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HomeMy WebLinkAboutBuilding Permit #589-12 - 24 HEWITT AVENUE 2/6/2012 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: z Date Received Date Issued: O TANT:Applicant must com Tete all items on this page LOCATION 7 �(.� AU'I— Print Print PROPERTY OWNER ri" t 00#1 C_/�_ Unit# Print MAP NO: t2 PARCELZONING 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 ❑One family 0 Addition ❑Two or more family ❑ Industrial \ ❑Alteration No. of units: ❑Commercial ARepair, replacement ❑Assessory Bldg iT Others: ❑Demolition ❑Other i�eP ® ell r� -- •r 0!F o 143 `OW"tlarids � � F ••-: t ,i • . I P- <Yxe W_.atershedstnct� t DESCRIPTION OF WORK TO BE PERFORMED: Z>,/ 9,Ac (Identification Please Type or Print Clearly) OWNER: Name: Phone: 6,9-3 Z/79 146'4 Address:_ ,4 f A�,wgu,� Pow �-1awi-� �w�Prov ^�`sLCL CONTRACTOR Name: t((„0 a !4 /o c,�-{U Phone: 7 Address: ?o 1 2_6 AWT_ p'�O, Ot f�) Supervisor's Construction License: _41 7l l 2 Exp. Date: Home Improvement License: SgZ Exp. Date: 3112-Z/Z ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $___4o FEE: $ ��'� •Od Check No.: ? Receipt t No. ` 6l 2 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Sci nature ofAgent/O:vvner,` Signatu'.reofcontra::., r_ tf.: . I i 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 ❑ Privatetic se Private(septic tank etc. ❑ Permanent Dempster on Site ❑ ` THEFOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING &DEVELOPMENT ❑ ❑ COMMENTS i CONSERVATION Reviewed on Signature - . I COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water&Sewer Connection/Signature&Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT -Temp Dempster on site yes no Located at 124 Main Street Fire Department signature/date rn��rn��.TTe 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 DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$1o0-$1000 fine NOTES and DATA— For department use ❑ Notified for pickup - Date L � Doc:.Building Permit Revised 20117une/mi l 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 Pp Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract I ❑ 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 i ❑ 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 I 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 9 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 I Doc: Doc.Building Permit Revised 2008mi Locationy� No. !1" �2" Date °? 6 TOWN OF NORTH ANDOVER �1 ED,t 46` i Certificate of Occupancy $ Building/Frame Permit Fee $ -- 00 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# 7 r , r 25012 B ilciing Inspector J f NORTH ,e i' To of over 9b q l o w {: No. � o dover1Iass., COCHICHE WICK V r f .tj A®SATE O PP. ,`°C� V i BOARD OF HEALTH Foad/Kitchen y Septic System PERMIT ,.. T / ` BUILDING INSPECT THIS'CERTI �E$ HAT.......... l ....... ... .�: ....... . . . ... ....... Foundation has permission to erect.........................................buildings on .. .:. .. ......:......... Rough to be occupied as..... .f , % r !!7�.. .....�:r!( �t�`� Chimney provided that the person accepting this permit shall in every respect conform t ter oit a app a on file in Final this office, and to the provisions of the Codes and By-Laws relating pectio da41,1111�tion and structi Buildings in the Town of North Andover. PLUMBING`INSPECTOR ' . Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL,INSPECTOR UNLESS CONSTRUCTION -TARTS �.... < �! ,1 !e Service. .. . .......... - ��BUILDING INSP R Final Occupancy Permit Required to OccupY Building GAS INSPECTOR ! "' Rough c' 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 1lERSE• SIDE Smoke Det. GENERAL BUILDING NOTES/CHECKLIST-NOT LIMITED TO ITEMS BELOW POST ALL LOT NUMBERS,ADDRESS, AND PERMIT(COPY OK)..or no inspections INSPECTIONS: (Minimum) Excavation , Footing, Foun-. Frame, Insulation, Final. FOOTINGS: Continuous Full 2x4 Keyway Continuous strip footings for interior columns FOUNDATION: Rebar as required Anchor bolts or straps Damproofing Foundation drain-pipe/stone/fabric filter/cover and outlet connection. FRAME:Fireblock-over girts/plates between floor joist Penetrations for plumbing, heat, elec, etc. Walls at stair stringers. Windbrace corners and center bearing partitions. Size ridge to provide full bearing at rafter cuts. Hip and Valley rafters-watch bearing at walls. Ridge&Hip-Provide proper connections. Cathedral roof rafters provide proper connections and use"Hurricane Clips"tie to plate. Stair stringers-watch cuts and heal support. Joist hangers-fully nailed w/hanger nails. Sill plates 2-2X6(1 PT)w/sill seal. Girts-solid brick or steel plate bearing at foundations %"air space at sides in foundation pockets. ~+ Lateral bracing at ends. Certified calculations. required for Beams/LVL's Trusses. Solid bearing support for Headers/Beams etc. Check headroom clearances-stairways, under beams Attic Access. (min.22x30 w/3' headroom above). Crawl space access. (min. 18x24). Bath exhaust fans to have metal duct to exterior(not in soffit). Firecode S/R wood frame of"0"clearance fireplaces&stoves Window Schedule or Every Habitable Room Must Have: Natural light equal to 8%of floor area. '/4 of required glazing shall be openable. Bedrooms required min. 20x24 egress window or door. Vent attic spaces-"proper vent", soffit and required ridge vents. Firecode under stairs if used for storage FIREPLACES: Separate permit required. Inspections at Footing-Smoke Chamber-Finish Smooth parging, clean joints,8"solid @ combust. DECKS: Lag to house, provide flashing. Rails min. 36"high, Baluster max space 5"on center. Over 8'above grade, use 6x6 posts w/lateral bracing. Lag all posts and rails. Pier footings down 48", Conc. pad at stair base. FINISH: Handrails returned to wall/newall post. Guardrails required alongside open cellar stairs. Exterior grading complete. Certificate or occupancy required prior to dccupying structure. Temporary Stairs required for inspection. Re-inspection fee- $30.00(Be Ready). Certificate of occupancy required prior to occupying structure. j NORTH An over, ,.' ' . M, Y i , "'2� L o dower,, S ICIss ,AKE ,•.r./.'� r ,y 'rp COCHICHEWICK �� (•'j:f' �. A \ ' °'?ATE BOARD OF HEALTH R M IT ,.: T, Fogd/Kitchen Septic System BUILDING INSPECTOR THIS CERTI �E$ i THAT...........r % ��......... ..= .a:'.. .......................................� . ...................................... " Foundation hasp buildings on ..::: ...�:...:. .............. g:, permission to erect................................ ................... Rou h to be occupied as..... ::-°" 1 , >'� �'f...:� �:`.�;.�e:.. '�-`;=�;"`. . .... � : . Q'�•�s'' � ...... : �d �� ;' Chimney R. provided that the person accepting this permit shall in every respect conform t e ter ait a app a on-file in Final this office, and to the provisions of the Codi and By-Laws relating o pectin ation and structi Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of & Zoning or Building Regulations Voids this Permit. Rough Final :. PERMIT EXPIRES IN 6 MONTHS " ELECTRICAL.INSPECTOR UNLESS CONSTRUCTIOI�STA.RFTS tRoup :' f ::,:•:::�r ,,: :l `� Service. -BUILDING INSP R , Final Occupancy Permit Required to Occupy" Building GAS INSPECTOR ; 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 RIEVERSE- SERE Smoke Det. c o AOL at��, For 0 0 O A"A,d Flo O C v O O O 0 0 rf2(-. o Lc C_ O L O O O C C c a O O ra / NORT :. 0 0 over .. , , ,01 . - r{ No. r Cf� dower; ,' _'rte �� Y ►7/S o , ., f COCHIC HEwICK QoRATED HEALTH U BOARD OF i , Fad/Kitchen Septic System PER I 1. 4 `c � BUILDING INSPECTOR' THIS CERTI �E i THAT.....:...._ 6.......:..� . . t`" ...... . a Foundation ............................... has permission to erect.... ............ A.... buildings on .., ........... Rough to be occupie a ��� �;,�.`. Chimney provided that e e ac. . . ...�. ... :...... . ...... :.�.. .. p p i perm' eve - eY conf m t erm of a application on ' in Final- this inal this office, a t the rovi ot`!he Cods ws r g I h ng�tion, on and Constru n of Buildings in t own of No dover. PLUMBING INSPECTOR VIOLATION of th8 oning or B Ing Regulations V s ermit. ♦ Roughs ``=r ' .`J; - •` Final PERMIT EXP IN 6 MONTHS ' �► ELECTRICAL-INSP,ECTOR UNLESS CONSTRUCTION, TARTS � ou�h�L��� .� �;-�-z..�� '' .::;. �:.�''�%. :. Service. .. s` ., :' ................ ......... 13UILDING INSPECTOR y Final Occupancy Permit Required to Occupy Building GAS INSPECTOR ` ugh." " =1 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. sumer. Street No. SEE REVERSE SEDE Smoke Det. Client#: 82154 NEWBURYPOR4 ACORD. CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DD/YYYY) 02/02/2012 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 policy(ies)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 NCONTACT AME: Diane Keenan HUB Int'I New England(WILSB) accAlc No o"no E,�:978-661-6635 866-460-8786 299 Ballardvale St E-MAIL diane.keenan@hubinternational.com Wilmington,MA 01887 INSURER(S)AFFORDING COVERAGE NAIC AI INSURERA:Commerce Insurance Co 34754 INSURED Newburyport Home Improvement Services INSURER B:Travelers Indemnity Co of Ameri Attn:Tony_Lowther INSURER C PO Box 1265 INSURER D Newburyport,MA 01950 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 CONTRACTOR 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 ADDLUB POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INS WVD POLICY NUMBER MM/DD MM/DD/YYYY LIMITS A GENERAL LIABILITY BBWHJW 9/06/2011 09/06/2012 EACHOCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY PREM S &ENTED 1ES occurrence $100,000 CLAIMS-MADE FX OCCUR MED EXP(Any one person) s5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,ObO'b0O POLICY jE O- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per $ AUTOS AUTOS ( ) HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS EMPLOYCOMPENSATION ILII IHUB7092X814 6/23/2011 03/03/201 X T, TATO- ETH. AND EMPLOYERS'LU\BILITY Y/N TORY LIMITS ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $100 000 OFFICER/MEMBER EXCLUDED? N/A B (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 107,Additional Remarks Schedule,If more space is required) Evidence of Coverage-Member,officer,sole proprietor excluded.Evidence of Coverage-24 Hewitt Avenue, North Andover,MA.01845 CERTIFICATE HOLDER CANCELLATION Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover,MA 01845 AUTHORIZED REPRESENTATIVE %VvZoL At Co— - ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S673088/M584096 DK001 Location vw I G ! U e— ,� No. 6 Date S �� 'Y AO RT: TOWN OF NORTH ANDOVER ►I. z Certificate of Occupancy $ sCMUs� Building/Frame Permit Fee $ � Foundation Permit Fee $ Other Permit Fee $ TOTAL $ �— Check # 0 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPAR'TMEN'T APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING .gyp ,µ.,� � I .iKti»%3 �S}-�.r � �..,.n, .�.s�t''4' 1�`�� ... ,, x� "". ; k yr rx: s�,. .x t Yt f'--^s- »� s ,a,k� �'z- '�1 ■�9 BUILDING PERMIT NUMBER: /' / DATE ISSUED _•�i j J� G ic SIGNATURE: - -'I Building CommissfonefflnseEtor of Buildings Date z SECTION 1-SITE INFORMATION 1.1 Property Address. 1.2 Assessors Map and Parcel Number: Map Number Parcel Number �\ 1.3 Zoning Information: 1.4 Property Dimensions: ZoningDistrict Pr osed Use Lot Areas Frontage ft 1.6 BIJU DING SETBACKS 00 Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.GL.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private 0 Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT str,r;c District: Yp_s —No M 2.1 Owner of Record a/,I)rr 1 2 Name(Print) Address for Service: t t Signature Telephone Q 2.2 Owner of Record: 0 Name Print Address for Service: z i Si ture Tele hone 90 SECTION 3-CONSTRUCTION SERVICES 3.1 LICUISed Construction Supe or: Not Applicable ❑ Licensed Construction Supervisor: [[ '� S D ��� License Number Ad ss Nate Signature Expi� ate Signature Telephone 3.2 Regist ed Home Improvement Contractor Not Applicable ❑ Cpmpany Name f S Registration Number Address � 7Jr�Sr7-2 Expiration on DaG) Signature Telephone A �f SECTION 4-WORKERS COMPENSATION(M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......❑ No.......0 SECTION 5 Description of Proposed Work check all a Hcable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ - Accessory Bldg. ❑ Demolition ❑ Other 0 Specify Brief Description of Proposed Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OMCIAtUSE ONLY Completed by permit a licant 1. Building ,-,`� �q(, (a) Building Permit Fee /i Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, ,as Owner/Authorized Agent of subject property Herebv authorize to act on My behalf,in all matters relative to work authorized by this building pen-nit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, as Owner/Authorized Agent of subject ti property `. Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name Signature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TEVIBERS 15 2ND 3RD SPAN DIMENSIONS OF SILLS DRaNSIONS OF POSTS DIMENSIONS OF GIRDERS t HEIGHT OF FOLTNDA17ION THICKNESS SIZE OF FOOTING X t MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND _ IS BUILDING CONNECTED TO NATURAL GAS LINE Board of Building Regulations and Standards One Ashburton Place - Room 1301 o o Boston. Massachusetts 02108 Home Improvement"Contractor Registration 0a Wco `' Registration: 100756 z o U-)¢ Type: DBA c Expiration: 6/23/2004 s ►= o �, RUBERA CONSTRUCTION INC. MLo W N Richard Rubera o co 201 Wheeler Street 00 v o Methuen, MA 01844 0° 40 z 3 w '�-m o i Update Address and return card.Mark reason for change. D w ) G✓ A.aldlresc F! Renewal .Employment f lost Pard oorvinoowsea`f�i a�/�aaaac�ucaella LU w Q = Board of Building Regulations and Standards _ License or registration valid for individul use only U w HOME IMk?RQVEMENT CONTRACTOR before the expiration date. If found return to: `-4 Re i�trat�on; Board of Building Regulations and Standards 9 t 100756 expiration 6%23%2004 One Ashburton Place Rm 1301 __ --- Boston,Ma.02108 -- =TYpe....l?BA RUBERA CONSTRCTtON 1NC ' Richard Rubera T 201 Wheeler Street Methuen, MA 01844 _ Administrator Not valid without-sinnature f .4 North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. The debris will be disposed of in: Z c/i cePv .St-rv/t (Location of Facility) l f Signature of Permit Applicant � 4 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector 1;6 �,..: u The Commonwealth of Massachusetts d Department of Industrial Accidents ' Office of Investigations F< �a Boston, Mass. 02911 Workers'Compensation Insurance Affidavit Name Please Print Name." r G a" Location: cc 60 Ci .��� z. Phone # e-2 I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Comioanyname: G-.�7 Address City: 1,2 Phone* 17 `7 ' Insurance.Co. Policy# �/<. jza -77U 9/WU2"6-01Y Company name: Address City: Phone#: Insurance Co. Policv# Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to$1,500.00 and/or one years'imprisonment-as_well_as_civiLpenaltiesinshe.f -m nfa_STOP WORK_ORDFR..and a.fine_of_(.$1DO.DA)_a day.againsi_me. 1 understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. i do hereby certify under th ains and enalti f pe ' ry that the information provided above is true and correct. Signature Date Print namC, 2!� �-��°�- P.hon.e#97r G87v 41' Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing Building Dept ❑Check if immediate response is required 0 Licensing Board F-1 Selectman's Office Contact person: Phone A E] Health Department Other NORTH TONvn of No. 1P 40 _ z- a dover, Mass. ✓� _6 '�W a A. COCHIC KE" V �d ADRATED P'P� y S uBOARD OF HEALTH PERMIT T Food/Kitchen Septic System THIS CERTIFIES THAT wI 001.1r.0 BUILDING INSPECTOR er.......... ........... ... ....................... ............................. Foundation has permission to erect...S .�. ......... buildings on .. .... .......... ..�. ......�. ! Rough to be occupied as *A"rr& ..W4%4.✓at*. ............................................. Chimney p' ...... 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 r ati to the Inspection, Iteration and Construction of Buildings in the Town of North Andover. 4 of 011P40 400M PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUCTION START&START ELECTRICAL INSPECTOR Rough Aff it 40 R ......................................AN................................................ 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 J1 Smoke Det.