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Home My WebLink AboutBuilding Permit #263-11 - 175 SALEM STREET 9/28/2010 i BUILDING PERMIT of ttORoT" qq, TOWN OF NORTH ANDOVER oa 16 o APPLICATION FOR PLAN EXAMINATION '' Permit NO: Date Received Date Issued. IMPORTANT Applicant must complete all items on this page 77 p"`?grr --s- _ .ur+,.4ww a"a-Ks .. x_s._'�' `*s 5��.�:�M..ti .'t y F�� :.. z ..'^ *�a[ �"' t _ �y,-.. r _.� � �»;. ,4..'F*-- *-,.rtire' '' 1,4 fid ,k. r AL t «mac mPR RTY*rte OWNER � •�- �r � �: .��-. � � � .� � R}�^e�2 -��,if,. .s."....-�.3,ea4n• .x.�rar.,t�.t .e�:: aA s#3 �t�E� s.-�...t.,'e�'�'.# w:�ka't a. r. }. I s�"`�F:j•,gpM sPr`�x P- ,��£ �.�- y x `�sf e��'' "�"^;�Pa a�'Ok�'`•'�+��- P r ntT-'. q' �' �.�'.�._ x.�-, r•' r:.' i � .,�.. ._�r-6��,,• Y�:, y � n rstonc`'Distnct xr � �� ,yes�.� �� ach n TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Buildinga anvil Addition Two or more family Industrial No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other . peptic 1Nell� _, � a ,Floodpla�n� � Wetlands � $ . 'µ W�ate shedD s�tr�ict a 4 7 rater/S`ewer '�' ..y Cwt. �# S^, f 'a" P S •"'35 F'w- ... �.# .^'`s- `'d .``, `S g �'Y#.i DESCRIPTION OF WORK TO BE PREFORMED: coq J� L jAll 54-et Wi^A,0-,-,Q5 Now C-LG }-S ®vr�- Identification Please Type or Print Clearly) OWNER: Name: Phone: q-?$' Address: 1 -75- S ��e, I ' W '�. s £� .3 = V"r,..' '' 1',.;'✓+�1 'F+'' t 9; d'z- g' :tis++,d ,�..fir"` z ,�- h' ,. ^t �g"� sr ' ` .s ur.1 -x- . 'r.1 °CONS R�,4C�OR a e �a° 5 � «Phone7C� � r iQ'AUl1fe„S.S', 3`.. - x3 �� -•ter ,,x9� '��-'�� F"�{� �.'.�--,� ,. '��r','°�-"`�„t'� - �� :. r � .� :.k'i` �"� �g.� ��-yr. �'"K�,.:.p'rr .�t.��-* �fsC -ys.^*r..�'�--..� ^� +w� �E t � _ .� �X �Dat� �.... .ii ..�``;-'�-� +a•-=� ARCHITECT/ENGINEER 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: $_ " FEE. $ , Check No.: � Receipt No.: ��((� NOTE: Persons contracting with unregistered contractors do not have access to guaranty fund S%gnatu�e ofAgent7 wner�' . R � _"�xS�gnatureofcontraCtO( -. _ � . r Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/MassageBody Art Swimming Pools Y Well Tobacco Sales Food Packaging/Sales Private(septic tank,etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Siqnature COMMENTS HEALTH Reviewed on " Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted. yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date - Drivewav Permit DPW Town Engineer: Signature: Located 384 Osgood Street +..°�'... ��F"r�,-�c•�a � FIRE DEPARTMENT, t ternp�Durnps�terigmsne yes zc. �c� y i �i .�=�as�. .;ter Located-at k124:MainStreet ; � _ f fr _ .�� ~ `s.,yr C4 .. .a .L� 4+�-- �r"L �SS +t�-S -w` 'aary 'fig. "�- Fire De�artmentsognature/elate r } a4 E ".ral,^* ,'�+ -�.s,+. �. +,._=t.., �"� a.a:, . � ..'a-�yt�-w e�"��Y�'; ,�.' �r ,� �Y h d Ys �, '.` �s.��r�----+r A ` �" .r � r -�r •�-x� r-�+..`�`_.g�tFt'..PCOMMENTS s._.. ...F.>,w.,�-..-��`.��"`.1-, --��;.�f...�...�- . _..,.�»..Fw•,.�x.� -tom na.�."'+.a.�..w. .... �e-.A.:...�,:......a.>m�.�,F�..:-%-� ,3�.:. I Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No .MGL Chapter 166 section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) i p 1 ❑ Notified for pickup - Date Doc.Building Permit Revised 2010 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits o Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or.C.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 Application Permit A lication ❑ 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 &fuck 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 appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2008 I l�.s� �� , Location No. Z!JM Date Id 40RTol TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ MUS Foundation Permit Fee $ Other Permit Fee $ TOTAL Check # IE F 234 ✓ 8 Building Inspector fie �aneuveh ulation. Office of,Consu►uer Affairs&$IIS1DCTOR I� HOME IMPROVEMENT CONTRA Registratio!%1T' I 296 Tr# 290924 Expiration 11119/2011. i i Type, rll G.. y � � �AOD��NG � (� TESTA BUILDIN' I G&F2E JAMES.TESTA' 5 APPLETON STREET Undersecretary. It N.ANDOVER, Vlassucbusctts- Department cif Public Safeo - Board of Buildin�gy Re '11ttti0n, untl Standards Construction Supervisor License r - License: CS 54718 JAMES M TESTA , 5 APPLETON ST N ANDOVER, MA 01845 Expiration: 6/8/2012 Tr#: 29825 1 ORTIy of over o _ ' O pry r-.� :',4:• 'i�'"` :R,,,x � , No. - Y __ - -o` dover, Mass., ry` 0 �= LAKE COCHICHEWICK 7,p A0 ATED P �CD SS BOARD OF HEALTH PERM IT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT................. ......................... .................. Foundation has permission to erect.......... ............................. buildings on ..........1.0 �...... .......4:56....................... Rough to be occupied as.......r-1. `t......�............... ......... ........ . l.! `! ....C,I.1!�.�r. . imn y Ch' e provided that the person accepting this permit shall in every res ect conform to the terms of the applicati on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN V MONTHS THS UNLESS CONSTRUCTIO TS ELECTRICAL INSPECTOR Rough .......................................................:.............:.........:.. Service - BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous- Place on the-Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. TESTA Building and Remodeling 5 APPLETON STREET NORTH ANDOVER,MA 01845 HIC Lie. 120296 Expires 11/19/11 (978)682 2023 CSL Lie.CS 54718 Expires 6/8/10 Proposal July 27, 2010 Proposal Submitted To: Peter and Arlene Devlin Home Phone: (978) 794-3196 175 Salem Street North Andover, MA 01845 Job: Remodel kitchen and Add Bathroom Obtain building permit Complete removal of all demolition and construction materials generated by Testa Building and Remodeling and its subcontractors. DEMOLITION : Remove all cabinets and counter tops. Total gut all the walls and the ceiling in the kitchen , half bath and kitchen table area. Remove the existing flooring down to the sub floor. CONSTRUCTION: Frame the new bathroom in the area of the old kitchen. Make door way into family room where the opening .Remove wall between kitchen and table area design and install beam. Frame the window openings if needed A finance charge of 1!/2%per month(18%per year)will apply to all accounts over 30 days past due. In the event collection activity is required the customer shall be responsible for all costs associated with collection,including reasonable attorney's fees. I propose hereby to furnish material and labor complete in accordance with above specifications,for the sum of: $48,329.00 Forty Eight Thousand Three Hundred and Twenty Nine Dollars One-third to start,one-third after insulated ,one-third upon completion. Authorized signature I reserve the right to cancel this contrac if not accepted in-30_days Signature Signature DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES WINDOWS : Supply three new Anderson windows and install in same locations. Patch the siding as close as possible . PLUMBING : Rough in the bath room toilet , vanity and the shower. Install all new plumbing fixtures in the bathroom . Remove the radiators and supply and install two new cast iron radiators that will be recessed in the walls. Move the kitchen sink under the window in the present table area. Move the gas line to the new stove location and hook up stove and the rest of the kitchen plumbing fixtures. Note : There is no allowances for plumbing fixtures for bathroom or kitchen. ELECTRICAL : Remove all old wiring in the kitchen area and the new bathroom area. Rewire kitchen and bathroom to code. Supply and install recessed lights. Supply and install under cabinet lights. Supply and install bathroom fan light combo. Wire and install light over vanity .Remove old circuit panel in the basement and replace it with a new one that is bigger and we can eliminate the double breakers in the panel. Note : There is no allowances for light fixture other than the one specified (Vanity , Pantry). INSULATION : Install R 13 insulation with a vapor barrier on all the exterior walls. Insulate the walls in the bathroom for sound. PLASTER : Hang %" blue board on the ceilings and the walls. Skim coat plaster will be applied to all the walls and ceiling in the kitchen and the bathroom . CARPENTRY : Install all the kitchen cabinets and molding as per the designers drawings. Install new trim in the kitchen around the windows and doors to match the existing trim in the house. Installation of all kitchen appliances. TILE : A finance charge of V/2%per month(18%per year)will apply to all accounts over 30 days past due. In the event collection activity is required the customer shall be responsible for all costs associated with collection,including reasonable attorney's fees. I propose hereby to furnish material and labor complete in accordance with above specifications,for the sum of: $48,329.00 Forty Eight Thousand Three Hundred and Twenty Nine Dollars One-third to start,one-third after insulated , one-third upon completion. Authorized signature I reserve the right to cancel this contract if not accepted in_30_days Signature ` Signature C DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES i Install under layment on floor where tile is to be installed. Install and grout the for kitchen floor, kitchen back splash ,and bathroom floor. Note : No allowance for tile and grout. Labor and adhesive only. VENTING : Pipe out the exhaust for the ceiling fan in the bath room . Pipe the exhaust blower for the stove. Will provide all duct work needed. THE HOME OWNERS WILL SUPPLY CABINETS AND APPLIANCES AND COUNTER TOPS THERE IS NO ALLOWANCE FOR PAINTING OR STAINING INTERIOR OR EXTERIOR ITEMS YOU WILL NEED TO SUPPLY I will supply you with all the sizes and the quantities you will need. Kitchen Kitchen cabinets Counter tops Tile for the floor and grout Tile` or the back splash and grout Hood over stove Stove Dish washer ? Refrigerator A finance charge of 1!/2%per month(18%per year)will apply to all accounts over 30 days past due. In the event collection activity is required the customer shall be responsible for all costs associated with collection,including reasonable attorney's fees. I propose hereby to furnish material and labor complete in accordance with above specifications,for the sum of: $48,329.00 Forty Eight Thousand Three Hundred and Twenty Nine Dollars One-third to start,one-third after insulated , one-third upon completion. Authorized signature I reserve the right to cancel this contract i not accepted in_30_days Signature Signature DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES 1 Kitchen sink Kitchen faucet Disposal ? Microwave Bathroom Tile for the floor Fiberglass shower stall Shower valve Vanity Vanity top Bathroom faucet Toilet Mirror Vanity light A finance charge of V/2%per month(18%per year)will apply to all accounts over 30 days past due. In the event collection activity is required the customer shall be responsible for all costs associated with collection,including reasonable attorney's fees. I propose hereby to furnish material and labor complete in accordance with above specifications,for the sum of: $48,329.00 Forty Eight Thousand Three Hundred and Twenty Nine Dollars One-third to start,one-third after insulated ,one-third upon completion. Authorized signature reserve the right to cancel this contrA if not accepted in_30_days Signature Signature DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES COLLOPY ENGINEER*ING CONSULTANT r FRANCIS H. COL.LOpY REG.PROFFESIONAL xn _ P.O.Box 1664 ENGINEER r Seabrook,NH 03674 Tel:603 760.2273 Structural Engineering Services September 14,2010 Mr James Testa Contractor 5 Appleton St North Andover,MA 01845 Dear Mr Testa: I am writing in regards to the proposed renovation that you are planning for the Devlin residence at 175 Salem Street in North Andover,MA. The enclosed beam design shown on the attached Sheet D1 is based on my site visit of September 13,2010, and the span measurements that I made at the site,and our discussion for the desire of adding a new support beam over an opening in the kitchen area. The enclosed design sheet shows two options for the beam,one in steel,and one using multiple lvls. The beam is designed to properly support the bedroom floor and attic loads above, including a bearing wall between the second floor and the attic framing. The loads landing on the first floor solid.wood girder due to the new design using the beam.over the desired opening are basically the same as existing. The load paths change since the new beam supports.the load above the first floor level,whereas the existing structure consists of bearing walls from the attic to the existing first floor beam that spans from the rear wail to the existing girder shown in View B.This first floor beam now only has to support first floor joist loads due to the removal of the wall between first and second,and the addition of the proposed beam option shown on Sheet D1. If you have any questions in this regard,please do not hesitate to call this Office,and we can discuss it further. Sincerely, COLLOPY ENGINEERING I 'evo Francis H. Collopy,P.E. Structural Engineer Enclosure; Sheets D1 cc:North Andover Building Inspector 1-7 S 5>X4ZAM .rr FRANCIS H. COLLOPY PE JOB Ptd VZ.I N �f 51 DEN e A1v• �1 a1 d�� Structural Engineer SHEET NO. I OF / P.O. BOX 1684 CALCULATED BY � `� DATE /✓ ` Seabrook, NH 03874 TEL: 603 760-2273 CHECKED BY L / DATE SCALE LIZ .........................._i..............s......................................... ..........................:.........._:.......... ....:............. ........... ............. .................. ........ ply 9: _...... .....:... . .. . ..... ...... . .. ... :_x'!57;;.. ? ''�..:. ....._°7 .. t ...........< .... L .r f .........:-...........:.........._.:._......-_:.................:......:........-_.............;..........-..:.............. :............ ........:...... ....:........ ... . i. _- ..... ..... I . I ..........................................i............'-_.........:_....... ... �'............ ... ...... ............... ...... L. ..........--........._:.... .�-....... .._.... ._:......_............... ..... _ ..... ...... 4 �. ,.'�. L USS �',�� ► ,, i9 ..:. f .. .... ...........-_:...........:. ... .. ......: ... ...:.... ...:.... ....:.. ...... .._. .... ... ..... .. �. ...o. ... .... , s>:... .. :. .,� tic wao� po5 ......: ..._. -_ ..................:.. . ----- ............. 4 ..... ..... ...... ..{. `rte. J - . _ .. ........ ........ ......................._....._.. FRANCIS H. G �.i OPY 5ca. �OT l7`: a .: . ... . � : X0172 � �w ,....-. < � /.._,� y ( r-rs? -:, .... ..... L�rclST 3/Z . ...... i 8 sr- ;vr ....w...�- ,.........f.�t .. .. . / ...�,.. �)s7 ..., <.... A)c Z91 :G S 3: o ......_...<_ ..........�, c 'i/ :w 5 �i ........... E ' r i t tsi ....:.... ..:.;.... : _ ............. ............ _ l ... .;. ........: __vQ ................................... ........................ ................... _.. . ......,.........................rte ..........:.. _ . .. ... _ .......... ... . r PRODUCT 204-1(Single Sheets)205-1(Padded) •1753/ ►► _ _ rto 0000 ` -- _._.. .2�.-" € 4 [ 1 +r _ OGS L �� - t W13 - �R[�LZ�-- --;�- �l�-9(v. -- �Ox�XoX.►ra�' --P�Pt��f'fat F�� r I T I i11 ; f ; j i 1 � I f I , s The Commonwealth of 1Afassachusett s Department o f'fradustrial Accidents Office of.£n yesti orIf8. s ..600 Washington Street Boston, AL4 02111 ki �aass°ov/didWorkers' Com ensaQon Insurance Affivit: Buiders /ContractorsEleApplicant Information ctricians/Plumbers Please Print Legibly Name (Business/Organiza>ion/Individual): Address: City/State/Zip: o -- �_ Phone#: Are.you an employer?Check the appropriate boat ------- LEI I am a employerwith 4. E] I am a o Type of project(required): L-eneral contractor and I I amloyees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 1� am a sole proprietor or partner_ listed on the attached sheet x 7• ❑Remodeling ship and have no employees These sul'contractors have emolition working forme in any capacity. workers cors 8. ❑D [No workers'comp. insurance 5. P insurance. 9. ❑ We are a corporation and its ❑Building addition 3.❑ required] officers have exercised their 10.[1 Electrical r I am a homeowner doing all work right of ex repairs or additions myself. [No workers'comp. c. 152 14),and e MGL 1 LO Plumbing repairs or additions insurance required.] t '� �4),and we have no employees. 12•7 Roof repairs Pomp.insuran e requi d 13.0 Ott :Any�a?icaa±thatck:._k.:box�1 r s?st require(L] homeowners who n"'s' titi cu!%fie sece eeiov�^ax .. Sub-it This affidavit a �^' A'L'r't'�?;'CO±L+ 7•; VI[mdz:atmg they are doing all-work and 'Contractors that checl;this box mus.a=ched an additional sheet showine the me o it contractor •;. submit a new amdavit indicating such. name of the sub-conttact0n and their workers'co mp.Pcyiicy I am¢n employer that is providing workers'compensation insurance for my employees Below is the olio inform tion. Policy and job site Insurance Company Name: Policy#or Self-ins.Lic. : Sob Site Address: Expiration Date: Attach a copy of the workers,compensation policy declaration. .aae aho City/State/Zip: Failure to secure coverage as required under Section 2 P b ( wing the Policy number"and expiration date). fine up to$1,500.00 and/or one-year imprisonmen aswellasMGvLdc' 152 can lead to the imposition of Of up to$250.00 a day against the violator. Be advised that a co criminal Penalties of a Penalties a the form of a STOP WORK ORDER and a fine Investigations of the DIA for insurance covers e v Py of statement may be forwarded to the Office of g erification. I do hereby c under the pains and ties o er .fp ju'3 that the information provided above is true and correct Signature: Q C) Phone#: Official use only. Do not write in this area to be completed by citj,or tome ofjzcial City or Town: Issuing Authority(circle one): I'ermit/License# I: Board of Health 2.Building Department 3. City/Tow 6. Other n Clerk 4.Electrical Inspector S.PIumbin� b Inspector Contact Person: Phone'n: y Information an_ d Instructions Massachusetts General Laws chapt„-r 152 requires all emnloyce;rs to provide workers'compensation for their employees. Y 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 t3ae legal representatives of a deceased employer, or the receiver or trustee o`an individual,partnership, association ox-other legal entity,employing employees. However the owner of a dwelling house having not more tan hthree ap >a arttints and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintea=ce,construction or repair work on such dwelling house or on the grounds or building appurtenarnt 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 agenep shall withhold the issuance or renewal of a license or permit to operate a business or to c ane buildings in the commonwealth for any applicant who has not produced acceptable evidence of coampliance 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 um.-Cil 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 al-q or Limited Liability partnerships(LLP)with no employees other than fiie members or partners,are not required to carry workers' comp ensation inatirance. 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 sttre to sign and date the affidavit The affidavit should be-mtuued to the city,or town that the apphca ion for the permit Qr Lce^.�e is,being reaues*.ed,not the.Department.of Industrial Accidents. Should you have any questions regarditt g the law or if you.are reY",, ed to oc. a workers' compensation policy,please call the Department at the numbe=r listed below. Self-insured companies should enter their elf-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 li vestigations 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 pest 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 oflnvestigations would Ince to than 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.fag number.._... The Commonwealth of Massachusetts DeparlMent of Industria=l Accidents Office of Investigations ions 600 Washingbn Street Boston,MA 02111 Tel. 4 617-72.7-4900 eat 440.6 or 1-9T7-NLASSAFE Revised 5-26-05 Pax it-i' 617-727-7 749 mrww.mass..zov/dia, NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: 125- 5 vR 1e--, 5 '1- is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 10A. ' The debris will be disposed of in: 05 0,J co�1,-cps --f6 2� (Location of Facility) Signature of Permit Applicant f o Date