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Home My WebLink AboutBuilding Permit #377 - 195 BRIDLE PATH 11/13/2009 i TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION L9lDf,� t - - Print a _ ,PROPERTY OWNER p - -Print _ MAP NO: -d PARCEL: ds ZONING DISTRICT: Historic DistrictY es no Machine Shop Village yes no 1 TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial j Repair,.replacement Assessory Bldg Others: j Demolition Other `Sepflc 111F, i -,` Floodplain Wetlands. `'Watefshed p strict Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: i f Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: CONTRACTOR Namez� / _Phone:_ 7��1�Z Supervisor's Construction.._License y3 y -Exp.. Date; Home Im rovemenfi L.�cense P f 9 CD _., Exp_ Date _ 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: $ 2�/00. FEE: $ �- Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Si nature of-A ent/Owner ': `Si nature of contra for 9 g _- _ _ __g �__ __. I Location d�r ��G t��A Na _ Date4 of, 3 v� MART„ TOWN OF NORTH ANDOVER .•,�O F � a i Certificate of Occupancy $ ACMUS t� Building/Frame Permit Fee $ 3� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ I Check # Building Inspector I I I i i i I t 1 Plans Submitted F1 Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ -T PI;O'F-;SEWERAGEDISP:OSAL- Public Sewer ElTanning/MassageBodyArt ❑ swimming Pools 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. DATEAPPROVED PLANNING & DEVELOPMENT El COMMENTS .CONSERVATION Reviewed on Si nature COMMENTS HEALTH Reviewed on Si nature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connectionis Drivewa Permit DPW Tows! Engineer: Signature: Located 384 osgood street FIRE DEPARTM,1:IST =-Temp Dumpster on site- yes.. . :, n Located at 124 Main Street Fire $igiiatureldate COMMENTS 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 ❑ Notified for pickup - Date Doc:.Building Permit Revised 2008 i Building Department artment 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 ❑ 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 P P 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 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: Doc.Building Permit Revised 2008 i i I NORTH own of No. 3 7 , - =-- A K E dover, Mass., • COC MIC ME WICK �d AORATED `s BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System • BUILDING INSPECTOR THIS CERTIFIES THAT...... .................S ..jJ �,!.............................. ........................ . ............................ Foundation has permission to er ct........................... ............ buildings on ..14C,...... . lk ... ..... .....�.. g to be occupied as.. ...� �ir.. ...... ....... �.� ..... Chimney provided that the person accepting thi ermit shall in every respect confor to a ter pplication on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, A oration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final • PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONS U STARTS 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. p� 67, Too�n��yy coea o� \ _ Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registrotion= 124961 Expiration: 0/17/2009 Tr# 132544 Type; Individual DARREN MARTINO ' , Darren MARTINO"-' `., •i' 44 ADDISON AVE. EXT._ ,, ` ' METHUEN, MA 01844 Administrator Office of Consumer Affairs& usiness Regulation HOME IMPROVEMENT CONTRACTOR Registration. `124961 Tr# 288159 Expiration; 9/17/_2011 Type, E_ Indvid6411- ;s � i11 n 4DARREN MARTINO �: Darren MARTINO 44 ADDISON AVE_EXT , ids METHUEN, MA 01844` Undersecretary I 9 A41-, Massachusetts - Dep,t,-trtjent of Pul)IiC Safety Beard of Building Re, julutions and Standards Construction Supervisor License License: CS 66342 Restricted to: 00 DARREN MARTINO 44 ADDISON AVE EXT METHUEN, MA 01844 f Expiration: 8/15/2011 (unm�issiuuer Tr#: 1170 i - I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, ASA192111 } www.massgovldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: ADD1 f -j /-,ULs el l City/State/Zip: &ViE4l,/nk_ 6/dry�, Phone #: 6 Z —77 Areou an employer? Check theappropriate bog: YType 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 2KI am a sole proprietor or partner- listed on the attached sheet.1 ❑ Remodeling I ship and have no employees These sub-contractors have 8. ❑ Demolition working for in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised their 3.0 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' 13.0'6ther j°6R'i/6 z comp. insurance required.] *.-.:.y anpli;ar:,that checks box 41 mus`also 811 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.#: Expiration Date: i Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Si atur . Date: Phone#: 41-7 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 apartrnents 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 bum 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 Washi glon Street Boston,MA. 02111 Tel. # 617-7274900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax# 617-72.7-7749 w-ww.mass.gov/dia Location ' No. Date o °RTM TOWN OF NORTH ANDOVER Lp ti Certificate of Occupancy $ Building/Frame F g/ rame Permit Fee $ GilusFoundation Permit Fee $ sssAEt ; i Other Permit Fee $ o Sewer Connection Fee $ - D k Water Connection Fee $ _ C> i TOTAL $ �Ouilding Inspector Div. Public Works PER31IIT NO. . APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. /AGIE 1 MAF-,17-40—. LOT NO. C702 RECORD OF OWNERSHIP DATE BOOK :PAGE _ Tis I _ ZONE SUB DIV. LOT NO. F- i LOCATION / Q ( ,1� PURPOSE OF BUILDING SUnroO,-% OWNER'S NAME !!p�7 'J > NO. OF STORIES SIZE /IbkGrf' �r�e�irli _ oot OWNER'S ADDRESS �r}s 3r/,^14 p�l� BASEMENT OR SLAB ARCHITECT'S NAME �77Qy'./U�uQ / SIZE OF FLOOR TIMBERS IST,,?J2ND 3RD BUILDER'S NAME ,DG SPAN DISTANCE TO NEAREST BUILDING h /+�' DIMENSIONS OF SILLS/ DISTANCE FROM STREET /v„ ♦�r� POSTS W 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 NL f MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND fr.) WILL BUILDING CONFORM TO REQUIREMENTS OF CODE Vey IS BUILDING CONNECTED TO TOWN WATER 1.Y.5 BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LIAE INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES EST. BLDG. C08Tf PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT. PAGE 2 FILL OUT SECTIONS i - 12 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR ZZ DATE FILED Z- BUILDINO INGP[CTOR SIGNATURE O OWNER OR THORIZED AGENT F E E OWNER TEL.# OD� CONTR. L. 3 70�-57 9 7 PERMIT GRANTED �19 CONTR.LIC.# CLIA 4z V(,O H.I.C.# /a/3/41 1 219% I 1 BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY St0RIEsICES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM LY OF MULTI. FAMIFLOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE 3 t 2 I3 CONCRETE BL K. PINE _ BRICK OR STONE HARDW D PIERS PLASTER _ DRY WALL _ UNFIN. 3 BASEMENT 11 AREA FULL FIN. B M AREA _ FIN. ATTIC AREA _ NO BMT FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE �_ WOOD SHINGLES EARTH _ ASPHALT SIDING HARDtrJ'D _ ASBESTOS SIDING COMMON _ VERT. SIDING ASPH. TILE _ STUCCO ON MASONRY _ STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. d FLOOR _ BRICK ON FRAME CONC. OR CINDER ELK. STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIOR I� POOR _ ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE I HIP BATH (3 FIX.) GAMBRELMANSARD TOILET RM. 12 FIX.) FLAT A SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING TAR & GRAVEL STALL SHOWER . ROLL ROOFING MODERN FIXTURES TILE FLOOR 'S TILE DADO 6 FRAMING I 11 HEATING t WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. 6 COLS. STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS ' OIL B'M'T 2nd _ ELECTRIC Ist 13rd NO HEATING NORTH Town of d 14 o K dover, Mass., 1 COCHICHEWICK ADRATED S BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System -�--- �� BUILDING INSPECTOR THIS CERTIFIES THAT ................................................................. . ... ...v./. ....................................................... "" Foundation has permission to erect........AP.. .l. l.cy..... mon .........../.9.a........ .......t�`�!�-T...l-!�.............. Rough t0be occupied as ..........................................................�. ..... /...lj............. .4'l,r�l./E�.��.C�..' ................................ Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STA. TS ELECTRICAL INSPECTOR Rough Service DING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner Street No. Smoke Det. i ,,, ✓�Ze �amrrearecuealC�t e`'� l�z;tsac�ccseCCs � OEPARTAIENT OF PUBLIC SAFETY CONSTRUCTION SUPERVISOR LICENSE Number: Expires: Birthdate: CS 966462 01;0512889 31/M/197 0 Restricted To: 89 O tt DAVID J CUNNINNG40 - 1922 4MESBURY RD HAVERHILL, NA 01830 _ (c\ 7�ie T�omvinmu�sra�l�i��.C�ucC�el� ADMINISTRATOR 1!O'M1I a 1,3-s F • I 4 N_E_Nnl i lA'DD.YZ 1 O.N- I SKYLt GH•TS t !Ct•�T__.__R.Oo� E'PSTING C1.1►Me►EY _ rx/.STING HaysF__ _ �C_Ol.►�1_I—. ADD1Tlot�.. _ t 219% ----•-��,..� ``Q Y e X11` v GH • j r,C`� �f�l t _.�' E rw L Ww N_�S__ L. N��i 7r'i-/_I_ t v /y, I /.Z 8 HMD Sa i S s f E�isTr�v� Fi..tr /Zook_ FYI 1i - - - Cm 114) - - - - 12 FLOOR To/5? @ /!v O. C. ,S_/,frEQED �yt'XT To__EXE y?iN6 ' „Zx�Z ROOF _RHFTERs - t Ex�sT/NG�Ov�E _t9s_3e.�ar►r�. 1P�eTH ' w IAI ex i j cx1.�TtN�Sky�c�t-iTs _ JJ FLitT CLOOF �)_b_E Ex)spina \ J . � 'ERCOLlN1 �na�T1o►J . 1 q S 13 Z�cv�L• �e�-UH._ - 7 - 76 i 2�o6E JENr _ Pawom _ .x10 _RHFtECZs @ tb o,c. R-3o 'L•.�suuaT�•oN I� - P2oPEQ VENT - - — - SLS w h-Yett 5t e\i 2 x to 4-tmvetZ z zx rlEr�o6,z P,WVf: TpoDR I / 44oVE 049,rcfL fj',OuNh (�1Nt 1GtaSG1A �Sa�F,TS Firi T v CN T ?�- 2xg ye14�ER i 'A'OO�Jt Wtw\DOW f j I � ii W k*LL- .rczv� b o.C. ---- � R-21 'Zasu�p�T_tcN_ � C c COMM Cy..c 3o�acto _E�ZCOL1 N\ AOD�T�O iJ -- - PATH.- 1 Alf -7.! ,Z,.XAl FLoof�_ SOts r $15UIZEc� N 7 TO D u1n1 $Y__D._C_U�Vi11LNGf/�t►�1 _Tn�SUI.AT\O�I FX15_TI14 zx Iz _ 7=0 \-2,t P��Z r • i + + 4 { e Z _A aw TiDN I Acs - 17. vNn/in!�.KAM LEFT EL EVA"V%ON . I 1 z _ 1 • � F_,�.CO L1N l._�a D 1'Cl ON-= j u��MRrr� • REAR E L EVAT IOM f Location No. Date kORT1y TOWN OF NORTH ANDOVER O?O•t*``D ,•,MOOp „ Certificate of Occupancy $ l * ; } Building/Frame Permit Fee $ So C" t �' Foundation Permit Fee $ � s�cHus t .' Other Permit Fee $ f Sewer Connection Fee $ q Water Connection Fee $ TOTAL $ wilding Inspector 06/17%0%S 58. Div. Public Works .�� PEEt)tiT NO. APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE ; MAP iqO. I LOT NO. 2 RECORD OF OWNERSHIP DATE BOOK ;PAGE — ZONE SUB DIV. LOT NO. I t LOCATION I q57 C��\ PURPOSE OF BUILDING v.NNER 9 NAME17— NO. OF STORIES SIZE WNER'S ADDRE36 ��/-' /7•l BASEMENT OR BLAB ARCHITECT'S NAME �� SIZE dF FLOOR TIMBERS IST 2N0 3RD UILDER'S NAME , ; SPAN t DISTANCE TO NEAREST BUILDING DIMEN5;0►:16 OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES — SIDES REAR GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDIyG NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BU.!:Q G ALTERATION E1�]� IS BUILDING ON SOLID OR FILLED LAND —_� ✓tiw V ILL BUILDING CONFORM TO REQUIREMENTS OF CODE 19 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 BLDG. COST PAGE 1 FILL OUT SECTIONS 1 - 3r- EST. BLDG. COST PER SQ. FT. -� PAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER ROOM ELECTRIC METEP9 MUST BE ON OUTSIDE OF BUILDING SEPTIC PERMIT NO. 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS Pycn9 MUST BE FILED AND APPROVED BY BUILDING INSPECTOR V DI�,TE FI ■UILDING INGPRA:T p SIGNATURE OF OWN UTHORIZED Y1 ENT a FEE OWNER TEL X PERMIT GRANTED Q / CONTR.TEL X 1:2D — S-727 19 CONTR.LIC.X t l r NORTFi Town of 0 dOver dover, Mass. — - 19 96 o f f f COC HIC HE WICK ORATED P'P��t� BOARD OF HEALTH Food/Kitchen PERMIT T Septic System �r BUILDING INSPECTOR THIS CERTIFIES THAT..............:............1 L�tae .......... .................................... ........�...�.�..�/.�..f....................................... Foundation has permission to weet'......P ................�i-flidinnc on 1 �" --- -�----................. /.....t.c?..€i./..... Rough to be occupied as.. . . . . . . . . . ... . . . .. . . . . . .. . . .. p . . . . . .. . . . . . . .. . . .. . . . . .. . . ....... ...�..��.............t�.............. ............................................ Chimney provided that the person accepting this permit shall in every respect conform to the ter of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION ST ELECTRICAL INSPECTOR Rough .................................. SOT . Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises -- Do Not Remove Rough No Lathing or Dry Wall To Be Done Final Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner Street No. Smoke Det. t; N0R71y ` °t •�`° •• ' p Fl /�/��G-e�?-- ) acv p /� � 3? 4,', • 1 9 a s • i a ��' •'�h BOARD OF HEALTH _5-' ss�c""SE NORTH ANDOVER, MASS. o t p-►S APPLICATION FOR WELL AND PUMP PERMIT Permit # Date l0 ^0 f A permit is requested to: drill a well install a pump r LOCATION: j 5 �� , rµ "`C-• Lot # Owner gOeR-V'"- GiL�IULI J i Address tq 5- 17(��c�Le 4�J , el q�� -0 3 - (70 %D-Q T (� L� , � ,- Well ContrctrC, fA• gOLL►NS =vjc• Add. (29 (3oxPo2�i ,r+nq. Tel 75^ 8&� Pump Contrctr S 1� Add. Tel WELLS (To be completed at time of pump test. ) Type of well Use J/� ` Diameter of well Size of casing Depth of bed rock Depth casing into be Seal been tested? Yes (_) No (_) Date of test �`� " Depth of well Water-bearing rock Depth to water Delivers GPM for (how long?) Drawdown feet after pumping hours at GPM Date of completion Signature of well contractor PUMPS (To be filled in before installation. )' Name &size of pump Type Size of tank Pump delivers GPM Pipe used in well: Cast iron (_) Galvanized (_) Plastic (_) Sleeve used to protect pipe? Yves (_) No (_) Type well seal Date Signature of pump installer Date water analysis report submitted to Board of Health Plumbing inspector Wiring inspector 21 13 2001 Board of Health TOWN OF NORTH ANDOVER ti HEALTH DEPARTMENT 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 SSACHUSE Sandra Starr Telephone(978)688-9540 Public Health Director FAX(978)688-9542 June 26, 2001 Robert Ercolini 195 Bridle Path North Andover MA 0 1845 RE: Application for a permit to drill a well Dear Homeowner: The Health Department has received an application to drill a new well at 195 Bridle Path, North Andover. Before a permit can be issued you must submit to the Health Department a site plan showing your house footprint and location on the lot, any wetlands within 200 feet of the proposed location for the well and the well location. This must all be to scale. Please note that you may also be required to file with the Conservation Commission if wetlands are near to the proposed well and to the Planning Board if you are located in the Watershed. If you have any questions about the Health Department requirements for the well permit,please do not hesitate to call me at 978-688-9540. Sincerely, Sandra Starr; R.S., C.H.O. Public Health Director Cc: Licensed well driller Conservation Dept. Planning Dept. File Of MORTh q TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 3= A 27 CHARLES STREET f ; NORTH ANDOVER, MASSACHUSETTS 01845 �,'°•,_•°��'t ss^CHusE Sandra Starr Telephone(978)688-9540 Public Health Director FAX(978)688-9542 MEMORANDUM DATE: March 28, 2002 TO: Jackie Byerley, Interim Town Planner FROM: Sandy S RE: 195 Bridle Path Last May the owner of 195 Bridle Path had his well driller apply to the Board of Health for a landscaping/irrigation well. The well driller was told that a Special Permit from the Planning Board was necessary before Health could grant him a permit. Can you please tell me if and when Mr. Ercolini, owner, received his Special Permit? I have had no further dealings with him on this matter and would like to know the status. Thank you. • Town of North Andover NORTh Of tSl!° 16,Q. Office of the Planning Department Community Development and Services Division 27 Charles Street North Andover, Massachusetts 01845 4--ACHUSE�< I Telephone (978)688-9535 Fax (978)688-9542 MEMORANDUM DATE: March 28,2002 TO: Sandy Starr,Health Director FROM: Jacki Byerley,Interim Assistant Town Planni rj71 . i RE: 195 Bridle Path In review of the Planning Department files as of March 28,2002 Mr.Ercolini of 195 Bridle Path has not filed and application for a Watershed Special Permit. Mr.Ercolini had made inquiries last summer but has not filed. i I BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANINTING 688-9535 The Commonwealth of Massachusetts Mike k"only Department of Public Safety X0.1 oseup w y 6 two owdN lug ✓ BATI OARD OF FIRE PREVENTION REGULONS 527 CMR 1200 3/90 fie.oe APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed In Accordance with the MAesachwens Electrkal Code.$27 R 12: (PLEASE PRINT IN INK OR TYPE ALL INFORHA=ON) Date � �� City or Torn of /V oar,# tow To the Ins for Sures: The undersigned applies for a(�per`mit two�per�fo the electrical work described below. Location (Street & Humber). I 1 J^ �T71C 1 C�` ? T}� Owner or Tenant 71(C�l Owner's Address (l __Is this permit in con unct on with a building permit: Yes �No ❑ (Check Appropriate 3W Purpose of Buildin S► P" Utility Authorization NO. Existing Service Amps / Zqo Volts Overhead ❑ vn4crd❑ No. of rAters--L— New Service Amps / Volts Overhead ❑ Undgrd❑ No. of Meters_ Number of Feeders and Ampacity, 17t! n and Hater of Propo ed Electrical Work lL I X C7k 1 '0eJ e� No f Lighting Outlets No. of Hot Tubs No. of Transformers Xotal XVA No, of Lighting Fixtures Swimming Pool Above In- rnd. ❑ d. ❑ Generators MNA No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Baste Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of RangesNo. of Air Cond. Rotas No. of Detection and Initiating Devices No. of Disposals No. of Heats Total loTons No. of Sounding Devices No. of Dishwashers Space/Area Heating IGJ No. of Sel( Contained Detectioe Sounding Devices_ No. of Dryers Heating Devices AJ Local❑Municipal ❑other Connection No. of Water Heaters Sins Ballasts No. of � Voltage No. Hydro Massage Tubs No. of Motors Total HP OTHER: INSURANCE OOVERAGE: Pursuant to the requirewawes of Massachusetts General Laws I have a current Li i Insurance Policy insluding Coepleted OperatioCoverage or its bstsatial equivalent. YES NO U Operations Coverage, have submitted valid proof of same to this office. =Agr NO If you have checked YES, please indicate the type of coverage by checking the approprL•.s box. INSURANCE M-B'= ❑ OTHER❑ (Please Specify) 197 at on to Estimated Value o Electrical Work S� Work to Start Inspection Date Requested: Rough �/ �� Final Signed %&"4er the penal ie�'oIf perjur;t FIRMS NAME - t l^�1 �� e 1 Y4 /�l G LIc. NO. Licensee 1 Signat-.tre, LIC. No. Address (01#0 Due. Ll. No. — Alt. Tel. No. OwKM,S INSURANCE WAIVER: I as aware that the Licensee does not have the iesurance coverage or u sub- stantial equivalent as required by Massachusetts Generalws,�that my signature on this pemit application waives this requirement. Owner Agent (Please check one) Telephone No. PERMIT FEE S• Signature of Owner or enc • _ � t Date.... T �f...�. .� • ' 586 TOWN OF NORTH ANDOVER .- ° '° PERMIT FOR WIRING ssAcnusE� :S' This certifies that ......... .... ....... .... has permission to per ... ............ .............................. c wiring in the building of.... .... 6. ..� .... .. ... .. ......................... at...f fes.J .. .... .. ... lee .. . .. .......... .North Andover,Mass. J Fee.-,R'S-f'40 ...w.. Lic.No.... D........................................................... J ��(�� ELECTRICAL INSPECTOR .f1'71.91`13:22 25.00 FOID WHITE:Applicant CANARY: Building Dept. PINK:Treasurer Date. . .. . .. . . .. ,40RTM TOWN OF NORTH ANDOVER 0 PERMIT FOR PLUMBING SSAA—A cmus This certifies that . . . . . . . . . . . has permission to perform plumbing in thz buildings of . . . . . . . . . . . . . at . .O-. . . . . . . . . . .... North Andover, Mass. . . . . . . . . . . . . . . . . . . . . . . F d—e . . . . . .Lie. No..9('y� . -'LUJ . . . . . . . . PLUM rN PECTOR Check # AP10 5335 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHU Date Building Location Owners Name f Permit# -f Amount Type of Occupancy New Renovation Replacement Plans Submitted Yes 0 No ❑ FIXTURES z d F ' E� W W. a C w w w x SLRBM BAWVM ]S)r>~IDCI2 �II FIAOlt 41H HOCi2 5M HJOCIt 6M11" 7M I" fM SIH FIfM 74 (Pjnt or type) Check one: Certificate Installing C aname / Corp. Adn`less E I - - Partner. USITS Ib one i FHmVCo. Name of Licensed Plumber: Insurance Coverage. Indicate type o ' surance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑. Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent ❑ I hereby certify that all of the details and informatio ave submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work ri ons-peormed under Permit Issued for this application will be in compliance with all pertinent provisions of the sstate bing Code and Chapter 142 of the General Laws. By: Signpdreofse um er Title Type of Plumbing License City/Town c se um e�� Master � Journeyman ❑ APPROVED(OFFICE USE ONLY � NORTy 1 s�•° Town of North Andover k = _ Office of the Planning Department �D Community Development and Services Division r '�.9 DgATlD r.•",�q`� 400 Osgood Street SSACH1IS� North Andover,Massachusetts 01845 NOTICE OF DECISION Any appeal shall be filed j within (20) days after the date of filing this notice in the office of the Town Clerk. Date: September 15, 2009 Date of Hearings: August 4,2009, September 1,2009, September 15, 2009 Date of Decision: September 15,2009 Petition of: Eugene and Anne Saragnese, 105 Bonny Lane.North Andover,Massachusetts, 01845 Premises Affected: 105 Bonny Lane,North Andover,Massachusetts,01845, Assessor's Map 62,Parcel 52 and located in the Residential 1 Zoning District. Referring to the above petition for a Watershed Special Permit from the requirements of the North Andover Zoning Bylaw, Section 4.136. So as to allow the razing of an existing dwelling unit and to construct a new dwelling unit, with an extended footprint, an increase in driveway area and the installation of stormwater management system, and related grading and landscape work within the 250 foot Non-Disturbance and 325 foot Non-Discharge Buffer Zones of the Watershed Protection District. After a public hearing given on the above date, the Planning Board voted to APPROVE a Watershed Special Permit for the Watershed Protection District,based upon the following conditions: Planning Board John Simons,Chairman Richard Rowen Timothy Seibert Michael Walsh Courtney LaVolpicelo cc: Town Departments Applicant Engineer Abutters 105 Bonny lane Map 62,Parcel 52 Watershed Special Permit—Construct Single-Family Residence September 15,2009 Assessor The public hearing on the above referenced application was opened on August 4, 2009 closed by the North Andover Planning Board on September 15,2009. On September 15, 2009, upon a motion made by Michael Walsh and seconded by Timothy Seibert to GRANT a Watershed Special Permit to construct a 3,537 sq. ft. single-family residence with attached garage and deck, expansion of an impervious driveway, installation of stormwater management system, and related grading and landscape work within the 250 foot Non-Disturbance and 325 foot Non-Discharge Buffer Zones of the Watershed Protection District under the requirements of Section 4.136 & 10.3 of the North Andover Zoning Bylaw. This Special Permit was requested by Eugene and Anne Saragnese, 880 Great Pond Road, North Andover, MA 01845 on July 2, 2009. The applicant submitted a complete application, which was noticed and reviewed in accordance with Section 10.52 of the Town of North Andover Zoning Bylaw and MGL Chapter 40A, Section 9. The motion to approve was subject to the FINDINGS OF FACTS and SPECIAL CONDITIONS set forth in Appendix A to this decision. The Planning Board vote was unanimous. A special permit issued by the special permit granting authority requires a vote of at least four members of a five-member board. The applicant is hereby notified that should the applicant disagree with this decision, the applicant has the right, under MGL Chapter 40A, Section 17, to appeal to this decision within twenty days after the date this decision has been filed with the Town Clerk. In accordance with 4.136 the Planning Board makes the finding that the intent of the Bylaw, as well as its specific criteria are met. This decision specifically stated by the Planning Board makes the following FINDINGS OF FACT: 1) That as a result of the proposed construction in conjunction with other uses nearby,there will not be any significant degradation of the quality or quantity of water in or entering Lake Cochichewick. The Planning Board bases this finding on the following facts: a) The project is located within an extremely environmental sensitive area and in close proximity to Lake Cochichewick. The final design reflects extensive discussions between the Town and applicant to ensure the continued protection of Lake Cochichewick and the safety and welfare of the residents of North Andover. b) The construction has been reviewed by Town Staff and the Town's consulting engineer, Lisa Eggleston,and with the application of the erosion control measures and modifications to the drainage and stormwater management designs, the consultant concluded that there will not be significant degradation to the quality or quantity of water in or entering Lake Cochichewick. The site drainage system and storm water management design are designed in accordance with the Town Bylaw requirements and Best Engineering and Management Practices, and has been reviewed by the outside consulting engineer, Lisa Eggleston. See letters from L. Eggleston dated August 21, 2009, August 19,2009 and July 27,2009 and letters from Sullivan Engineering Group dated June 30,2009 and August 12, 2009 respectively. Further, adequate safeguards have been provided to mitigate pollutants from entering Lake Cochichewick through the installation/implementation of the following Best Management Practices relative to a single-family dwelling: i) Roof runoff is routed to infiltration areas. The new structure calls for recharging 1,398 s.f. of roof area, thus providing a net reduction of 363 s.f. of impervious cover. The new structure 2 v 105 Bonny lane Map 62,Parcel 52 Watershed Special Permit—Construct Single-Family Residence September 15,2009 will have gutters and roof drains that will direct runoff to the drywell, which has been sized for the 100 year storm event. ii) No new lawn area is being proposed and the existing"grassy area" as noted on the plan, will remain and will not be expanded. Tree cutting within the 150 to 250 ft. buffer area to the lake is limited to that which is required for construction and for on-going maintenance. There will be no tree cutting within the 150 ft.buffer area to the lake. iii) Fertilizers are limited to those which are either organic or slow-release nitrogen and phosphorous-free. This restriction will be noted on the deed. c) The existing structure is connected to the Town sewer and water systems. d) The topography of the site will not be altered substantially. The new dwelling unit will be built on the foundation of the existing dwelling unit. I 2) There is no reasonable alternative location outside the General, Non-Disturbance, and the Discharge Zones for any discharge, structure or activity. The new dwelling unit will be built on the foundation of the existing dwelling unit. In accordance with Section 10.31 of the North Andover Zoning Bylaw, the Planning Board makes the following FINDINGS OF FACT: 1) The specific site is an appropriate location for the proposed use as all feasible storm water and erosion controls have been placed on the site; 2) The use will not adversely affect the neighborhood as the lot is located in a Residential I Zoning District; 3) There will be no nuisance or serious hazard to vehicles or pedestrians; 4) Adequate and appropriate facilities are provided for the proper operation of the proposed use; 5) The existing lot does not conform to the minimum lot area requirements for a lot within the Residential 1 Zoning District as shown in Table 2 of the North Andover Zoning By-laws and is grandfathered as a lot that existedrior to the change in lot size f p g e or this Zoning District.. i 6) The Planning Board also makes a specific finding that the use is in harmony with the general purpose and intent of the North Andover Zoning Bylaw. Upon reaching the above findings,the Planning Board approves this Special Permit based upon the following SPECIAL CONDITIONS: 1)Permit Definitions: a) The"Locus"refers to the 1.47 acre parcel of land with frontage on Bonny Lane as shown on Assessors Map 62,Parcel 52, and also known as 105 Bonny Lane,North Andover, Massachusetts. b) The"Plans"refer to the plans prepared by Sullivan Engineering Group, dated June 30,2009 and revised to August 12, 2009 and August 24,2009, entitled"Site development Plan of Land, , located in North Andover,North Andover,MA. prepared for Gene Saragnese". 3 105 Bonny lane Map 62,Parcel 52 Watershed Special Permit—Construct Single-Family Residence September 15,2009 c) The"Project"or"105 Bonny Lane"refers to the razing of a 2,148 sq. ft. existing dwelling unit, and the construction of a 3,248 sq. ft. single-family residence with attached garage and deck, expansion of a driveway, installation of stormwater management system,and related grading and landscape work within the 250 foot Non-Disturbance and 325 foot Non-Discharge Buffer Zones of the Watershed Protection District. d) The"Applicant"refers to Eugene Saragnese,the applicant for the Special Permit. P e) The Project Owner refers to the person or entity holding the fee interest to the title to the Locus from time to time,which can include but is not limited to the applicant, developer, and owner. 2) The Town Planner shall approve any changes made to these plans. Any changes deemed substantial by the Town Planner would require a public hearing and modification by the Planning Board. 3) Fertilizers are limited to those which are either organic or slow-release nitrogen and phosphorous-free. This restriction will be noted on the deed. 4) Prior to issuance of a buildingpermit: a) A performance guarantee bond of four thousand dollars($4,000.00) made out to the Town of North Andover must be posted to insure that the construction,erosion control, measures, and performance of any other condition contained herein will take place in accordance with the plans and the conditions of this decision and to ensure that the as-built plans will be submitted. b) All erosion control measures as shown on the plan must be in place and reviewed by the Town Planner and Conservation Department. c) Fertilizers are limited to those which are either organic or slow-release nitrogen and phosphorous- free. The applicant shall incorporate this condition as a deed restriction and a copy of the recorded deed shall be submitted to the Town Planner and included in the file. 4) Prior to release of the Performance Bond: a) The applicant shall submit an as-built plan stamped by a Registered Professional Engineer in Massachusetts that shows all construction, including storm water mitigation trenches and other pertinent site features. This as-built plan shall be submitted to the Town Planner for approval. The applicant must submit a certification from the design engineer that the site was constructed as shown on the approved plan. b) The Planning Board must by a majority vote make a finding that the site is in conformance with the approved plan. 5) No open burning shall be done except as is permitted during burning season under the Fire Department regulations. 6) The Contractor shall contact Dig Safe at least 72 hours prior to commencing excavation. 7) The provisions of this conditional approval shall apply to and be binding upon the applicant, it's employees and all successors and assigns in interest or control. 4 � l 105 Bonny lane Map 62,Parcel 52 Watershed Special Permit—Construct Single-Family Residence September 15,2009 8) This Special Permit approval shall be deemed to have lapsed September 15, 2011 (two years from the date of issuance) exclusive of the time required to pursue or await determination of any appeals, unless substantial use or construction has commenced within said two-year period. Substantial use or construction will be determined by a majority vote of the Planning Board. 9) This decision must be filed with the North Essex Registry of Deeds. The following information is included as part of this decision: a) Plan titled: Site Development Plan of Land 105 Bonny Lane,North Andover,Mass. Prepared for: Eugene Saragnese 105 Bonny Lane North Andover,MA 01845 Prepared by: Sullivan Engineering Group 22 Mount Vernon Road Boxford, MA 01921 Scale: 1"=20' Date: June 30,2009 and revised August 12,2009,August 24, 2009. Sheets: 1 cc: Director of Public Works Building Inspector Town Manager Conservation Administrator Drainage Consultant Planning Board Police Chief Fire Chief Applicant Engineer File I 5 t40RTH TOWN OF NORTH ANDOVER R �`' oma OFFICE OF ° BUILDING DEPARTMENT c » + 1600 Osgood Street Building 20, Suite 2-36 * 4 camca+aw q�gATED�� ty North Andover,Massachusetts 01845 �SSgcHusE� Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION i Please Drint DATE: JOB LOCATION: LE PA-7 Number Street Address Map/Lot HOMEOWNERRL1eCOL-jAi/ -76 -6�3 Name Home Phone Work Phone PRESENT MAILING ADDRESS l 5_ -iREIPLE PM-7t /J. ApXwEk M4 City Town State Zip Code The current exemption for"homeowners"was extended to include owner-occupied dwellings to two units or less and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) F DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned"homeowner"assumes responsibility for compliances with the State Building Code and other Applicable codes,by-laws,rules and regulations. j The undersigned"homeowner"certifies that he/she unders nds the Town of North Andover Building Department minimum inspection procedures and re ire m nts and th he/she will comply with said procedures and requirements. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption i BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 The Commonwealth of Massachusetts Department of Industrial Accidents Office ofLnveshgations 600 Washington Street I Uf Boston, MA 02111 www.mas&gorldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information p Please Print LeQibl Name(Business/organization/Individual): Q -� �2CO L //v/ k Address: 'l g-5- J990 i City/State/Zip: A), /Uao V n Y) Phone#:_ 42 Are you an employer?Check the appropriate box: 1-❑ I am a employer with 4. ❑ I am a general contractor and I Type of project(required): 2.❑ employees(full and/or part-time) * have hired the sub-contractors 6 New construction I am a sole proprietor or partner- listed on the attached sheet $ �• ❑Remodeling ship and have no employees These sub-contractors have 7-- working for me in any capacity. workers' comp.insurance. 8. ❑Demolition [No workers' comp. insurance 5• ❑ We are a corporation and its 9. ®Building addition required.] officers have exercised their 10 ❑Electrical repairs or additions 3am 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 4 insurance required.] t employees_ [No workers' 12•❑Roof repairs I Pomp.insurance required.] 13•❑Other m"at^plicant that checks box 4i must also Cul out the section belo.un _ e�^n�:her wort a s'com^a,s�cn po-i-..y ra fi ..-'r- Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors mustsubmit a new affidavit indicating such. $Contactors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information.I an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: j Attach a copy of the workers'compensation policy declaration page(showing theoli y num ber and expiration date). Failure to secure coverage as required under Section 25A ofM'GL 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 W of up to$250.00 a day against the violator. Be advised that a co WORK ORDER and a fine Investigations of the DIA for insurance coverage verification PY of this statement may be forwarded to the Office of I I7dohby cfffins of perjury that the information provided above is true and correct Se: 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.PjumbinQ 6. Other b Inspector 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-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 retuned to the city or town that the applicetion for the pe:-cwt or ficense 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 bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would Ince to thank you in advance for our cooperation and should you have an questions, g Y Y P Y Y 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 021.11 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-72.7-7749 Revised 5-26-05 wWV7.mass..gov/dia TOWN OF NORTH ANDOVER AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application MGL c. 142 A requires that the"reconstruction, alteration, renovation, repair, modernization, j conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units...or to structures which are adjacent to such residence or building" be done by registered contractors, with certain exception, along.with other requirements. Type of Work: ADD 177 01J -f rcEgbUA-n orf Est. Cost C325,�0 Address of Work QS P.JSCk-,- PAITlf M, /kNZ>6VE ; /11/}- Owner Name:_ 1?-019L-ILT EzC p LI l\1 f Date of Permit Application: hereby certify that: Registration is not required for the following reason(s): For office Use Only Work excluded by law Pemit No. Job under $1,000 Date Building not owner-occupied X Owner pulling own permit Other (specify) Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FIND LINER MGL c. 142A. Signed under penalties of perjury: I hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. OR: Notwithstanding the above notice, I hereby a for a permit as the owner of the above property: Date Ow er Name i i 09/13/2006 14:25 6177961086 INSPECTIONAL SERVICE FAbt U1l01 i I ENERGY 0 LOW-RISE RESIDENTIA.L NEW CONSTRUCTION and AJA TIONS 786 CMR Appendix I Applicant Name: P,0130ZT eZ_C0 U N( Site.Address: jq6 WAD—L6 PA-10+- Applicant Address: I QS fie�nl /i-litCity/Town: N.ApDaya i m A 2av60\4- Use Group: RZ,f tO�yT7A C _ Date of Application: Applicant Phone: 1"0—b 67—tel:v Applicant Signature: Compliance Patti(check one): ❑ ,Prescriptive Package(Mmiled to 1-or 2-family wood frame buildings heated with fossil fuels only) Package(A,through KK from Table 15.2.1 h): Heating Degree Days(:RPD.')from Table J5.2.1 a:._ (For items d. through i.,fill in all values that apply from Table 15.2.1.b:) a. Gross Wall Area _ sq.ft f. Wall R-value R- b, Glazing Arca' sq.ft. g. Floor R-value R^_ h. Basement wWJ d. Glazing U-value U- i. Slab Perimeter. R- e, Ceiling R-value R- j. bleating AF'UE ❑ Component Performance:"Manual Trade-Off'(Limited to wood or metal framed buildings only) i Climate Zone(frons Figure J6.2.2) ❑ Zone12 [I Zone 13 ❑ Zone 14 � Anaeh Trude-OflWorksheet from Appendix J,[and HVAC 7}ade-Off Warksheet,if applicable) ❑ MAScheck Software ,nrtaeh Compliance.Report and 1mvpection Checklist printouts ❑ Home Energy Rafting System Evaluation . I Attach Horne Energy Rating Certificate(HERS rating score must be 83 or higher) ❑ Systems Analysis OR ❑ Renewable Energy Sources Attach Mass Registered Architect or Engineer Analysis ALTERNATIVE FOR ADD.I,T,TONS ONLY:. a.Gross Wall+Ceiling Area 4022 sq.t3. b.Glazing Area' ZZ-Q sq.ft. c.Glazing%(tum x h a) e� ❑ ADDMON with Glazing%(c.)op to 40%may use 780 CMR Table J 1.1.2.3.1 below; MAXIMUM U-valve MINIMUM R-values Fenn�tratMn' colmna, 1 Wall Floor Bai°ment Wali SMh Perimeter Deoth D i9' R-17 I R-13 R-19 R-10 R-141 4 it I Glazing Area may be either Rough Opening or Unit dimensions. 2 Based on NFRC listing. Applies either to every unit,or to arca-woightod average of all units. 3 R-32 ceiling insulation may be used in place of R-37 if the insulation achieves the full R-value over the entire ceiling area (i.e.-not compressed over exterior walls,and including any access openin,p.) ❑ "SUNIROOM"addition(greater than 40%glazing-to-wall And ceiling gross area) Attach"Consumer Informiation Fm-m"from 780 C..MR Appendix B. ' Official's Name: _.,�. Official's Signature: Application Approved ❑ Denied ❑ Date of.Approval/,Denial: Reason(s)for Denial: (provid<,additional details as needed on back side) j I x.10 R TIy own of o '" C,o - E dover, Mass., $///s X/40 .10 Aj COCMICMEWICK ORATED �� BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT....... ... ..0. 66 ........... .......................................... ............................. Foundation has permission to erect........................................ buildings on .... Rough to be occupied as........... .; �..k ... ...s.......% � T(tB / f 3.....' 7��,5' Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION S TELECTRICAL INSPECTOR S Rough ..................... ............ ........................ .. Service BUILDINECTOR 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 Until Inspected and Approved by the Building Inspector. Burner FlRE DEPARTMENT Street No. SEE REVERSE SIDE Smoke Det.