitted to the Department of Industrial
Accidents for confnmation 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 off cially 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 fox 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:
Tho CO MMORMalth ofMassarliwu is
Departmeiat of.indusWal Accldonts
OBice of1"Ostigatiom
600 Wasbixt&a Street
Boston? MA 021 X X
TO, # 617-727-4900 Qxt406 or- 1-87?MMASSA'.,
Revised 5-26-05 Fax -� 617-727;7749
'vv_macc antrfi�ia
10509
Date.y--.V� . ..
-,Oq
,6 V
.........
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
TAik � r 1 C- 12 �-' r-14
This certifies that .......................... ......
has permission to perform ....................
..................... ......... ....... i�
plumbing in the quildings of ... ..... .................
at t ..... ..... &.! n ................................ North Andover, Mass.
FeA.1,50 ... Lic. No. .13.75V.0 M.
( ..............................................................
PLUMBING INSPECTOR
Check #
MASSACHUSETTS
UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUFOBIN!G WORK
� I �W�i
CITY �` /.�t�/DA E � MA,. T PERMIT #
I JOBS! i E ADDRESS — s
OWNER'S -
'NLA -IME
OWNER ADDRESS:
TYPE OR TEL
: FAX
PRINT OCCUPANCY TYP COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL ❑
CLEARLY NEIN: ❑ RENOVATION: ❑ REPLACEMENT: P_**"'
_ PLANS SUBMITTED: YES ❑ NO ❑ i
FIXUTRES 1 FLOORS -y Bsmt 1 1 1 9 1 z I i t
BATHTUB
CROSS CONN DEVICE
DEDICATED SPECIAL WASTE SYS
DEDICATED GAS/OIUSAND SYS
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYS
DEDICATED WATER REUSE SYS
DISHWASHER
DRINKING FOUNTAIN
FOOD WASTE GRINDER UNIT
FLOOR / AREA DRAIN
INTERCEPTOR INTERIOR
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/ MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
N
INSURANCE COVERAGE 111 1
I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES W/N0
If you have checked YES please indicate the t Te of coverage by checking the appropriate box below. ❑
LIABILITY INSURANCE POLICY
OTHER TYPE INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER: I am aware_ that the licensee does_ not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
SIGNATURE OF OWNER OR AGENT
CHECK ONE ONLY: OWNER ❑ AGENT ❑
JI I hereby certify that all of the details and information I have -submitted (or entered) regarding this a licatio
Knowledge and that ali plumbing work and installations performed under the permit issued or this ap i ation wi e in d m f ante to
best t' my
Provision of the Massachusetts State Rumbinc Code and Chapter 142 of the General Laws,
p all Pert'
PLUMBER NAME: V (_
LICENSE r gp SIGNATURE' COMPANY NAME: AVL /YJfj ADDRESS:
ESA
R SAA.) QR
CITY: LLC'
STATE: ZIP:
FAX:
TEL: QdHa171-K05/� , CELL:4aEMAIL: _
MASTER [v]' JOURNEYMAN ❑ CORPORATION
!� ®PA,RTiJERSH'IP LLC ❑ t I1'1
3
DIVISION 0- p130FESSIONAL LIFE~
LICENSE N YY,, EXPIRATION DATE SERIAL NO.
DIVISION 0irkOFESSIONAL LICENSURE - 130ARD OF
LICENSE
LICENSE NO
EXPIRATION DATE SERIAL NO.
4vjo 9i; A
FIESSIONAL UCENSURE - BOARD 0E-
.5,
PH
411MVU
EXPIRATION DATE
s
f NORTH 1
�r p Town of North Andover
It Machine Shop Village Neighborhood Conservation District Comrnission
�,'°.r •��t<y
1600 Osgood Street North Andover, MA 01845
SSACHUSE
Application For EXCLUSION From Certificate to Alter
Certain alterations are exchtded from review by the Machine Shop Village Neighborhood
Conservation District Commission i t accordance with the Bylaw. Applicants for exempt projects
must fill out the form below and subtnit to the Commission Chairperson (contact info below).
Date: 3/ 13 ) f1 3
Contact Name & Address:
-- MARK k A T TC Pfl-T-IF (Ova-tf2w(2�rI OPU _
33 wl�L
Not�FLt A��atie,— �E}
Project Address: �y6 i IA5e Ave
Project Description (attach additional pages, if1needed): , ,9
n1,1 � I t fe y
h,16c S t ji n cis rcip Rerrvt t'+ re
r ? 7 Bax :& wrt 4wJ wA Uasy
Exclusion From Review Requested For: Qkxk
❑ 1. Interior Alterations
❑ 2. Stortn windows and doors, screen
windows and doors.
❑ 3. Removal, replacement or installation of
gutters and downspouts.
❑ 4. Removal, replacement or installation of
window arid door shutters.
❑ S. Accessory buildings of less than 100
Square feet of floor area.
❑ 6. Removal of substitute siding.
❑ 7. Alterations not visible from a public
Way.
C�
8. Ordinary maintenance and repair of
architectural features that match the
existing conditions including materials,
design and dimensions.
❑ 9. Replacement of existing substitute
doors, substitute siding or substitute
windows with new materials that are
substantially similar to the existing
condition.
10. Replacement of original fabric
windows or doors with substitute
windows or doors that maintain the
architectural integrity with respect to
form, fit and function of the original
windows or doors.
11. Reconstruction, substantially similar in
exterior design, of a building, damaged or
destroyed by fire, storm or other disaster,
provided such reconstruction is begun
within one year thereafter.
MSV NCDC Page 1 Current Chair: Lia Fennessy, 77 Elm Street, lizettafennessvC yahooxom, 978-688-2915
J
If
NORTH 9
OE t".. ,ei ti0
02 y- - ` °A Andover
Town of North
Machine Shop Village Neighborhood Conservation District Commission
�qs A,rEoW���c5 1600 Osgood Street North Andover, MA 01845
SgcNuS
Application For EXCLUSION From Certificate to Alter
For Items 9,10 or 11, provide the following documentation:
Photos/drawings of existing doors, windows or siding, as applicable
X Description/Catalog Cuts of proposed materials to be used for doors, windows or siding
Plan and elevation of reconstruction for Item 11
Determination:
This project is determined to be
X exempt
O not exempt
from review by the Machine Shop Village Neighborhood Conservation District Commission. Projects
that are not exempt must complete the Application for Certificate to Alter, available from the Building
Department and be reviewed by the Commission.
Determination made by:
'4`
Signature
Lizetta M. Fennessy
Neighborhood Conservation District Commission
27 March 2013
Date
MSV NCDC Page 2 Current Chair: Liz Fennessy, 77 Elm Street, lizettafennessy(d�yahoo.com, 978-688-2915
M
BROSCO
8
BROSCO Window Units
Windows shown with optional Wood Grille patterns.
Rough Opening 2'-0" 2'-3"
'Glass Size 6' 7'
rM
LLLI
171711
3'-1" 12'41T - -
3'-5" 13'-1' j 8 6' x 8' -
3'-9" 13'-5' 19" - T x T
4'-1" (3'-9' 110' - -
4'-5" 14'-1' j 11 ° - -
4'-9" 4'.-5'112' - -
VA" 14'-9' 113" - -
5'-5" {5'-1' j 14" - -
5'-9" 1,5'-5-115-
6'-1"
5'-5'$15"6'-1" [5'-9' 916" - -
BROSCO
2'-6" 2'-9" 3'_O" _3•_6"
6 5/e _ 2 -9 5/s _ 3 3 5
2/a
_.a. _9. 10: 12"
FM
8'xT 9"x7' — —
8'x8' 9"x8' 10'x8' —
8'x9' 9'x9" 10'x9' —
8'x10" 9"x10' 10'x10' —
8'x11' 9"x11' 10'x11' —
8'x12' TOT 10'x12' —
8'x13' 9"x13' 10'x13' —
9'x14' 10'x14" —
9'x15' 10'x15' 12'xIT
10' x 16' -
Unit Dimensions, other Rough Openings
and Unit Options can be found at the end
of this Double -Hung Section.
Replacement Sash Available
`Glass sizes are approximate.
Low "E" Energy Panel Tilt'N Clean Unit-
Rough Opening_
1'-1 U'
2'-6"
3
Sash Opening-md
1 75/e_'_
provide better energy efficiency.
_2'-9" _
_
'Glass Sae
16'
24'
27'
Energy ►
1
Energy Panel. Energy Panels
i+
3'-5" (3'-1' ;16'
16'x 16'
24' x 16'
—
4'-1" j3' -9'j20'
—
24'x 20'
-
4'-9" �4'-5' t 24'
—
24' x 24'
2T x 24'
Windows shown with optional Wood Grille patterns.
Rough Opening 2'-0" 2'-3"
'Glass Size 6' 7'
rM
LLLI
171711
3'-1" 12'41T - -
3'-5" 13'-1' j 8 6' x 8' -
3'-9" 13'-5' 19" - T x T
4'-1" (3'-9' 110' - -
4'-5" 14'-1' j 11 ° - -
4'-9" 4'.-5'112' - -
VA" 14'-9' 113" - -
5'-5" {5'-1' j 14" - -
5'-9" 1,5'-5-115-
6'-1"
5'-5'$15"6'-1" [5'-9' 916" - -
BROSCO
2'-6" 2'-9" 3'_O" _3•_6"
6 5/e _ 2 -9 5/s _ 3 3 5
2/a
_.a. _9. 10: 12"
FM
8'xT 9"x7' — —
8'x8' 9"x8' 10'x8' —
8'x9' 9'x9" 10'x9' —
8'x10" 9"x10' 10'x10' —
8'x11' 9"x11' 10'x11' —
8'x12' TOT 10'x12' —
8'x13' 9"x13' 10'x13' —
9'x14' 10'x14" —
9'x15' 10'x15' 12'xIT
10' x 16' -
Unit Dimensions, other Rough Openings
and Unit Options can be found at the end
of this Double -Hung Section.
Replacement Sash Available
`Glass sizes are approximate.
Low "E" Energy Panel Tilt'N Clean Unit-
BROSCO's Low "E" Energy
-
Panel is available on most
3
single thick glass (SSB) units to
provide better energy efficiency.
5 %
'Note: Energy Panel Sash are
Low "E"
uniquely profiled to accept the
Energy ►
Energy Panel. Energy Panels
Panel
cannot be applied to existing
Nl,
SSB sash.
='I Ile BROSCO Window Units
BROSCO
CasingOptions OPTIONS
P (Primed) ) Clear Cedar
Brickmould Casing Flat Casing
(standard) —11h6" x 33/4° Head & Sides
11/4" x 2" (Primed Composite)
(Primed Composite)
—11/16" x 51/4' Head & Sides
—11/16" x 51/4° Head Casing
w/ 11/16"x 33/4" Sides
(Primed Pine)
Main Sill w/Standard Sill
Nosing/Connector
(Primed Composite)
(Included with Basic Unit)
Extension Jambs
(Clear Pine)
69/16" Wall
(applied or K.D.)
Wood Grilles
Shipped K.D. and Poly -bagged
complete with fasteners
(picture grilles are set-up).
14
Flat Cape Cod
Casing
11/16"x 41/2"
(Primed Composite)
Main Sill
w/Optional Historic Sill
Nosing/Connector
(Primed Composite)
s
0000<
I a w
1,
Flat Casing
—11/16" x 33/4" Head & Sides
—1'/n" x 33/4" Head Casing
w/ 11/16" x 33/4" Sides
• Naturally decay resistant Clear
Cedar Sill
• Sill and casing completely caulked
• Casing applied with stainless
steel fasteners
Moulded Urethane Window
Head & Trim
Insect Screen
White aluminum full screen with plastic
comers and charcoal fiberglass mesh
Cam Sash Lock
4
White is standard.
Brasstone is optional.
Long Sill Horns
On "NO CASING" orders,
33/4" homs will be used
unless otherwise specified.
--- Simulated
i�4 ... Divided Light Sash
Available
Wood or Composite Sash
Contact your
BROSCO Dealer
'r /oE
Date . GJ �...... .
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ..1) % Uy 14 / � d` �.
has permission for gas installation ...'?? .I. a! s.��
..............
in the buildings of ...........................
at ... .. /,.y & x ................ North Andover, Mass.
Fee..�4? .. Lic. No.` YC.r.... .. ....
GAS INSPECTOR
Check # 'V ?
5179
.*
MASSACHUSErIN UNIFORM APPUCATON FOR PII NUr TO DO GAS FnTING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building LocationQ
s v -t t4�� AV 17-- -
r
Date 7—/L'�),5
Permit # S l %9
Amount $ ..5 a
Owner's Name ^ .,ke-
New ❑ Renovation ❑ Replacement Ef Plans Submitted ❑
(Print or t ) _ Check one: Certificate Installing Company
Y!� Pe (
Name �� fcl cz '� r V ''v^ L c °'�9 ❑ Corp.
Address O a A`I°r_ A-1 E'FjrnVCO
arIner.
usiness Te ep one 7� 1/ yi 3 7
Name of Licensed Plumber or Gas Fitter u ✓�
INSURANCE COVERAGECheck o
I have a current liability Insurance policy or it's substantial equivalent. Yes f No ❑
I- d 1 dicate the t e coverage by checking the appropriate box.
If you have chec a yes, p ease n yp ❑
Liability insurance policy Other type of indemnity ❑ Bond
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner ❑ Agent ❑
I hereby certify that all of the details and mtormation i nave suormrreu kur cnrcrcu� ,11 auwc ayN„LaL,tj„ ME; «u�, auu a., u.—« L., L„�
best of my knowledge and that all plumbing work and installations performed upoer Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts Stat*eeoCapter 142 of the General Laws.
OVED (OFFICE USE ONLY)
Signature of Lice ed PlumbOr Gas Fitter
❑ Plumber
Gas Fitter License Nu7mer
Master
❑ Journeyman
4TH. FLOOR
5TH. FLOOR
6TH. FLOOR
(Print or t ) _ Check one: Certificate Installing Company
Y!� Pe (
Name �� fcl cz '� r V ''v^ L c °'�9 ❑ Corp.
Address O a A`I°r_ A-1 E'FjrnVCO
arIner.
usiness Te ep one 7� 1/ yi 3 7
Name of Licensed Plumber or Gas Fitter u ✓�
INSURANCE COVERAGECheck o
I have a current liability Insurance policy or it's substantial equivalent. Yes f No ❑
I- d 1 dicate the t e coverage by checking the appropriate box.
If you have chec a yes, p ease n yp ❑
Liability insurance policy Other type of indemnity ❑ Bond
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner ❑ Agent ❑
I hereby certify that all of the details and mtormation i nave suormrreu kur cnrcrcu� ,11 auwc ayN„LaL,tj„ ME; «u�, auu a., u.—« L., L„�
best of my knowledge and that all plumbing work and installations performed upoer Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts Stat*eeoCapter 142 of the General Laws.
OVED (OFFICE USE ONLY)
Signature of Lice ed PlumbOr Gas Fitter
❑ Plumber
Gas Fitter License Nu7mer
Master
❑ Journeyman
Date ...! .�v<..� Z ..... .
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ..77;??.�?'�g►' d
has permission for gas instal ation .. n .��.... �k .....
rl
in the buildings of . ..../.1..... � .................
at ..... �.!r ..� ..... , Nort ndover ass.
Fee � i � Lic. No. ? *O ... ......... .
GAS INSPEC R
Check #1 f Z
,I't(, a ,,..11��� v��c vu1y 1U.IMU to ft
Installing Company Name: jF
` j ❑ Corporation
Addresse6' %Z City/Town: State:
❑ Partnership
Business Tel: ?7)" %� 9— H ? Fax. -92k ��'�f' A'3"
�- �.Firm/Company
Name of Licensed Plumber/Gas Fitter_1/ 6 ,�
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 have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy, Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
"�- Owner ❑ Agent
Signature of Owner or Owner's Aaent
Dy cnecKmg Lms box LJ; I hereby certify that all of th details and information I have sub or entered) regard this ation are true and
accurate to the best of my Knowledge and that all pl mbing work and installations perfo a under the permit ued this ap 'cation will be in
compliance with all Pertinent provision of the Massa usetts State Plumbing Code and Ch er ws.
By : / Y/ // U/T e f License:
lumber
Title El Gas Fitterf
nature f 1_ic nsed Plu erlGas Fitter
aster
City/Town ❑Journeymannse Number: G /
APPROVED (OFFICE USE ONLYI ❑ LP Installer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
CitylTown•_ MA. Date: 06 Z Permit#
Building Location: Owners Name: til l �, �� C., 1-�►^'� "1
Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential
New: ❑ Alteration: ❑ Renovation: ❑ Replacement: z Plans Submitted: Yes ❑ No ❑
,I't(, a ,,..11��� v��c vu1y 1U.IMU to ft
Installing Company Name: jF
` j ❑ Corporation
Addresse6' %Z City/Town: State:
❑ Partnership
Business Tel: ?7)" %� 9— H ? Fax. -92k ��'�f' A'3"
�- �.Firm/Company
Name of Licensed Plumber/Gas Fitter_1/ 6 ,�
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 have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy, Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
"�- Owner ❑ Agent
Signature of Owner or Owner's Aaent
Dy cnecKmg Lms box LJ; I hereby certify that all of th details and information I have sub or entered) regard this ation are true and
accurate to the best of my Knowledge and that all pl mbing work and installations perfo a under the permit ued this ap 'cation will be in
compliance with all Pertinent provision of the Massa usetts State Plumbing Code and Ch er ws.
By : / Y/ // U/T e f License:
lumber
Title El Gas Fitterf
nature f 1_ic nsed Plu erlGas Fitter
aster
City/Town ❑Journeymannse Number: G /
APPROVED (OFFICE USE ONLYI ❑ LP Installer
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Installing Company Name: jF
` j ❑ Corporation
Addresse6' %Z City/Town: State:
❑ Partnership
Business Tel: ?7)" %� 9— H ? Fax. -92k ��'�f' A'3"
�- �.Firm/Company
Name of Licensed Plumber/Gas Fitter_1/ 6 ,�
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 have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy, Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
"�- Owner ❑ Agent
Signature of Owner or Owner's Aaent
Dy cnecKmg Lms box LJ; I hereby certify that all of th details and information I have sub or entered) regard this ation are true and
accurate to the best of my Knowledge and that all pl mbing work and installations perfo a under the permit ued this ap 'cation will be in
compliance with all Pertinent provision of the Massa usetts State Plumbing Code and Ch er ws.
By : / Y/ // U/T e f License:
lumber
Title El Gas Fitterf
nature f 1_ic nsed Plu erlGas Fitter
aster
City/Town ❑Journeymannse Number: G /
APPROVED (OFFICE USE ONLYI ❑ LP Installer
y
AL\ The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02III
www.mass gov/dia
Workers' Compensation Insurance Affidavit: guilders/Contractors/Electricians/Plumbers
lnliranf• linfnr..,�f:....
Name
- Address:
�--- - - - --;�- - -7
City/State/Zip: ,(9, M4 P Phone #:
Are, on an employer? Check the appropriate boa:
1I am a employer with
v
4. ❑ I am a general contractor and I
employees (full and/or part-time).*-
2. ❑ I am a sole proprietor or
have hired the sub -contractors
listed
partner-
on the attached sheet. t
ship and have no employees
These sub -'Contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.)
3. ❑ I am a homeowner doing
officers have exercised their
all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § IN, and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
*A 'Y ap pl=cant that chec:s box #1 zest also fill out the
section belay, ���•,ri�� +xe �
Type of project (required):'
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10-ElElectricalrepairs or additions
11. ❑ Plumbing repairs or additions
12-F1Roofrepairs
13.❑ Other
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.
lam 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. Lie. M
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).
o se overage as required under Sec ' . 2 A ofMGL c. 152 can lead to the imposition of criminal penalties of a
cup to $1,500.0 d/or one-year impriso nt�-at
ll as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day a st thej�iolator. a ad a copy of this 'statement may be forwarded to the Office of
3�vestigations of the DIA or uishrance 6o erau .,,,
Ido
i�iV-90
that the information provided above is true and correct
-. PoIZ
Official use only. Do riot write in this area, to be completed by city or town official
City or Town: Permit/License #
Issuing Authority (circle one):
L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing inspector
6. Other
Contact Person: Phone #:
0,
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 6r 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' another -who employs -persons to .do maintenance,.coastructioh or -repair -work on -such dwelling -house-. .--- - --.— or on the grounds or building appurtenant thereto shall not because of such employment be deemed to bean 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), addresses) 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 anLLC or LLP does have
employees, a policy is required. Be.advised that this affidavit maybe 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 Ietamed to the city or town that the ay plic4oa for the pe:knitor hce SY �S baiflg req�aeSt�d, 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 permithicense 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 bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would'like to tbank you in advance f6r your cooperation and should you have any questions,
please do nothesitate 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, IFA 02111
Tel. # 617-727-4900 ext 406 or 1-8.77-M. ASSARE
Revised 5-26-05
Fax # 6.17-727-7749