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Building Permit #827 - 197 CAMPBELL ROAD 5/17/2012
TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 1;-�-� � Permit NO: j1 Date Issued: IMPORTANT: Date Received must complete all items on this LOCATION Print PROPERTY OWNER AJ. /-- Z)A6 Unit # J Print MAP NOfPARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no 100 year-old structure yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building X One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial j(J Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other s laic ;D �Wetlauds P_ q ~'�Watershed�Distnct; , �(j:Septic ,0'iWell `E(]�Flood iA:Water/Sewer - - I)ESUK W 11UN Ut W UK& t U 15r rr✓iU vtuvIr,L: 0'1 (Identification Please Type or Print Clearly) OWNER: Name: ���sl.c� �..� Phone•gPF 6 19 `�E� � Address: 19 % A�«� 4"/Yam �}waa vF,, /Yr9 01y� CONTRACTOR Name: T/Kic v,t �— /CGdFiN(r Phone: 9n &J3,3 yd -o Address: o? O 0 SL; i7D� Supervisor's Construction License: g ��5� �' Exp. Date: /-0� Home Improvement License: 16 `/Yz y 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: $ /D (Po o' 6 ° FEE: $ 1 d ` Check No.: Receipt No.: 0'�5 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund • () l; C.._-.-- , - Location1 No. Date. Check# k� 25314 TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee Foundation Permit Fee Other Permit Fee TOTAL Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ 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 DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature C©MMENTS 3 Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comme Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date C3 o c � a C ` C y O_ C o O v C2 •d'O O. C t0 O m C ;Z O ' � O EQ L w CD a m w CL P-4 N C a o� w ts cm CD C z C L N R CDm p ca N cm O CD m� o Cc 0 l: N C T R N CD 0 CV L N O m C O Q N O,CZ O O H Ci Z C }. O ; Ca -,DC = OCL.O_, p w N COD rp� C CD ea t = O •GNA w. C w OC oC 'E CL v N LU C1 fl �F c CD o CIO o `/) � = P 60 A .0 O 2 C i a G w � o � r W o `° q ° a4 x w cn w" a°' w p cn C/)- n zCL a €o U C� i� 0 0 � U cf). C w �U CD cm 'v^J c cm w . C C12 PL4 L O Ql C' G N CD t 0 Z C2 s . -X O_ 006 dmmmw� a N v O O LLI Ul ca 19 W LLI W U) o c � C ` C y O_ C o O v C2 •d'O O. C t0 O m C ;Z O ' � O EQ L CD • m CL N C o� 0 0 ts cm CD C C L N R CDm p ca N cm O CD m� Cc • r l: N C T R N CD 0 CV L N O m C O Q N O,CZ O O H Ci Z C }. O ; Ca -,DC = OCL.O_, p H N COD rp� C CD ea t = O •GNA w. C w OC oC 'E CL v N LU C1 fl �F c CD o CIO 40 O O� S N = P 60 A .0 O 2 C a €o U C� i� 0 0 � U cf). C w �U CD cm 'v^J c cm w . C C12 PL4 L O Ql C' G N CD t 0 Z C2 s . -X O_ 006 dmmmw� a N v O O LLI Ul ca 19 W LLI W U) The Commonwealth of Massachusetts c I Department of Industrial Accidents Office of Investigations 'L r 600 Washington Street w = ; Boston MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): OAS TRI CO N L I 1 00 —1 N G St p t (V6- Address: V6-Address: a 0 0 Su ; ro lQ STt�f-F r , 50 1 T E .Z)- t- City/State/Zip: N 0. And oy iC H/4 01 k f Phone # 7b 6 J 3 3�Ao Are you an employer? Check the appropriate box: 1. M I am a employer with v 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. $ 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.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12X Roof repairs 13.0 Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors acid their workers' comp. policy information. 1 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. #: we_() 6)3 / 8 M13 Expiration Date: �J3 Ioa Job Site Address: ) -1 (3t L1— D{�i�City/State/Zip: Re, &JD �\'i III' Public Jafcn of Bijijdin, R(..,tj Construction supervisor Specialty License License: CS SL 99358 Restricted to: RF,WS DAVID CASTRICONE 31 COURT STREET NORTH ANDOVER, MA 01845 Expiration: 12/16/2013 Tr%;: 7924 Office of C( Isil I 11C Bmsiliess ME IMPROVEMENT CONTRACTOR t:: jirj IIS Registration; '104569 Type: Expiration: 7/14/2012 Private Corporalio T ICONE ROOFING, SIDING & David CastriCone 200 SUTTON ST SUITE 226 NORTH ANDOVER, MA 01845 CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) ACORD 9/23/2011 THIS CERTIFICATE 1S ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW: THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(Sy, AUTHORIZED rLr�IT11 Tn/r An nn AnllA rn •\In Tllr �r nTlrll'�Tr nnr•n IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTAUT NAME: Eastern Insurance Group LLC - Main PHONE wc.No.E ),508-651-7700 aCNo508-653-8089: 233 West Central Street EMAIL Natick MA 01760 ADDRESS: INSURERS AFFORDING COVERAGE NAIC b RSURERA:Commerce Insurance Company 34754 INSURED 31 969 INSURER B David Castricone Roofing & Siding Inc INSURER C: 200 Sutton Street #226 INSURER D: North Andover MA 01895 INSURER E COVERAGES CERTIFICATE NUMBER: ?1 41 634407 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR un u�.r rv�mocn ��tMEY FIEF rt Ir .92 �XP mi VAX GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FlOCCUR EACHOCCURRENCE $ PREMISS a occutrenoel $ MED EXP (Any oneperson) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- jECT F7 LOC PRODUCTS - COMP/OP AGG 1 $ $ A AUTOMOBILE X LIABILITY ANY AUTO ALL OW14EDX SCHEDULED AUTOS AUTOS NON -OWNED HIREDAUTOS X AUTOS BCNGCV /1/2011 /1/2012 LV�UWIBIN 1000000 BODILY INJURY (Per person) $20000 BODILY INJURY (Per accident) $40000 ) PROPERTY DAMAGE Peraocidenl $ UMBRELLA UAB EXCESS LIAR OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION$ $ g WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNEMXECUTIVE OFFICERIMEMBER EXCLUDED? (Mandatory in NH) If Tres, descnlbe under DESCRIPTION OF OPERATIONS below N / A WC003989723 9/23/2011 9/23/2012 X WCSTATU- OTH- E.L. EACH ACCIDENT $100000 — E.L. DISEASE - EA EMPLOYE $100000 E.L. DISEASE - POLICY LIMIT $.500000 u wunv i wry yr arc n1a n�rva w�wuVrva / v[MIRt2i IAnacn AGOMU 101, Additlonal Remarks Schedule, If more spooe Is required) T Castricone Roofing & Siding Suite 226 200 Sutton Street North Andover, MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 01988.2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD AIS CERTIFICATE OF LIABILITY INSURANCE D/9/2'°° 9/9/2011 1 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the pollcy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, csrteln policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endersamantfal. PROOUCER Willows Insurance Agcy 51 Cochichewik Dr North Andover MA 01845 INSURED - DAVID CASTRICONE ROOFING 6 SIDING INC 200 Sutton St Suits 226 NORTH ANDOVER MA 01945 �9- 970 475 3414 _- DDItE":. - — ......_._ MYCER ONES ID I. _.. iNUIRER(S) AFFORDING COVERAGE _ NAIC SURM A widen Specialty Ins Co aURER C GVVtKAUE5 CERTIFICATE NUMBER:CL119906259 REVISION NUMBER, THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTAN01W ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOW_ N MAY HAVE BEEN REDUCED BY PAID CLAIMS. LJTSRA i TYPV OF INSURANCE POLICY MLAMER P EFF 4 1 W1`O`0Y EXP ---' UMRe j OENEttAL uABIUTY EACH OCCURRENCE S 1000000 I X COMMERCIAL GENERAL LIABILITY — "---.. _.... .— -- ... � PREM�I5�,S1Ctieenrrenm� 15 50000 A II CLAlM34AADE I x l OCCUR Qn00031600 9/06/2011 /6/2012 MED EXP (Any enson S 1000 pER-SONAL 6 ADV INJURY t 1000000 GEML AGGREGATE LIMR APPLIES PER AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS UMBRELLA LIAROCCUR EXCESS LIAB cwM$ DEDUCTIBLE AEWEMPLOYERS• LIABILITY WEXECUTIVE OFFICE ANY PRDPRIETOWPARTNEYIN RMEMBEREXCLUDED? (MIA (MM MetM In NM) o 9 Yap, deaeAbe ,ndw DISC RUMOM OF OPERATIONS I LOCATIOM I VEHICLES (Albeh ACORD 1(1, AddRlonsl Remake Sehsdule, R Ihen apses k Mquired) TE GENERAL AGGREGATE S 200000_0 PROD41; S • OMWDA AGG 5 1000000 S COMBINED SINGLE LIMIT (Ea sGCidsnl) s BODILY INJURY (Per pen0n) S BODILY INJURY (Per awdwl) $ PROPERTY DAMAGE (Pw ecGdenQ S S S EACH OCCURRENCE >i DISEASE . EA EMPLOYE S SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN David Cas tricone Roofing 6 $iding Inc ACCORDANCE WITM THE POLICY PROVISIONS, CastriCone Roofing 200 Sutton Street Suite 226 AUTHORIMUPRaaTATTVE N Andover, MA 01845 n ACORD 25 (2009/09) INS025 (zooeo9l The ACORD name and logo are registered marks of OR ORD CORPORATION. All rights reserved. Town of North Andover 0�4st�° p Building Department o - - L. 27 Charles Street '' 3 North Andover, Massachusetts 01845 (978) 688-9545 Fax (978) 688-9542 �RAreo A -F t7 '4�SN C NU Sit DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and a condition of Building permit # the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c•11, sl 50a. The debris will be disposed of in /at: /— Z- } E IN(f Facility location Signature of Applicant Date NOTE; A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector• DAVID CASTRICONE CASTRICONE ROOFING & SIDING INC. ROOFING, SIDING & REMODELING REPLACEMENT WINDOWS HOME IMPROVEMENT CONTRACTOR REGISTRATION NUMBER 104569 200 SUTTON STREET, SUITE 226, NO. ANDOVER, MA 01845 In North Andover 978-683-3420 In Boxford 978-887-6147 In HoverhW 978-374-7314 Uwe the owner(s) of the premises mentioned below, hereby contract with and authorize you as contractor, to furnish all necessary materials, labor and workmanship, to install, cons ct and place the improvements according to the following specifications, terms and conditions, on premises below described: �r77 /�pp // vv Owner's Name..... r(, 1.Ls.r.11.....�........................................................... Telephone #..... �r 8l.....7.�c:1.A..(�S........ 17Z... ..., , Job Address ............. �r�xt.� .r................... Crty......c?,.....kt„ .V(Lf .................. State.....:...... Specifications: ................................................................................................................................................... ✓Strip existing shingles. �J� -4pply new drip edge to all edges. D!'7r:�t� ........................................... t/Apply feet ice and water shield membrane to bottom edges of house. 3 feet ice and in valleys and bottom edges of any unheated areas of house. 3 ............................................................................................. ,Apply felt papgrytrdyrlayment Mall ridge vent to ,,.Reroof ting ,, �r r - , n )r� rrfc �f tY ...................................... membrane j............................ ...................................... ............................................................. shingles with a� year warranty. ................................................................................................................................................................................................. t.e6unterfash chimney. New vent ripe fashing. c� egal disposal of all debris. ...........................................0.....s.�.........A7ea(s) to be worked on: l..l...../�G?rr....... .....ft ...........:1i..rza�.. ............a'./ .. ...J`. .. .. i. ... ... .......Y...(.`/.xn:......�.�z..�.�1'c�.......���........[z.........l.:Y�,�,sa,S :........,1.7i�....... cK.�cS.......................................................... i ................................................................... ........................`................................................................................................................... Roof board replacement if necessaryQ en /sheet or � °-!-/foot. ............................................................................................................................................................................ .......................... Two Year Workmanship Warranty (Not Transferable) M'anufacturer's Warranty as specifi manufacturer .. The for agreeerform the work ish the materials specified above for the SUM o ...,�Cj.1 ..Q.Q............. 1 a able .. Q.D....... on .... ........... Payable .... =r= ............... on ......... .=............... alance Diable on completion of iob Owner or Owners are not responsible for Property Damage or Liability wh fob is in operation. Contractor is not responsible for any damage to the interior of property, including pre-existing conditions (i.e. water stains, crumbling plaster, exposed nails) or conditions resulting from application of materials specified above (i.e. objects coming loose from walls, crumbling plaster, exposed nails, dust in attic or other living spaces). Items in attic may need to be covered by homeowner. All materials are property of contractor, Any dumpster placed by contractor is for his use only. Upon completion of above work, all undersigned agree to execute and deliver to contractor, their joint note in accordance with his (their) above obligation as requested by contractor. Upon refusal to do so, contractor may at its option declare the entire contract price or so much as then remains unpaid, immediately due and payable. It is agreed that, if permitted by law, contractor shall be paid by the owner(s) all reasonable costs, attorney fees and expenses, in addition to the amount due and unpaid, that shall be incurred in enforcing the terms and conditions of the contract and/or any lien in connection herewith. It is further agreed that this contract may be assigned by contractor, and also that the obligations hereof shall bind and apply to their heirs, successors or estates of the parties. The undersigned warrant(s) that he is (they are) the owners(s) of the above mentioned premises and that legal title thereto stands of record in his (their) names(s). There are no representations, guaranties or warranties, except such as may be herein incorporated, if any, nor any agreements collateral hereto, nor is the contract dependent upon or subject to any conditions not herein stated. Any subsequent agreement in reference hereto shall be binding only if in writing and signed by all parties. All Home Improvement Contractors shall be registered and any inquiries about a contractor or subcontractor relating to a registration should be directed to: Director, Home Improvement Contractor Registration, One Ashburton Place, Room 1301, Boston, MA 02108 Tel: 617-727-8598 Any and all necessary construction -related permits shall be obtained by the Contractor. Any Owner who secures his own construction - related permit or deals with unregistered contractors is excluded from the Guaranty Fund provisions of MGL c. 142A. Approximate starting date of work ................................................ Completion date ......................................................... Receipt of a copy of this contact is hereby acknowledged, and it is further acknowledged by the undersigned that the foregoing provisions have been read and the contents thereof understood and that no representation or agreement not herein contained shall be binding upon the parties and that all of the agreements and understandings of said parties are contained herein. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Owner has three business days to cancel this contract and incur no penalty (see notiCtice of cancellation). y IN WITNESS WHEREOF, the parties have hereunto signed their names this ..../ J.� day of....... 20.IA�.�.. Accepted: Signed ..� l�L . :-7 ......:. ..... r�..::: ,. Owner Signed............................................................................. Owner ................................................................... David Castricone, President ori �e, 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.s100-s1000 fine NUI tb and uA I A — (I -or department use ❑ Notified for pickup - Date Doc:.Building Permit Revised 2011 June/mi 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 ❑ Building Permit Application ❑ Workers Comp Affidavit r ❑ Photo Copy of H.I.C. And/Or C.S.L. Licenses t ❑ Copy of Contract ❑ Floor Plan Or --- 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 o 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 2008mi Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or nr.%Ors V 6W Ihspector of Buildings N(A 0�8��' DEC 1 X011 TOWN OF NORTH ANDOVER To: Board of Health or HEALTH DEPARTMENT Board of Selectmen RE: Insured: 7z�;ft Property Address: l q T e44V Policy Number: � 37,99 3� Date/Cause of Loss: /o! / 11 14'A 4 S -Iii5vm File or Claim Number: .tgos ��64� Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. On this date, I caused copies of this Notice to be sent to the persons named above at the addresses indicated above by First Class Mail. &6" ► 01 Signature - nd Dale I NEW ENGLAND CLAIMS SERVICE, INC. 131 DODGE STREET, SUITE 6 BEVERLY, MA 01915 Location No. Date NORTIy TOWN OF NORTH ANDOVER Certificate of Occupancy $ � Illp �� ; Building/Frame Permit Fee $ �,SSACMUSEt� Foundation R,.eqit Fee $ Other Permit Fee VJ- $ f Sewer Connection Fee $ Water Connection Fee $ . TOTAL 0� $ Building Inspector 8548 D� Div. Public Works 0 u > > mfn 0 0 m m m m N - 0 F r a 0 0 m c i a m m i -ni Z Z a a N w Z N M C 0 J 0 z w m f N y N> o 0 o m> �= 0 0 r N A o r C C - C> - it > i > > r Z z 0 > Z m 0 m �_ 0 0 0 0 n m n m n m A m n y y > 90 r O z 'n Z m Z 0 r 0 A A O a Z i> m O Z > Z Z m z>> 0 r O Z m i 0 i 0 i m > 3 m y o m m m r a 0 Z m > -+ r i A z M ro vi 0 A r i -04� 0 3 z m c =V TI N \ v m > '< A n m a o a Q Z/ coli '� �� ° z A m Q ^ p 0 10 Z i U) T ^S , z Z 0. 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C0 OG 0 0 a 0 G1 z b �. cn x d po tz 03 O C 411 in CD N The Commonwealth of Massachusetts Department of Industrial Accidents /1ff= 8/18ramilffAff 600 Washington Street Boston, 3fam 03111 Workers' Compensation Insurance Affidavit the following workers' compensation polices:`---" comoanv name: _ ! do hereby certify under the pains a!y penalties ef perjury than the infor»tarion provided above is true and correct Print name A 0 . \\ �UiZ . J _Phone it (D(a q (o 1l otricial use only do not write in this area to he completed by city or tow t♦ official city or town: permMicense X f ; Building Department E3 check if immediate response is required contact person: (nva.d IAS PJA) OLicensing Board ClSelectmen's Office [3Health Department phoae ft; rSOther (n__ se pr;nt; D.� Town of North Andover BUILDING DEPARTMENT Homeowner License Exemption tiu �_ Street Aadress Sec__on or tct.;r Hcme Le/one Dior:: .:one eAm?-,lrat-2� A►.� 0\1ra V?. n_ .S LG LC Z -p "homeo,,mers" was extenQe-J to incl utile of.;i e or six units or Less and to allow such homeo.;;te__ t� for hire who aces not possess a License, pro'.:. ac ---z as supervise_. (S tat=_ Buiidinz Code , Sec t_orl �Gr-of Land on wn_c:l Slle ^� res�c�s or 1.^.__.. Ls_.c o" a lei 1S, Or is in -ended Lo be, a one to Luh_ a. G__`. .....e�_. Cr QaG.._Gr..len .5•Lr uc ..ur=s ac. eJ .l�%rLo such use c•1 t:c.i wr _. t who construc_s more than one home in a- c �e cor.siaered a homeowner. Suc:/ "homeowner" sila'-_- ✓�yUf=_c4al on a ior.m acc=o:acie to the Buid_nZ , t::�_ be reGconsibie _`o_ all such .ior.._ per - or-ea�ui . __ �..- on 101,.1.i; _a. .. __--._�__-_ .�._-.:�,.•-__ Je:.a_ _..._ _^ •^_.,_.•etc^ _n=I✓�.___c:: orJ�.�r•,._-s -1�•- _ - __ _ ( -----LGr_.___ TOWN of NORTH ANDOVER AFFIDAVIT Ike bpmymEnt Cudactor Law anilem3ittD lit tgAicatim !Ik -• a 1 1 1 - 0•• ■ ■ Irz.r: ■ • 0 M RZ I• w to I M Itz•:1 I am Il•. Z. 41 VIM ■ Is 1 W64 0:•.Y • II• • OI16 011• i •011• ■ • •' •• . ■. w • •' .4•1 ■ • /• . .:.�� w • • ••• •1 0• • 1 • K1160101it"Mrs0. •- •'lot 1 •1 •- • • 1 • O.J �• •• 1■I: I• A 1 1 •� Y.1 �••arw • . • I tali to 1X011111 Type of Work: �Dk e- e K Est. Cost ll2orj- Address of Work X91 (� A nn93 E LL k)2 A Q 'CDU 52 . Owner Name: e tZ' I A r.3 • ioo� . FG �Zi- Date of Permit Application: (o -2-4 - q,zr I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under $1,000 Building not owner -occupied _/Owner pulling own permit Other (specify) Notice is hereby given that: Far awe Use Only Rpt ND. Date OWNERS PULLING THEIR OWN PERMIT OR DFA1JNG WITH UNREGISTERED OONTRACMRS_' FOR APPLICABLE HOME IMPROVEMENT` WORK DO NOT HAVE ACCESS TO THE ARBITRA- TION PROGRAM OR GUARANTY FUND UNDER MGI. c. 142A. Signed uYhr penalties of perjury: I hereby apply for a permit as the agent of the owner: (0 Date OR: Contractor Name Registration No. Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property:,,� "-:pI G -29-961" ' Date ner Name BY-1�2=;% --__DATE 6= eZUS PROJECT---- C--�------------------------- SHEET NO. ----•---OF------ CHKO. BY -------DATE------- ----------------------- ----------------- JOB NO.------------------ Lis C W 1.�„'yiS of IM u Lo r-� � O Ji1d3S zz�,- -moo. U �n � u N (y I r i IM u Lo r-� � O Ji1d3S zz�,- ~ ^ BY -__-_----'- DATE -------- PROJECT -------------------------------------- SHEET NO --------- OP ' 48 v 4-8 \\\ O I 14 ' 48 v 4-8 \\\ O I NOTICE OF DECISION Any appeal shall be filed within (20) days after the date of filing of this Notice in the Office of the Town Clerk. April 19 , 1985 Date............ ............ Petition No........ - ' 85 ............... Date of P -3aring ..Apr i 1.. 8 , ..:19.8 5 Petition of .....BRIAN FORD ................................... I ...........» ............ Premises affected .... 19.7. Campbell _ Road .................... ........................ Referring to the above petition for a variation from the requiremen ; of the . Z oni'ng . By. Law Section. .7,. Paragraph.7...3. and..Tab.le. 2 ................ ....................... so as to permit relief .from..the .side..line. s.etback .requi_remen.t .to .allow the. conti, nued..e xis tence . of.. a. garage ......................................... After a public hearing given on the above date, the Board of Appeals voted to .. Grant ... the variance.. aTaexaX�;lc�kila���coc�x pmlli ox............................. .................. ............................ � )sec �brrroiio�,�sE�lgec �tbvac���s:b�s�a�kka�����t Signed Frank .Se.rio., . it ..,..Chairman ........ Alfred E...Fi ze11e,. Esq..,. Vice.Chairman Augus.tine . W.. N.ick_�rs.on.,..Cl.etk.:. . William. J.. -Sullivan .............. . Walter- F.. Soule........ ... .. . . Board of Appeals R EO L• !YE 0 _fir DANIEL LONG ,�°°"'°�"T� ; �; PML NORTH:I:OVER '49ss' ��•�:� ►,� Acriu �, APR i 9 3 37 PM '$5TOWN •rrtvt� OF NORTH ANDOVER MASSACHUSETTS BOARD OF APPEALS NOTICE OF DECISION Any appeal shall be filed within (20) days after the date of filing of this Notice in the Office of the Town Clerk. April 19 , 1985 Date............ ............ Petition No........ - ' 85 ............... Date of P -3aring ..Apr i 1.. 8 , ..:19.8 5 Petition of .....BRIAN FORD ................................... I ...........» ............ Premises affected .... 19.7. Campbell _ Road .................... ........................ Referring to the above petition for a variation from the requiremen ; of the . Z oni'ng . By. Law Section. .7,. Paragraph.7...3. and..Tab.le. 2 ................ ....................... so as to permit relief .from..the .side..line. s.etback .requi_remen.t .to .allow the. conti, nued..e xis tence . of.. a. garage ......................................... After a public hearing given on the above date, the Board of Appeals voted to .. Grant ... the variance.. aTaexaX�;lc�kila���coc�x pmlli ox............................. .................. ............................ � )sec �brrroiio�,�sE�lgec �tbvac���s:b�s�a�kka�����t Signed Frank .Se.rio., . it ..,..Chairman ........ Alfred E...Fi ze11e,. Esq..,. Vice.Chairman Augus.tine . W.. N.ick_�rs.on.,..Cl.etk.:. . William. J.. -Sullivan .............. . Walter- F.. Soule........ ... .. . . Board of Appeals . op l4z:�) 07 -.--GOT-- .r...-. --1 OF t%vo r. 2.1 1 � A Date ... `�.-3/—// .. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that" S WZz-- Z-- - -- has permission to perform .....Q.......... f � .j.�................................................ wiring in the building of ......1�! 2«... R aM ........ ....... at-.,V.............e!��6 ................. .North Andover, Mass-, i Fee ... :............. Lic. No.. 993 3'......................... .. ...... . ...... ..... . . .... . P f E CTRICALINSPECTOR w~; Check # 10 423 K N Commonwealth of Massachusetts official Use Only Permit No. AN 2-:-:5 OEM WON Department ®f Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL. WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perfotryle electrical work described below. Location (Street & Number) ell rzt Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. / Existing Service 2 CV Amps /2PI 12Y6, Volts Overhead Undgrd ❑ No. of Meters / New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and.Ampacity 1 Location and Nat -pre of Proposed Electrical Work: Comnletion ofthe following table may be waived by the Inspector of Wires. No: of Recessed Lum .^aires - - No. of Cell: Susp. (Paddle) tans No. of Tota! Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators ICVA No. of Luminaires Swimming Pool Above ❑ 'In-❑ nd. nd. o. o Emergency Lighting Batter Units No. of Receptacle Outlets No. of Oil_ BnMeTIR FERE ALARMS No. of Zones Ido. of Swdtches No, of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond, Total Tons No. of Alerting Devices . No. of Waste Disposers p Heat Pump Totals: NumberTons KW ........... No, of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑Other Connection No. of Dryers Heating Appliances KW Security e ices `' No. of Deor E uivalent No. of Water KW . Heaters No. of No. of Signs Ballasts • DataWiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: /U — ? / — // Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage rce, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE OND ❑ OTHER ❑ (Specify:) I certify, under the pains andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: /7- e � 4 /11 // Ie � IC. NO.: Licensee: `�,� �� ter•, G � Signatures LICC.2NO.: p �� (If applicable, enter `exempt" in the license numb line.) Bus. Tel: Address: /i 7/�-3S/ �/-;o Alt: Tel. No.: *Per M.G.L c.147, s. 57-61, security work requires Departmenf of Public Safety "T' License: Lie. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. nwnrr/AaPnt r -/- j F, KIA The Co><mmomwealth of Afassachuset& Department of I. ndustrial Accidents Office of Investigations 600 Washington Street Foston, MA 02111 { ' www.imss gov/dia . Workers' Compensation Insurance Affidavit: Builders/ContiractOrsXleotricians/Plumbers Applicant Information Please Print Legfily Name (Business/Organization/Individual): Address: City/Statelip: Phone FAYreyou an employer? Cheek.the appropriate.box:ro a employer with 4 Type of prgject (required): ❑ l am a general contractor and f employees (full and/or part-time). have hired the sub -contractors 6• ❑Newcoristructioh .❑ 1 am.a.sole proprietor. or partner_ listed on the attached sheet. 7• ❑ Remodeling ship and. have no employees These su&contractors have Demolition - 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 3. ❑required.] officers have dxercised their 10•Q Electrical repairs or additions 1 din a homeowner doing all work right of exemption per MOL 11-❑ Plumbing repairs or additions myself, f No•workers' camp. c. 1.52, § 1(4); and we have no q ] .employees. [No workers' insurarlce•re uired. t 12.[] Roof repairs comp. insurance required.] 13❑Other *Any applicant That checks boP# l must also fitt out the section below showirxg their workers' bompensation policy information, t Homeowndrs who submit this affidavit indicating thr y are doing all work and their hire outside contractors must submit a new affidavit indicating such, IConlJactors that oherJr this tiox musisttached an additional Fhsctshocviag. t_he r.�are of tare sub-conhactor turd their tferkz s' camp. policy i nfa n iron• 1 On an employer that is proaidiag:wQriceP:r' co�itpevlseadOrg ieasaar,7XCe 0r a to ees: Belacv is the oldc and 'ob site information. f y P Y ! Insurance Company Name: ' Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' 'compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Secfion 25A of MGL c. 152 can lead to the imposition of criminal penalties of a - fine up 10,$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 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 ofperjury that tate infoFination provNed afiovn is true and correct: Official case only. Do not wz a hs >'kis area, to be a?,_plgted by ru y or tt7wa of�ciat' City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building 6. Other Department 3. City/Town -Clerk 4. Electrical Inspector 5. Plumbing Inspector Contact Person: Phone #: Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Inspector of Buildings To: Board of Health or Board of Selectmen /Y( qN4 0 'j -r (-. 1"M P RE: Insured: SAD Property Address Policy Number: Date/Cause of Loss: /6/ / it` , File or Claim Number: ,6oS �4 �, Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 315 is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. On this date, I caused copies of this Notice to be sent to the persons named above at the addresses indicated above by First Class Mail. s► � II Signature A And Dade NEW ENGLAND CLAIMS SERVICE, INC. 131 DODGE STREET, SUITE 6 BEVERLY, MA 01915