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Building Permit #479-16 - 57 CHICKERING ROAD 5/1/2018
BUILDING PERMIT of NORT1� q �t TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: ln Date Received A°R�TEo "c5 gSSACHUSE'( Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION 44 Print PROPERTY OWNER -X� Print 100 Year Structure yes no MAP _PARCEL: D ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building R-C1ne family [I Addition [I Two or more family 11 Industrial ❑Alteration No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑.Septics ❑Well ❑ FIoodplain ❑Wetlands 0 Watershed Distract DESCRIPTION OFWORK TO BE PERFORMED: /� Identification- PI e se Type or Print Clearly OWNER: Name: nn ®® Phone: Address: &_7 f 2e- am!��< zz)v- Contractor Name: W&V.— Phone: 'z� '44y "G 73 7 Email: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: 103,36 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: $ �D40 ' FEE: $ Check No.: S93- Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access the uaranty fund Location C �7 i c � 4 No. L/7% /6 Date /O /5' /- • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check wilding Inspector 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 PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS e 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: FIRE Located 384 Osgood Street ,r�_ �DEPAR�TMENT TempD er,onwsite, , s� _ umpst ` t dati124 - +,Loewe - (MamfSt[eet s �Fi_re�Department�sgnafure/date COMMENTS. 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 q pp requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$10041000 fine I NOTES and DATA— (For department use) ® Notified for pickup Call Email Date Time Contact Name Doc.Building Pennit Revised 2014 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 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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks 4. 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/Cross Section/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 OTE: 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 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 NORTH Town of t EAndover 0 No. zo r,4-L ver, Mass, 2COCHICH04 a ICK �1 pDRATED S U BOARD OF HEALTH Food/Kitchen PERMIT LD Septic System THIS CERTIFIES THAT ......... .. .. .....� ...................... BUILDING INSPECTOR .... .....: -.... .... ................. ... .... .... .... . . Foundation has permission to erect ............ buildings on .�.�.. .......�c: .........` ......... ..... ......................... Rough to be occupied as ..................`.5:��:' ....... .`:..`....� ............................................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO TARTS Rough 4 y� ............................ Service ""' Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Buildinz Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final YY No Lathing or Dry all To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. Page# of pages CS # 022680 978-688-6737 HIC# 103358 A. J. Walsh & Sons or 159A Waverly Road 1-978-912-2853 North Andover, MA 01845 Propose!Subm' To: Z Job N � Job# Address gee Job Locap�n✓. ---- Datep�� �, �--►- Date of Plans Phone# !! vw�ciL Fax# Architect We hereby submit specifications and estimates for. ramal c� ' J Zi LZc� ail v v W7--�I-7e hereby to furnish material and labor—complete in accordance with the above specifications for the sum of: ,y o UD0�a ��lo <<,Q ,., 7lJU�f Dollars 1 with payments to be made as follows: I! Any alteration or deviation from above specifications Involving extra costs will be Respectfully executed only upon written order,and will become an extra cMrge over and d above the estimate.AN agreements contingent upon stokes,accidents,or delays submitted beyond our cohtroi. Note—this proposal may be withdrawn by us if not accepted within days. 2a tan Fherebyaccepted. s,specifications and conditions are satisfactory and are Signature You are authorized to do the work as specified. Payments will be made as outlined above. Date of Acceptance Signature MASSACHUSETTS HOME IMPROVEMENT CONTRACT This form satisfierall basic requirements of the state's Home Improvement Cotitractor Law(MGL chapter 142A),but tloes not include standard language to protect homeowners. Seek legal advice if necessary. Any peison•plamung home*iuprovements ahoula1ist obtain a copy of"a Massachusetwconsumer:guide to home improvement"before agreeing to any work on yourresidenoc.You may obtain a free.copy by'calling the' Office of Consumer:Affaim and Business,Regulation'a Consumer Information Hotline at617-973-8787 or 11888.2834737: . Homeowner Information Contractor Information ' Name S _ (¢O not Post ffia Brox address OwnerName City/Town State Zip Cbde luduess Address(must include a street address)Df/tim . ePhone Evening Phone I"ity/Town / State Zip Code Mailing Address(It different from above) 3usinia Phone llederal Employer ID or S.S.Number W mpuun um mca=il• some acmmearaga:3hMbcr :8xphpi®dga eontrrlgo bwg ` ' craiwadmm®6er The Contractor agrees to do the following work for the Homeo star: or / ` Required Per inits-The-61lowing building peimits aro required Proposed Start and Completion Schedule-The fdllowing schedule will and will besecured by the contractor as the'homcowzu:6 agent; be adhered tauIdes s circymstances beyond the contractors'control arise (Owners who secure their own permits will be �r excludedfrom=the-GuaranD upwh"contractor will begineoatracted work MGL chapter 142A.) when contracted .work will be nbstantially completed. Total Contract Price and Payment Schedule , The Contractor.agrees to perform theIwork,furnish-the material and labor specified above for the total sura of- Payments f Payments will�8 de according to the following schedule: upon.signing contract(nottn eitceetl 1/3 of the total.eontract price.sr the cost:of special order items,whichever is. $ � by_l-�= or upon completion of S4 Oby /�!�or upon completion of $C-.� upon completion of the contract (law forbids demanding fWl payment until.contract is completed to boths satisfaction) 71e following material/equipment must be specialS e paid for ordered before the contracted work begins in order S to be paid for to moat the completion schedule.(**) 'NOTES:(•)iucluding all finance charges(••)Law requires that any deposit or down-payment required by the contractor before work begins may not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of atiy special equipment or custom made material which must be special ordered in advance to meet the completion wilt dine. Express Warranty-Is sn express.warranty being provided by that•ntr.ctor+ No Yes ( termspf the wartaaty must be attached to ffie contnMt Subcontractors-The contractor agrees to be solely responsible for completion of the work described regardless of the actions'of airy thrid Party/subcontractor utilized by the contractor, The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this aeTeement Contract Acceptance-Upon signing,this document becomes a binding_contract under law. Unless otherwise noted within this document,the contract shall not imply that any lien or other security interest'tas been placed on the residence. Review the following cautions and notices carefully before signing this contract • Don't be pressured into signing the contract Take time to read aced fully understand it Ask'question's ifsomiffi-iiig is unclear. • Make sure the contractor has a valid Home Improvement Con=ctorRegistration The taw requirrs most home improvement contractors and. subcontractors to be registered with the Director ofHome Improvement Contmetolc Registration. You may inquire about contractor registration by writing to the Director at:One Ashburton Place,Room 1301,Boston,'MA 02108 or-by.calling 617-727-3200 or 1-800.223-0933. • Does the contractor have insurance? Check to see that your contractor is properly insured • Know your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home IMprovement Contractor Law. You may cancel this agreement if it has been signed at a place o1her.than the commctdr's'normal place of business,provided you not the contractor in writing at his/her main office or branch office by ordinary mail posted,by tele sent or delivery, third business da followin the signing 8� by elk.not later thaamidnight of the. Y g. going trf this agreement.See the notice of cancellation form for an explanation of.this right DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPAC'ES!!! t o idea' 1 a the ccaaact must be eoarph W and$ited One capy.should go to the honeowner.The other copy should cbe kept by the contragtor. Homeowner s Signature �L— Contmctor's Signature Date Date Contractor Arbitre6n The Home Improvement Contractor Law ppovides;homeowners withthenght.to initiate an arbitration action(as an alternative to courtachoia)if they;have a dispiie with.a contractor. The same tightis nb`automatically afforded to'a. contractor,however.:The.contractor.would have.tp resolve any;dispute he/she.has with a homeowner in court unless both parties agree to.the optional clause provided below..This clause would,give the contractor the same right to arbitration as is afforded to the bomeowner.by the Home Improvement Contractor Law. . . The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispute- concerning this contract,the contractor may submit the dispute to a.private arbitration firm which has been.approved by the Secretary of the Executive Office of Consumet Affairs and Business Regulation arndihe consumer shall lie required to 2cowner's o such arbi tion as provided In•Massachusetts General Laws,cha 142A. signaure Contractors Signature NOTICE:`The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the contractor::The=homeowner.may initiate alternative-dispute resolution even where this section is not separately signed-by-the patties:: Homeowner's Rights A homeowner's rights unde%tlxe Home'1nprovement Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e.MGL chapter 93A)may not be waived in any way,even by agreement: However,homeowners may be excluded from certain rights if the contractor they choose is not properly registered as prescribed by law. Homeowna¢who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Inrprovement Contractor Law. The contractor is responsible-for completing the work as described,in a timely and:workmanlike•manner. Homeowners-may be entitled to.other specific legal rights:if the contractor guarantees. or provides.an.express warranty for:workmanship oi•materials. In addition to.guarantees or warranties provided by the contractor,all goods sold in Massachusetts carry an implied warranty of merchantability;and fitness-forr-a particular purpose. An enumeration of other matters on which,the homeowner and contractor lawfully agr'eeMay be added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. If you have questions about your consumer/homeowner rights;contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all'exhibits and referenced documents have been attached Parties are also advised not to sign the document until all blank sections have been filled in or marked as void,deleted,or not applicable. One original signed copy of the contract with attachments is to be given to the owner and the other kept by..the contractor. Any modification.to the griginal contract must be in writing and agreed to by both parties.Contracted work may not begin until both parties have received a fully executed copy of F the contract,and the three day recission period has expired. 06 Accelerated Payments A contractor may not demand payments in advance.of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However,in instances wherea.contractor deems him/herself to be financially insecure,the contractor may require thatthe.balance of fords not yet due be placed in'a joint escrow account as a prerequisite to.continuing the contracted work. Withdrawal of funds from said account would require the signatures of both parties. Additional Information If you have general questions or.need additional information about the Home ImprovementContractorLaw or other consumer rights,or if you wish to:obtain a free:copy of "A Consumer Guide to the Home Improvement.Contractor Law,"contact Cgnsumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza,Room 5170,Boston,MA 02116 (617)973-8787 or 1-(888)283.3757 If you want to verify theaegistration of a contractor or if you have questions or need.additional information specifically about the contractor registration component of the Home Improvement Contractor"Law,contact: Director of Home•Inrprovement Contractor Registration Bureau of Building Regulaiions and Standards One Ashburton PIace,Room 1301,Boston,MA 02108 (617)727-3200 or1-800-223-0933 For assistance with informal mentation of disputes or to register formal complaints against a business,call:' Const aiier`Complaint`Section Office of the Attorney General (617)727-8400 AND/OR Better Business Bureau (508)652-4800 (508)755-2548 (413)734-3114 The Commonwealth of Massachusetts . Department of IndustrialAccidents n F a 1 Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia yV� Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Avylicaut Information AJ6 9L4 Please Print LeOb Name(Business/Organization/Iudividual): Address: City/State/Zip: /10 0,4tA,4, jn,1- Phone#: Y?S''4I-E—6737 Are you an employer?Check the appropriate box: Type of project(required): 1. am a employer with l.. : employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3..❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 �Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. oof repairs These sub-contractors have employees and have workers'comp.insurance.x 6.Q We are a corporation and its officers have exercised their right of'exemption per MGL c. 14.Q Other 152,§1(4),and we have na employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this aff davit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must-attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name:_lei `-z 4(z- ,4z_ Policy#or Self-ins.Lie.#: �a��'�y�D ��-0-0/5— Expiration Date: Job Site Address: S City/State/Zip: Attach a copy of the workers'compensatio policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.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 thepains /aandpenalties ofperjury that the information provided above is true and correct. Signature: 0Date: ,:�' /` J Phone#• e- 73 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 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=contractors)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 cant'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 foi•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 burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.# 617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia .4c 0 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) k�I -_ 01/12/2015 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(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 00775-001 fi2A?CT Durso&Jankowski Insurance Agency Inc NIo.Ext: (978)682-5175 c.No.: (978)794-0313 198 Mass Ave Suite 101 B �Sss: North Andover,MA 01845 N A• A.I.M.Mutual Insurance Company INSURED .33758 Arthur Walsh A J Walsh & Sona 55 Pleasant Street North Andover, NA 01845 _IN5URER D: 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 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. ILTR TYPE OF INSURANCE IWO WVD POLICY NUMBER MMID[j/YYYY � � LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ P I CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ EN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S ff�OLICYRO- OC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ d ntl ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS (Per accident) $ UMBRELLA LIAB I OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE AGGREGATE $ yypR{KD�ED_CCQQMM RETENTION $ g U 7H $ ANNNyyDPPERRM��PppLROYE�E77RppS�LIARRBILNNIEETRRY�� X TfRY 71% OER /� OfFICER/NIdMBEWEXCLUDED?ECUTIVE N E.L.EACH ACCIDENT $ 100,000,00 Y N/A AWC-400-7014648-2014A 11/14/2014 11/14/2015 (Mandatory In NH) er E.L.DISEASE-EA EMPLOYEE $ 100,000.00 DEN OF OPERATIONS belowE.L.DISEASE-POLICY LIMIT $ 500,000.00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,it more space Is required) The workers compensation policy does not provide coverage for Arthur J Walsh CERTIFICATE HOLDER CANCELLATION Town Of North Andover 1600 Osgood Street SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE North Andover,MA 01845 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD •t 1 Massachusetts -Department of Public Safety Board.of Building Rcgulations and Standards Construction Super%isorev , License: CS-022680 ARTHUR J WAL 0 JR ' 159A WAVERLY RD s N ANDOVER Mk 01845 , Expiration Commissioner 06/09/2016 �//te Dant-�xnntleltlf�O�C��`avJrcc�rtJn�.f Off ce of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR egistration: 103358 Type: yxpiration: 7/7/2016 Private Corporatio. A.J.WALSH&SONS,INC. Arthur Walsh 55 Pleasant St l -- — N Andover,MA 01845 Undersecretary Location r� Yx-i i No. /SCS Date dL-- ,kORTN TOWN OF NORTH ANDOVER � p i Certificate of Occupancy $ b �sS,CHUSttA Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # '+ 5 V L 0 / —Building Ins r TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING 7777777777 -ss rn BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioner/12UEtor of Buildings Date Z SECTION I-SITE INFORMATION IO LI Property Address: 1.2 Assessors Map and Parcel Number: 00-2 Map Number �— Parcel Number .1V,4!q0 I VIP 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Rapired Provided Required Provided v 1.7 water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System 0 SECTION 2-PROPERTY OWNERSIDP/AUTHORIZED AGENT rn 2.1 Owner of Record/ �� f Name(Print) Address for Service: -- SaQ� Signature Telephone 2.2 Owntr of Record: Name Print Address for Service: O Z rn Signature Telephone 90 SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable 0 Licensed Construction Supervisor: O License Number Address Expiration Date ic Signature Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ v Company Name Registration Number '"M Address � � r (j4e I - J lO� Expiration Date nz Si ature Telephone "- 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.......❑ SECTION 5 Description of Proposed Work check all applicable) New Constructio *0 �F,xi l4tg Bui�itig ❑ Repair(s) ❑ Alterationo ❑ Addition ❑ r . . Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(8)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 � LO/�as 1, M f' �e' Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in is relative to work auth i ed by s tildi g permit application. 9 -� ✓ V Signaf Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, ,as Owner/Authorized Agent of subject 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 T11VIBERS iST 2ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING x MATERIAL OF CHINMY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Town of Andover 0 0 coC CA.7 Ll - W W C C Q dover, Mass, the W CQ ORATED i"?�O 5 IT BOARD OF HEALTH Food/Kitchen PER' ) T T D Septic System BUILDING INSPECTOR 4&4 A 06 THIS CERTIFIES THAT.. .................. ...................................... Foundation has permission to erect........................................ buildings on*44 Rough .......4-1 A 4 ........ ..... to be occupied a ........ ......... ..... Chimney .00 �c�e s provided that the person acce g this permit shall in ei��4i t conform*o"r'm*' *the'* **'terms*"****"of't,the application*n*,on file in Final Oro ng to the Inspection, Alteration and Construction of this office, and to the provisio of the Codes and By-Laws et 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 -CONSTRUCTIONY ELECTRICAL INSPECTOR 0550*� 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. ✓lie v�anvnaoruueat'o�� k�G�+ Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 122153 Expiration: 7/26/2004 type: DBA E JOHN BERTHOLD CONSTRUCTIO i )ohn Berthold 15 Popular Rd Salem,NH 03079 Administrator j