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HomeMy WebLinkAboutBuilding Permit #313 - 34 MOLLY TOWNE ROAD 10/19/2006 N011TM O't, o. 7M0 ' TOWN OF NORTH ANDOVER #•�' :; APPLICATION FOR PLAN EXAMINATION ,SSICHUSet Permit NO: Date Received � I E Date Issued: 6 IMPORTANT: Applicant must complete all items on this page LOCATION YL/ AO�Y (0��� ` ' LOT-,� / • �n 4 Print PROPERTY OWNER Nr-+\n w�nc-oki 24A 14-1 Cnre Print MAP NO.: 667 PARCEL: ol'9a ZONING DISTRICT: "a TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ,X�4ew Building Xone family Ej Addition E,Two or more family E. Industrial Alteration No. of units: Repair, replacement C Assessory Bldg C Commercial Fit Demolition F; Moving(,relocation) D Other E Others: 1 Foundation only DESCRIPTION OF WORK TO BE PREFORMED 6rJ9WUC-I- 5 l o i r4� 5c��tA� �rsrnyst `�Y l g Identification Mease Type or Print Clearly) ` OWNER: Name: &v%QJ' - 1Vo,l�f�►/ 449 ZW- lit Phone: 91e 4 W(977(- Signature (977(- Signature Address:_ 45-5 C- r L4A P0.4, ��4ar���►�S���IA, .ore 36 CONTRACTOR Name:Arno-S Cqlyt I,( i Phone: 13.791479-a-17G Address: 10 3 gcs�lej J04A 4 4,a2w?4 M& O 0810 Supervisor's Construction License: C5 O 6 SS-03 Exp. Date: 7')9 - 200? Home Improvement License: Exp. Date: ARCHI"TECTi FNGINF.FR I. NI'L <�;e j i AatS Name: Phone: q78 `'lam" 6 4 3� Address:579 4- &V) 6"0- �►<<s�eM,Mu O(T-V-17iSReg. No. 33994 FEE SCHEDULE:BOLDING PERMIT:$10.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON $12.5.00 PER S.F. a Total Project Cost :$ S�y'7� x�� 0-FEE:$/ Check No.: Receipt No.:�'�-�` TYPE OF SEWARGE DISPOSAL Tanning/Massage/Body Art _ Swimming Pools =; Public Sewer X _ Tobacco Sales — Food Packaging/Sales Well ;_; - Private(septic tank,etc. Permanent Dempster on Site ;.-! NOTE: Persons conlracling with unregistered conlrneto rs&o not[lave access to the guaranty fun& Signature of Agent/Owner V C.w Signature of Contractor V � � Plans Submitted 25 Plans Waived ❑ Certified Plot Plan ® Stamped Plans THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF- U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ U ja4� ❑Water Shed Special Permit ❑ Site Plan Special Permit ❑ Other COMMENTS 4j t,►frit 07e .; �,r�. �s'v�,1�1'/ Ah-7/4- A Vq 1.00 P-SA (;V- �2��t�A,-L 16 tl?L06 A D ATE REJECTED DATE APPROVED CON SERVATI�011-;2���� I� (°l 2('vCP COMMENTST� LI DATE REJECTED DATE APPROVED '-EALTH ❑ ❑ 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 Temp Dumpster on site yes I no Fire Department signature,'date Building Permit Approved and Issued by: i Building Setback ( Front Yard Side Yard Rear Yard Required Provided Required Provides Re uiredProvided ao s8 ' C�w r / Y DIMENSION N umber of Stories: Total square feet of floor area,based on Exterior dimensions. ��8 Total land area,sq. ft.: 4)c7.0 4 I I N(YI'l:S and DATA—( or department use) I I I i I DOC:INSPEC"I ZONAL.SLAMCL'.S UPPAR 1'MLNT.1,11H)IkMQ5 Ov'lled AIC J.m._Riil. 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 ❑ Debris Removal Form ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work Addition Or Decks ❑ Building Permit Application ❑ Form U ❑ Surveyed Plot Plan ❑ Debris Removal Form ❑ 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) New Construction (Single and Two Family) ❑ Building Permit Application ❑ _Form.U, ❑ 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 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:1\SPEC'rIOVAL SERVICES DEPARTMEVTMFORN105 1 — Location No. Date NORTH TOWN OF NORTH ANDOVER 3?O�t"•o ••',iMOp � 41 A • t0 ' Certificate of Occupancy $ , IT CM ate' Building/Frame Permit Fee $ —� � Foundation Permit Fee $ J Other Permit Fee $ 2 TOTAL Check # 19 ! 09 P ---� Building Inspector CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 313(10/,19/2007) Date: September 18, 2007 THIS CERTIFIES THAT THE BUILDING LOCATED ON 34 hNb owne Road MAY BE OCCUPIED AS Single Family Dwelling IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: North Andover HWU Cora 34 Mollytowne Road North Andover MA 01845 Building Inspector ` r10RTH '9 t � Town of _ ove o Na:513 IRM- 1,0115 dower, Mass.,/OZ - 06 o A COCMICKEWICK RATED PPS` �5 `s BOARD OF HEALTH PERMIT T.. D Food/Kitchen Septic System BUILD INeG INSCTOR THIS CERTIFIES THAT �.� _. =_ """"' Foundation`) Gam'/L'/ has permission to erect........... ....a. I. ...T � ra. ') ........^......�.... build! son ....... .... a �....... ............. ne to be occupied as. �I>t �j,......0 �...... ..... �....... .. ...�. ..� F1.000.................... provided that the person accepting this permit all in every respect onform to the terms of t application on file in ,�( office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of ►\ 4(X'7-- this Buildings in the Town of North Andover. y g p P UMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. e?f 61 :7� IRE IN 6 MONTHS OC PERMIT EXP S ELECTRICAL INSPECTo /00 UNLESS CONSTRU S TS . .. .. . .. .. .. .....ev # rp*dt AL ........... Service BUILDING INSPECTOR Occupancy Permit Required to Occupy Building GAS INSPECTOR R(q Display in a Conspicuous Place on the Premises — Do Not Remove , ,2 No Lathing or Dry Wall To Be Done FIRE DEPAR'T'MENT Until Inspected and Approved by the Building Inspector. Burner { , � Street No. ' x SEE REVERSE SIDE Smoke Det. �� F7�- Town of North Andover IAORTh Building Department 3? y..., 1.. 'e ° 27 Charles Street o North Andover, Massachusetts 01845 4 (978) 688-9545 Fax (978) 688-9542 O cocwicniwuw 1• SACH ��� APPLICATION FOR CERTIFICATE OF OCCUPANCY/ INSPECTION ADDRESS 3.1 Mot I�T©W n e_ LOT NUMBER 'DIVISION r-h n C�aSQ DATE REQUEST FILED 9T--; 0-7 DATE READY FOR INSPECTION © 7 FIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED ALL WORK AND SIGN-OFF'S MUST BE COMPLETED WITHIN THIS TIME FRAME. A RE-INSPECTION FEE OF TWENTY-FIVE ($25.) DOLLARS WILL BE CHARGED IF THE STRUCTURE DOES NOT MEET ALL APPLICABLE CODES. SIGNATURE OFFICIAL USE ONLY ROUTING CONSERVATIO _ ATE PLANNING Off , DATE �1!$, D.P.W. —WATER METER DATE 7/5/hOI D.P.W. MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO THE INSPECTION REQUEST DATE. LAM 6MzV4 � SIGNATURE/DPW AUTHORIZATION �jf LOT 9 V\ FOUNDATION ELM=216.2' 111a ZONINO DIMICT R-2 MIN. AREA = 21,760 S.F. MIN. .Lar WIDTH = 100" MIN. FRONTAGE = 100' 40N. MOST SETOACK - 20 1 TiANSEN MIN. SIDE SEMACX = 20' ARM REAR $CMACK 20' THE STRUCTURE lWA' Y RE PlACM UPON A sim, Lor LINE WITHOUT A SIDE SE78ACK, PROVIDED THAT W ADJACENT LOT To WHICH THE zrRo MMACK IS LOCATED HAS rHE- REQUIRED SIDE YARD SMACK) CERA-Y M97 ME P000-9r SMUMW SHOWN COWORW TO FOUNDAWN LOCATION PLAN 7W WRaOlOoe SCTiMa MMUM&M OMC kXAL AMCA&Z ZON94 Or-UWY IN fil=' WHIN Con,-Ma=, (,11=1CAROM DOES NOT COWDER ANY OrHrR 40 - I SUCH AY oft",ft or 0"Mofflm.) CUENT: NORTH ANDOVER REAU)" 'THIS DJUMO IOU Mr &E USED RY TK CLkWr FOR ANY PVAPMC WWR RM TMr OVMWAD A80v&rx6cfr wim rhr THIS CERTIFICATION IS MADE!AND LIMITED offrEm Almum" ar entiviAkaw & sr"l fivr- AWNCRWW rKii "AKW M IW COMMIrD M.PiM TO THE ABOVE OL,'roVr. OF MM71ANUN & SM A"- AAD vo 4#,#lAiMi0-?i2CP VSr RW 7K UNAUMPIZED USE qi�,r PA4"109 ANY LOCA 770M J.54 MOLLY TO WW RD, SM YON 06NIAWO lusOR- NORTH ANDOVER, kA. HEW" X4Lr.- 1# = 60' DA Tr.- 1012,51,06 CHRIS TIANSEN &'SERGI LAND SLfRVC1C%T 160 SUMM.'R Kr HAWRHALLMA. 918M TEL 97,R-57J-0dt0 CD.= SlY ChMMANSCk Q SEM AVC, L----- D WING NO. 970650lCf v i� O LOT \ 58.2' d FOMDATICN 26.6' ZONING DIMICT R-2 �-- MIN. AREA = 21,?60 S.F. �br MIK. ,LOT WIDTH 1007" MIN. MONTAGE = 100' MIN. FRONF SETVACK - 20' C I TiANSEN wN. SIDT SMACK = 20' 41 ti miN, REAR S,ETRACIC T 20' (s - THE STRUCTURE 9r1Y Or PLACED UPON A SIDE LOT LINE WITHOUT A SIDE � `�,S�QNM, SET8ACK, PROVIDED THAT THE ADJACENT LOT TO WHICH THE ZERO SETBACK IS LOCATED HAS ?'Hf REQUIRED SIDE YARD SETBACK.) FOUNDARON LOCATION Pi-AN 7W HOWWX SCMA4K&MACM&M Or MC LOCAL - - —•--- APi1UCW ZONING ,BY--LdiVV IN E7TtCt x'NSN CONSr7P11CP£D. I7NtS CFRT)i<7CAMY DOES NOT CONSIDER AN OTNCR Ri'�4atTr�'hD+rJ SUCH AS COYEAti1NIS.WE7LAND�Fi{SLafEN73, O"m OF CON01riDnS .) CLIENT. NORTH ANDOVER REAM' THIS OPAWIW SWU NOT BE USED RY nK aAW FOR ANY PN&VSC 0MC9 MAN TMr OUTUMrO ABOVF.L'XCl•PT WAfH rn-r THIS CERTIFICATION IS MADE!AND LMTED fYR/TTFN ND?6Ilm" 41"CHR/5 A"rN & sr"I INC. AWNCRAW TH15 llkdKW w TW COYIXWFEO PWPERTr TO THE ABOVE CLIENT Of GwRIB'111h' W & WK 1NC. AND MY 41PALTifOR120 YSE IS PRIIOHIB/MCN&S'TIAMSEN k SZP.W:.TAXFS ND WSAOWSJR4m LOCA r/OH. #34 MOLLY 'TOWN RD, MAS ATTO Owi4tva HEREON�or��iS,pA,��,+c��ANY JMi yR- NORTH ANDOVER, MA. P5, SCALE' 1 — 60' 1 DA It: 10125106 CHRIS TIAs�'SE/i SER ,7 f PItDiT�TSlA4'AL E,YOINEFRS C LAMS SURVEY{`1R7 160 SUMu617 V. HAVCRHILL f1A. 918JO TEL 97A-M-mfO /� n2446 Nr CW--nANSq SEW ANC, 70 -WING (V0. 9706531 FG i GELINAS STRUCTURAL ENGINEERING LLCSN=NO. 579A North End Blvd. DAMSalisbury, MA 01952-1738 aY Phone:97$.465.6436(Fax 5160) e-mail:danlgelinas@adeiphia.net 406 V , ....... . s [ - � P t� OAh'lEL L G - GE iU7kR �, . . _.._..� _. . . . ._.��..... ........ . ... ...._..;......: .3399 ... .. ...... Na 4 Swa I,P,w,NESS CUSTf.K p,1rA1nn,e icc Rat Nc.a'.IMIJ"�, i TUO iF$�Q�� :?AI uti. E,l32iE ZT� _Z 5H FU1. YY4_ �0 L.%z/C5 Irk Permit# Permit Date REScheck Software Version 3.7.3 Compliance Certificate Project Title: 8721 Report Date: 10/18/06 Data filename:Q\Program Files\Check\REScheck\PL8721.rck Energy Code: 2000 IECC Location: North Andover,Massachusetts Construction Type: Single Family Glazing Area Percentage: 160/6 Heating Degree Days: 6322 Construction Site: Owner/Agent: Designer/Contractor: Permit Date:7-11-06 Compliance: Passes Maximum UA: 562 Your • 1 •• • • M1 R-Value Ceiling 1:Flat Ceiling or Scissor Truss: 2040 30.0 30.0 35 Wall 1:Wood Frame,16"o.c.: 3136 13.0 13.0 126 Window 1:Vinyl Frame:Triple Pane with Low-E: 468 0.330 154 Door 1:Glass: 39 0.330 13 Basement Wall 1:Solid Concrete or Masonry: 2040 19.0 19.0 120 Compliance Statement.The proposed building design described here is consistent with the building plans,specifications,and other calculations submitted with the permit application.The proposed building has been designed to meet the 2000 IECC requirements in REScheck Version 3.7.3 and to comply with the mandatory requirements listed in the REScheck Inspection Checklist. Builder/Designer Company Name Date Project Notes: Previously saved project information: COLONIAL HOUSE BRUNO ASSOC. 28 BERKELEY ROAD N.ANDOVER,MA 01845 8721 Pagel of 4 REScheck Software Version 3.7.3 Inspection Checklist Date: 10/18/06 Ceilings: ❑ Ceiling 1:Flat Ceiling or Scissor Truss,R-30.0 cavity+R-30.0 continuous insulation Comments: Above-Grade Walls: ❑ Wall 1:Wood Frame,16"o.c.,R-13.0 cavity+R-13.0 continuous insulation Comments: Basement Walls: ❑ Basement Wall 1:Solid Concrete or Masonry,8.0'ht/7.0'bg/4.0'insul,R-19.0 cavity+R-19.0 continuous insulation Comments: Exterior insulation must have a rigid,opaque,weather-resistant protective covering that covers the exposed(above-grade) insulation and extends at least 6 in.below grade. Windows: ❑ Window 1:Vinyl Frame:Tdple Pane with Low-E,U-factor:0.330 For windows without labeled 1-1-factors,describe features: #Panes Frame Type Thermal Break? Yes No Comments: Doors: ❑ Door 1:Glass,U-factor:0.330 Comments: Air Leakage: ❑ Joints,penetrations,and all other such openings in the building envelope that are sources of air leakage must be sealed. ❑ Recessed lights must be 1)Type IC rated,or 2)installed inside an appropriate air-tight assembly with a 0.5"clearance from combustible materials.If non-IC rated,the fixture must be installed with a 3"clearance from insulation. Vapor Retarder: ❑ Required on the warm-in-winter side of all non-vented framed ceilings,walls,and floors. Materials Identification: ❑ Materials and equipment must be installed in accordance with the manufacturer's installation instructions. ❑ Materials and equipment must be identified so that compliance can be determined. � P ❑ Manufacturer manuals for all installed heating and cooling equipment and service water heating equipment must be provided. ❑ Insulation R-values and glazing U-factors must be clearly marked on the building plans or specifications. Duct Insulation: ❑ Ducts in unconditioned spaces must be insulated to R-5.Ducts outside the building must be insulated to R-6.5. Duct Construction: ❑ All joints,seams,and connections must be securely fastened with welds,gaskets,mastics(adhesives), mastic-plus-embedded-fabric,or tapes.Tapes and mastics must be rated UL 181 A or UL 181 B. Exception:Continuously welded and locking-type longitudinal joints and seams on ducts operating at less than 2 in.w.g.(500 Pa). ❑ The HVAC system must provide a means for balancing air and water systems. 8721 Page 2 of 4 Temperature Controls: ❑ Thermostats are required for each separate HVAC system.A manual or automatic means to partially restrict or shut off the heating and/or cooling input to each zone or floor shall be provided. Service Water Heating: ❑ Water heaters with vertical pipe risers must have a heat trap on both the inlet and outlet unless the water heater has an integral heat trap or is part of a circulating system. ❑ Insulate circulating hot water pipes to the levels in Table 1. Circulating Hot Water Systems: ❑ Insulate circulating hot water pipes to the levels in Table 1. Swimming Pools: ❑ All heated swimming pools must have an on/off heater switch and require a cover unless over 20%of the heating energy is from non-depletable sources.Pool pumps require a time clock. Heating and Cooling Piping Insulation: ❑ HVAC piping conveying fluids above 105 degrees F or chilled fluids below 55 degrees F must be insulated to the levels in Table 2. 8721 Page 3 of 4 Table 1:Minimum Insulation Thickness for Circulating Hot Water Pipes Insulation Thickness in Inches by Pipe Sizes Heated Water Non-Circulating Runouts Circulating Mains and Runouts Temperature(°F) Up to 1" Up to 1.25" 1.5"to 2.0" Over 2" 170-180 0.5 1.0 1.5 2.0 140-169 0.5 0.5 1.0 1.5 100-139 0.5 0.5 0.5 1.0 i i Table 2.Minimum Insulation Thickness for HVAC Pipes Fluid Temp. Insulation Thickness in Inches by Pipe Sizes Piping System Types Range ff) 2"Runouts 1"and Less 1.25"to 2.0" 2.5"to 4" Heating Systems Low PressureiTemperature 201-250 1.0 1.5 1.5 2.0 Low Temperature 120-200 0.5 1.0 1.0 1.5 Steam Condensate(for feed water) Any 1.0 1.0 1.5 2.0 Cooling Systems Chilled Water,Refrigerant and 40-55 0.5 0.5 0.75 1.0 Brine Below 40 1.0 1.0 1.5 1.5 NOTES TO FIELD:(Building Department Use Only) 8721 Page 4 of 4 N." •jI`k-t VATEAlffitlPy IYY' Af-L� CERTIFICATE O� LIABILITY INSURANCE I THIS CERTIFICATE tti ISSUED AS A MATTER OF INFORMAT!0N ✓- P-ROBERTS TNSIMAUNCE A(;ZNCY INC, I ONLY AND CONFERS NO RIGHTS UPON YHE CERTIFICATP 10 60 0 S GCOD STPZET H=�ER. THIS CIFIR11FICATE DOES NOT Amr:N:), EXTEND OR L_.ALTER THE COVERAGE AFa ORDL-D ry 4 K po,.,C;E$ NOXTH )VMQV'i.R MA 01845 INSURERS AFFORDING COVERAGE NAICt F A V R N'ORT JIM CARROLL —IN's L)R 6 R 0 459 E.).ST m'.53-L-1,; P C f'IXVF RH ll.L.L, Mh 01830 )IISLRER'3 PLN-' i!CAN ASSURANCE No URER E 7',E=01L 3F lll;•SURANC F I.IS7E D SELI)W HAVE BEf N 18FQc 0 TO THE IN JRED NAVEU MOVE AOR HE tOUC P[P!00 Ji)f�,k TED h0TVVITn5Ji;t,,-iN(At'� REQ!jIRDy-NT OR CONDITION GF ANY CCNTRkGT OR 01HOR DOCUMENT vVITH RESr"ECT TO WHICH TH;3 QFRTiFICATE rvi,k)' BE I^SUED 09rAAII PERTAIN 'EHE IN5J.-LANCE AFFORDE0 BY THE POLICIES DESC.RIBED HERr,'.IN:,(;SMECT TO ALL--*'F. TERMS,EX01,L1SIONS ANO :0NDITIOWS or AGOR�.aAl'--*1.13v31T8S,'-IOWkMiYHAVlEDr.ENREDO(;EDF.3Y PAIOCLAA15 POLI-�.v-L—ffi(TTI-vp.75 ,rp uWac' -Ypr n,- poluo 4:J)As:fl 01-TU'M b',I LIABILITY ABII.IT-Y OCCUR nF.RbollA, !,A::-Vlr4jUMY _I_'_—_... FllZ 'AI. AGGRZIAll' OEM; �f�A7 AV'IES PLP. V X i I ; WANNU)SING'E L 11.4)T A;-7C N,LIR, pe Derqon3 m;7KEC AUMSI- 30I)ILYINJURY X,IAA(3I, A�71,11Y•ER 11 Al 11 r THAH Ek. 'rk c.p I hUTO ONI.Y. 401, Ul\9ILIry orcuRRLqr: :A t7lAIIASMADE 6 A T C RE T:Ni ION t ------------- T;ON AND 7 Y X 0r/13 C 5 00.. a Q,0 L) E.L.LllSWFEA?WLOYEL 5 0 0 0 0 �acrn .j PM-l.?R4vl S:I)NS ndlow F.I. (:161ASe-rC)L'(:Y 1.10111 0 LC D-F -,DQF -RUVI) )E- 'c';0,7 ATIC VC 0 0 Y V NXI,Rf, �lrz 1 T r -NS FAX: '-FRTiF!CATE HOLDI:iR CANCELLATION ShOULDANY O� TOM4 OF INORTH MMOVER . 7FR.4UQVE 0J.Tr. THZ'QOF, THF.ISSUING INSURER MLL VIL)GAV,)R ICI YA-10 tq0fll:=-l0THE Ct:HYlFl0/,TF HCl!)f'RNAWL)TU THE Lt:j'r,EVI IMPOS; NO Oki(AlION^R �M:,.7y `NY �N'--W',lN 7!:C INSURER T MORTH ANDOVER, WA 01945 o' KE?RESKNTAriVES ALIT[IOP VE:�REPRE S!- ..HrA71VIF. I lZ 9—t— CO R 1.) 5(2 0 10131 DA(-,OR[)C ORPORATION 198s The Commonwealth of Massachusetts Depaniment of Industrial Accidents Office of lnvesUgadons Boston, Mass. 02191 Warkers'Compensation Insurance Affidavit Please Print Name: Location: cily Phone 0 am a homeowner performing all work myself. �k 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. Comma name: ��CxO QA Address mag A- 0(8 3 Ptiarte# q'78 SS(p 3 y Insurance Co.A/he tC*A►/ Nie 4<u a f4ACe-f•,1S Policv# Company name: Address QqY: Phone#: Insurance Co. Policy# 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 civil penalties in the form of a STOP WORK ORDER and a fine of(5100.00)a day against me. I understand that a oopy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. 1 do herby certify under the pains and penny t s;of perfury that the information provided above is true and correct. Signature 0-20, V ( Date l C 6 Print name ,10 S ((�D � Phone#278 Of ial use only do not write in this area to be oompleted by city or town official' 0 Building Dept Chex*if imnwdrate response is required Building Dept p licensing Board p Selectman's Office Contact person: Phone X 0 Health Department Other FORM WORKMAN'S CO&WNSATM BOARD OF BUILDING REGULATIONS i License: CONSTRUCTION SUPERVISOR � -C 063503 NumberxGS,-� �` B• d 965 a =�b E 20`+07 Tr.no: 14926 Restrrictedrl,AO.- _ JAMES V CARROLL 163 HIGHLAND ANDOVER, MA 01810 Commissioner 10/10.1200 6 09:08 9 7 627 23960 0-HRISTIAH!SEtJ & SER:iI PAGE 02/02 CHRISTIANSEN & SERGI, INC. FRQFESSIONAL ENGINEERS AN0 LAND a4%R,'EYQRS 160 SUMMER STREET,HAVERHILL,MA 01MV1e � (979)3730310 PAX:(970)372-3460 October 18,2006 Mr, Lincoln Daley, Town Planner Town of North Axtdover Planning Departrnert 1600 Osgood Stmt North Andover, MA 01845 Re: Interim A3-Built Plans for Abby Lane&Molly Towne Road ("Autumn Chase" Subdivision) Dear Mir. Daley I hereby certify that the utilities and street binder pavement ftwn on the 9127/x6 Interim As-Built Plans fbr the above referenced project substantially comply with the Definitive SubdivWon plans approved by the Planning Board. Very trul ours, Chri n Sergi nc_ fit"OFPNILIP 0.s r oHIRIS N hi ' G. tjIJlt IVo.2se� C.C. Janes Carco;J.North Andovez Jtealty ONAL E�� I i Name iklIz"I Location ZO Check# l�� Date Note: F NORTH TOWN OF NORTH ANDOVER or Fee $ Sewer Mitigation H F Sewer Connection Fee $ SSS^cHUS Water Connection Fee $ } Meter Fee $ Other $ RECEIPT NO. TOTAL $ I 1563 Div.Public Works WHITE: Applicant CANARY: Department PINK: Treasurer GOLD: File I