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Home My WebLink AboutBuilding Permit #550 - 64 CAMPION ROAD 3/28/2008 i BUILDING PERMIT o "O oT 6�ti TOWN OF NORTH ANDOVER ? ° ''`- ._}..�6 ° 3 L APPLICATION FOR PLAN EXAMINATION Permit NO: SS� Date Received ?s q°gwno��'4y �SSCH►1`�E� Date Issued: IMPORTANT: Applicant must complete all items on this page ,ten - .�,„ w, _ +�+.moi-,,c•�^ ++�..G.'�Jaa+�- '�"�sem' z � .`'n� ��,,u. - c s� l:;� y �". ,�..� e.�� . .+�,-•.., �,.. ',ter` ^ ' rte., �� wt�-;_`_'�c�- :._�aT' _ _21 .. 52 W-4;5 r �-f -,A J, SF'"-RN a v: i 'i`-xi � '' va � 'sz� �xa��.�"M�'��'h a'"RFy�p'' yam'' ,��.-s�•,y°S.Sz'}t .K''" ..; q pj _ f, --7 ` "•1°r i `14 r" `�i-' x -_.' �.y--sfia �iC y "9..:np r3' '�-; '�4�;., .Y13'".- ,f•.fl*s'- z7Y��tl1Y0��"�`�`i d'"!.`_��R � 'i'�-�c��V+l+,v71%�I�l`7 �37��J�1�5✓kt�'�^� �r<'�"''"rY t a'�5r-�� t �/ ."".�- rc-: `tY"�*-.y�r�'�.e� �s �r .a �_-�`-�s`� �"x.. -�.�i^.°.'�r�,.. --�- r�-'� � N ,.'-�• �..�'��. i ��'�.� z.�v�� 4-w* TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other IN w'i MMA -#sx_$ 'Pz I ic' M c epd � �13, �� sapa Imes ershdDrr�rot ON t-� %'�` -.d^' -r Ms.t. Y `r� '�" ,•a" -tea '"- �". ' , ma i�"wry-.fit-4�ara i �,r ,r�`• �' _15 a 4FeT�s�11a12t -` .�'� }+`' - 5 „ r'K: Sfsm.e,- .;.4..«�ti'ki^-`�.. .. v x.. � - DESCRIPTION OF WORK TO BE PREFORMED: ` r I I Identification Prlea,se Type or Print Clearly) OWNER: Name: (�� (1-`� ! � ✓Lc't,�L,'Pt�J Phone: Address: �`� �f �(0�4 9�{- +t z �� r+ ' k erc'"tv.`EL.-�zy " " .Frvown 3' w�„ .„ t .. �;. p"" ,p ytyir„�.5. ,:� - res ki t s�� -�' --.4gjo_1011HF .Qet�'v 'ff y ar`5:..�' IS1`iaiM1 f �..°"'�3-� - � �N�f't s ��.?'�h'�� a• �. _.. �� x---L^�i y.s'r, �.c�-u+ '� .�' 1::�a .� . t �or�ne4�,rover.# ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 7— dZ;D FEE: $ 3 Z-/ �p ; Check No.: 2�o° Receipt No.: a�eZg NOTE: Persons contracting with egister contractors do not have access to the guaranty fund Snatur oAenan�n� ._ �z. g �: n� u . 6 - �. � hre o�f: I Location I No. .��'d Date � i i MpRTM TOWN OF NORTH ANDOVER � s * Certificate of Occupancy $ �►s',"°''<� 9 Buildin /Frame Permit Fee $ ?�cMusa Foundation Permit Fee $ Other Permit Fee $ TOTAL $ i Check # ` ! 025 Building Inspector . 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 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 t -'COMMENTS i HEALTH COMMENTS I i i 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 Located at 384 Osgood Street I �1RE DE� f3TA�lEl�11'�� eiaap� aperoa��te Vires no LocateW_ � �7Ulairt tr eta ti s "�a`�:y;_ ^ elm, Fite hep 5 �n1pp n t»r�� URI The Commonwealth of Massachusetts Department of IndustridUccidents Office of Investigations 600 Washington Street Boston, AfA 02111 www.mass.gov/dia Workers' ComPensa6on Insurance , Affidavit: Builders/Contractors/Electrlcans/Plumbers Aapiicant Information Please Print Le�bly Name(Busyness/orgamzahon/Individual):_ � � �^ C �.� 1 P�f ,(1 Address: rel l v✓1 n Q�s-W . • City/State/Zip: Phone.#: _t Are,you an employer?Check the appropriate box: Type 1. of I ro'ec ❑ I am a employer with 4. ❑ I am a general contractor and I � project t(requ>tred):.` employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling . ship and have no employees These sub-contractors have working for me in any capacity, employees and have workers' 8. ❑Demolition [No workers' comp.insurance comp. insurance.# 9. ❑Building.addition required.] 5. We are a corporation and its 10.0 Electrical repairs or additions 3f I am a homeowner doing all work officers have exercised their m 11.❑Plumbing repairs or additions myself [No workers comp. right of exemption per MGL insurance required.]t c. 152, §1(4), and we have no 12.0 Roof repairs employees. [No workers' 13.❑ Other 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 affidavit indicating they are doing all work and them hire outside contractorsmust submit a new afdavit indicating such. 'Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities employees. If the sub-contractors have employees,they must provide their workers'corm,Policy number. have I am an employer that is providing workerscompensation insurance for my employees. Below is the policy.and job site information. 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 Section 25A of MGL c. 152 can lead to.the imposition of criminal penalties-of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy,o f maybe forwazded to the Office of Investigations of the DIA r insurance covers a verification. I do hereby certify un a hep nd penalties of perjury that the information -----------provided above is true and correct Signat ie: Date: 3 1-11-31 (j G Phone#.: 77 0 S Official.use only. Do not write in this area, tb 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 InspeEPlumbingluspector 6`Other Contact Persoa• Phone#: i 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." r i 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,bpera"tem 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 M2,§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 time contracting authority. Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC) or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If.an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit; The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if youare 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.Offidals Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to.contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address" the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related'to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone-and fax number: The Commonwealth of Massachusetts Deparinent of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.# 617-727-000 ext.4.06 or 1-877-MASSAF)r ` Revised 11-22-06 Fax# 617-727-7749 _ t wwwMass-govlciia x.10 R TIy Town of � Andover "'k 0 No. o dover, Mass., 3 a • a COCMICMEWICK ADRATE D OP�,`�� `s BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System T / BUILDING INSPECTOR THIS CERTIFIES THAT......4 !. .................................................... ": Foundation has permission to erect........................................ buildings on .. / �� N �.....�............................ Rough to be occupied as....��,7x.! .......7....f...... o.� Chimney .................................................................................................... provided that the person accepting this permit shall i ery respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings In the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough 3Z Final PERMrr EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI TS Rough .......... ....................................................................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal 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. TOWN OF NORTH ANDOVER o"T" OFFICE OF 0 `� ;, BUILDING DEPARTMENT 1600 Osgood Street Building 20,Suite 2-36 eF North Andover,Massachusetts 01845 • s � ,JSAGWs Telephone(978)688-9545 Gerald A.Brown Fax (978)688-9542 Inspector of Buildings HOMEOWNER LICENSE EXEMPTION Pleasant / DATE: k) c 'In 1 JOB LOCATION: 1arJ, Map/Lot Number Street Address ells — ZS z s Phone HOMEOWNER Work Name Home Phone PRESENT MAILING ADDRESS v &-C��16 � City Town State Zip Code j i provided that the The current exemption for"homeowner s"aiindividual foor hire who does not posseinclude owner-occupieds a linen e,p ov to two units or less and to allow such homeowners to engage owner acts as supervisor). State Building (Code Section 108.3.5.1) DEFINITION OF HOMEOWNER on which there is, Person(s)who owns a parcel of land on which ho constructs more thes or at one home n a two-year periodrshall is noted to rson whoobe be,a one or two family structures. A pe considered a homeowner. i es responsibility for compliances with the State Building Code and other The undersigned"homeowner"assum Applicable codes,by-laws,rules and regulations. dover The undersigned"homeowner"certifies that he/she e u atthes he wil e Town c y with said PTOcedUTeSnand Department minimum inspection procedures and requirements requirements. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 10.2005 Form Homeowners Exemption CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 BOARD OF APPEALS 688-9541 i i TOWN OF NORTH ANDOVER AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application c. 142 A requires that the"reconstruction, alteration, renovation, repair, modernization,arex sting owner occupied building containing at least one but not more than four dwelling units...or to structures which are adjacent to such residence or building" be done by registered contractors, with certain exception, along with other requirements. T e of Work: I� ��G� Est. Cost-z-&—,060 Yp Address of Work j O(� 2-D Owner Name: Date of Permit Application: fin,, , 2�3 208 1 hereby certify that: Registration is not required for the following reason(s): For office Use Only Work excluded by law Permit No.-. Date Job under $1,000 B (ding not owner-occupied ner pulling own permit Other (specify) Notice is hereby -given that: NTRACTORS OWNERS PULLING THEIR OWN PERMIT OR DEALING IMPROVEMENT WORK DO NOTTH UNREGISTEED HAVE ACCESSTO THE FOR APPLICABLE HOME E ARBITRATIION PROGRAM OR GUARANTY FIND LINER MGL c. 142A. Signed under penalties of perjury: I hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. OR: jOwner mit as the owner of the above property: Notwithstanding the above notice, I hereby apply Date ��' ame / 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 a r Electrical Inspector Yes q PP oval of No DANGER ZONE LITERATURE: Yes MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NO NOTES and DATA— (For department use i ❑ Notified for pickup - Date Doc-Building Permit Revised 2007 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 p NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit P Addition Or Decks ❑ Building Permit Application o 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 9 g NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (OneTo 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 I Revised 2.2007 P"LNorth Andover MIMAP August 21, 2014 47F4y { u � t I s r � i t 2`�t sine Y is I c z S' e` y, f � J V 1� { �S y^ h A { Interstates I —SR Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83, Meters Data Sources:The data for this map was produced by Merrimack Roads NORTH Valley Planning Commission(MVPC)using data provided by the Town of e Easements Of e ,•�y North Andover.Additional data provided by the Executive Office of C3 MVPC Boundary �t *�00 Environmental Affairs/MassGIS.The information depicted on this map is f Parcels 3' _ L for planning purposes only.It may not be adequate for legal boundary !O 9 definition orregulatory Interpretation.THE TOWN NORTH ANDOVER MAKES NOOWARRANTIES,EXPRESSED OR IMPLIED,CONCERNING # THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY t + OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT M�o� ♦ ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION 1SSACMUS�t 1"=73ft ` Date... ....................... i s &ORT/, TOWN OF NORTH ANDOVER PERMIT FOR WIRING �ssAcHusE� This c'e'rtifies that .:�Uw`............CY1 't� has permission to perform ........ .. Tex SCJ .................................................................. wiring in the building of.... ............................................ (, �� at -! PI�'"' � ,North Andover,Mass. Fee... .5 ........ Lic.No.......3... YL ............... .... ...... ` ELECTRICAL INSPECTOR Check # �5 93906 �i Commonwealth of Massachusetts Official Use Only Department of Fire Services P `N° Occupancy and Fye Checked BOARD OF FIRE PREVENTION REGULATIONS pLv. m7] ;,ave blank ArPPUCAtTION FOR PERMIT TO PERFORM ELECTRICAL WORK All wort:to be performed in acc a&nae with the Massachusetts Electrical Code(MEC'),527 CMR 12.00 {PLF-4SE PRINT IN OR TYPE ALL INFORALMOA9 Date: 5/11/10 City or Town of NORTH ANDO'V'ER To the Inspector of Fires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 64 Campion Rd OwnerorTenant Greg Titterington TelephontNo.978-835-1526 Owner's Address 64 Campion Rd. Is this permit in conjunction with a building permit? Yes ® No � (Check Appropriate Boz) Purpose of Building Utility Authorization No. Existing Service 2 0 0 Amps 120/240 Molts Overhead Undgrd® No.of Meters 1 New Service Amps ! Volts Overhead❑ Under d❑ No.of Meters Number of Feeders and Ampacity i/rf Location and Nature ofProposed Electrical Work: Install new 18kw generator and automatic transfer switch. _ -- CoMeletiongLihefollowingtable maybe waived by the I or of Wires, No,of Recessed Luminaires No.of Cell.-Susp.(Paddle)Fans o.of otal Transformers _ KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Abograve e 13 ❑ Bette Units ency atm, No.of Receptacle Outlets No.of Oil Burners FIRE Ai.AEMS INe,of Zones No.of Switches No.of Gas Burners No. action and Initia a Devices No.of Ranges No.of Air Con& Ton No.of Alerting Devices Disposers #p ' °' No.of waste o.o conrain Totals: Deteetion/Ate Device No.of Dishwashers SpacelArea Heating KNil Larsi❑ M nnni�oa ❑ Other No.of Dryers Heating Appliancm KW Security Devices � r'Y No.of evices or Eauivalent No.of Water lid o.of o.of Data Wiring: Heaters S' Ballasts No.of Devices or evivalent No.Hydromassage Bathtubs No.of Motors Total HP edecommuni ce o mag: � No.of Devices or Equivalent OTHER: Attach additional detail if desirei4 or as required by the Inspector of Brea Estiniated Value of Electrical Work: 1, 5 0 0 . 0 0 (Vben rquired by municipal policy.) Work to Sart 5/13/10 Inspections to be requested in accordance with IVIEC 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 is in force,and has exidbited proof of same to the permit issuing office. CHECK ONE: INSURANCE K] BOND L7 OTHER p (Specify.) I certify,under thepains andpenddes ofper,jurl',that the information on this application is trite and complete. FIRMNAW: Essex Newbury North Contracting LIC.NO: E38842 Licensee: Tony Schiavone Signature _ LIC.NO.: {If applicable,enter"exempt"in the license number line=) Bins.TeL No.; Address: 65 Parker Street - Newburyport, MA Alt.Tei.No.: *Per M.G.L c. 117,5.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNWS WSURANCE WAI'V>:;R: I am aware that the Licensee does not have the liability ksrarice coverage normally required by law. By my signature below,I hereby waive this requirement I am the(check one) ❑owner ❑ownWs agent. Owner/Agent PERMIT FEE:Signature Telephone No. a The Commonwealth of Massachusetts Department of Industrial Accidents Office of Fnvestigations 600 Tfirashington Street Boston, M-4 02111 www.rnass.gov/dia Workers' Compensation;Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ,Applicant Information Please Print Leoibly Name(Business/Organizahon/indiv€dual): Essex Newbury North Contracting Corp. Address: 65 Parker Street - Unit 5 City/StatelZip: Newburypo rt, MA Phone#: 978-463-5414 Are you an employer?Check the appropriate box: Type of prosect(required): 1. 1 am a employer with 2 0+ 4. ® I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.[] I am a sole proprietor or partner- listed on the attached sheet.$ 7• Remodeling " ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g. Building addition [No workers'comp. insurance 5. We are a corporation and its 10.0 Electrical repairs or additions required.] officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' 13.[:]Other comp.insurance required.] '.`.ny applicant that chi box=1 must also fill.out the sa tin^l:c? ovr ShOwing fh.air wokers'comp�seeoa policy irh-rM.-.tion t Flom=v.m=who submit ibis affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContrmetors that check this box must attached an additional sheet showing the name of the sub•contmetors and their workers'comp.policy information. I ant an employer that is providing fvorkers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Gencorp Insurance Group Policy#or Self-ins.Lic.#: WC 5 318 5 9 0 10/15/10 Expiration Date: t 64 Campion Rd Ci /State/zi N. Andover, MA Iab Site Address: City/State/zip:P� — ,+ Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of dais statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certtfy under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: 5/11/10 phone#' 978-463-5414 Ofi7cial use only. Do not write in this area, to be completed by city or town official City or Town' Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical inspector 5.Plumbing Inspector 6.Other i Contact Person: Phone#: Date. C . ... .. NpRTp of OWN OF NORTH ANDOVER f.� F 9 • PERMIT FOR GAS INSTALLATION SACHUSE� This certifies that . 1`l . t!� . . .,�'Y�L.. . . . . . . . . . . . . . . . . . has permission for,gas installation . . . . . . . . . . . . . in the buildings of . . . .! . . T . . . . . . . . . . . . . . . . . . . . . at C. �� . . . . . . . . . . . , North Andover, Mass. Fee., 1.` . Lic. No..1()Z 2. . . . . . . . . . . . . . . . . . . . . . . GASINSPECTOR Check#✓ 7244 t tti MASSACHUSETTS UNUFORM APPLICATON FORPERMIT TO DO GAS FMING (Type or print) Date l NO fy NORTH ANDOVER,MASSACHUSETTS -Y Building Locations ( I. mot cl)l 120 Permit# A)n And 4..- Amount$ Owner's Name New Renovation ❑ Replacement El Plans Submitted rl u d r� U v� x [a. Cz m i- W p O U p Z F h C C7 w d w w F w w m d w x z w �a W a u F Z E- O > w w F W 0 c E W C C4 3 c a a > c a0 c SUB -BASEMENT U B A S E M ENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . FLOOR (Print or type /� Name_ TTA-V k)-Q!'S '( 2t S j r, C CheKe: Certificate Installing Company Address C"ef Partner. Busmess a ep one - Z7 7 L�f Firm/Co. Name of Licensed Plumber or Gas Fitter �j oMc S 0 CC pf i INSURANCE COVERAGE Check o I have a current liability Insurance olicy or it's substantial equivalent. Yes Noo If you have checked yes,please' dicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity Bond Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application'will be in compliance with all pertinent provisions of the Massachu State Gas C e and Chapter 142 of the General Laws. k By: Signature of Licensed Plumber Or Gas Fitter Title Plumber City/Town Gas Fitter I-icense Num5er Master APPROVED(OFFICE USE ONLY) Journeyman r A The Commonwealth of Massachusetts Department of industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www:mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeQ><bly Name(Business/Organization/IndividuO): Address: City/State/Zip: Phone#: Areou an y C heck theappropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors b• ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet t 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. [No workers' comp. insurance 5. El We are a corporation and its 9 ❑Building addition required.] officers have exercised their 10.El Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL .11.❑Plumbing repairs or additions myself [No workers' comp. c. 152, §1(4),and we have no insurance required-] t 12.❑Roof repairs q ] employees. [No workers' comp.insurance required.] 13.[] Other ' `=n5'applica t that checks box#1 must also rill ou;the sectirm below sao••.•i*,b+heir �=' information. T Homeowners who submit this affidavit indicating the„are doing all work and then hire outside ontractors must submit a new affidavit indicating such. $Contractors that check this box must aitached an additional sheet showing the,name of the sub contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy7 and job site information. Insurance Company Name: Policy#or Self-ins. Lie.#: 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. i I do hereby certify under the pains and penalties of perjury that the information provided above is true an�correct Si ature: f Phone#: Official use only. Do n:oe). in this area, to be completed by city or town o�ciaL I Cita or Town: I'ermit/License# i Issuing Authority(circL Board of Health 2. Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: r Information an d Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their cerdficate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested.not the Depa=--nt.of Industrial Accidents. Should you have any questions regardfixg 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 Iegibly. 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 pennit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hositate to give us a call The Department'¢address,telephone and fax number. The Commonwealth of Massachusetts Department of In Accidents Office of tnvestibations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 vrvrv1.rnass..o ov/dia Location No. n3 Date 1 NORTIy TOWN OF NORTH ANDOVER O F R A =o �; Certificate of Occupancy $ Building/Frame/Frame Permit Fee $ s�CHUS 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ D Check # �i 17 2 U b Building Inspector I I TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING r BUILDING PERMIT NUMBER. DATE ISSUED: ic SIGNATURE: Building Commissioner/Irls or of Buildings Date _,�- —e)I Z SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: O Pl orl� 2040 b I Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning Distiict Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: n Public 0 Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System 0 RECTION 2-PROPERTY OWNERSEIPIAUTHORIZED AGENT Historic District: Yes No 111 2.1 Owner of Record Name( n Address for Service: 778 . 259 . Z�S Signature Telephone 2.2 Owner of Record: Name Print Address for Service: M Signature Tel hone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: O License Number Address Expiration Date Signature Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ v Company Name rn Registration Number Address r Z Expiration Date Signature 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 Workcheck elle llcable New Construction ❑ Existing Building Fr Repair(s) Alterations(s) ❑ Addition 0 Accessory Bldg. ❑ Demolition ❑ Other 0 Specify Brief Description of Proposed Work: '5& N�j C4,4 iW_P�CO_ WJ� es k k'E_ 'CA SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant 1. Building (a) Building Permit Fee 7 r r7vC7 Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X tbl 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 DU Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT ORnCONTRACTOR /APPLIMI ES FOR BUILDING PERT 1, �( � '7 �i nS (-2:9'n Cts�0>1/Authorized Agent of subject property Hereby authorize to act on My behalf,`in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 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 Prin Signa of O er ent Date NO.dF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINMERS iST2ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE t%ORTN Q�RtIYD f fi q'Y Town of North Andover Building Department 27 Charles Street North Andover, MA. 01845 Sac►�us� D. Robert Nicetta Building Commissioner (978) 688-9545 (978) 688-9542.Fax HOMEOWNER LICENSE EXEMPTION Please print. DATE JOB LOCATION (S/—1 C,Avy\'P 1)1'� n-0 A-0 Z_ Number Street Address Map/lot "HOMEOWNER ( 1 �rl� c� • Z�8 �`7U• `T�, f�2� Name Home Phone Work Phone • PRESENT MAILING ADDRESS 6 "fit"(D('A aDAj 04 City Town State Zip Code The current exemption for"homedwners"was extended to include owner-occupied dwellings of two units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. (State Building Code Section 108.3.5.1) DEFINITION OF HOMEWOWNER: Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling,attached or detached structures ac- cessory to such use and/or farm structures. A person who constructs more than onehome in a two-year period shall not be considered a homeowner. The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned"homeowner"certifies that he/she understands the Town of No. Andover Building Department minimum inspection procedur and requirem t and that he/she will comply with said procedures and requirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFICIAL 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: (Location Facility S' ature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector I 5 C 1�J �. 'tOPOL.�'�p I� — __ �:-L?'`zfi_.._ �-+, I I I i I I III I I I I I I � i G�[.2 SW,Ir�_ �� !�• _ ---- I - if- ' 0 41R 'r rl fllf nns+l• - i II I I j I - - ' i ��'c�: errs 4 i -FI�7!:,2vr�yTt. I Yxl>ir T�s:a� - •`�- - � Idi�1111'r Ri`!1 - C�2:?DT sGVQ41Qr C,4,AA O, 3 I ✓ I I I. I I 7 4,f Ij i-1 I '. -`L'."i'1-r - i I I I j' I1Ij i . : jI I jI IIIII' I � i f jllli ! II j it i I i IZ of-FL WS � - �F-V _ - i I� I. 6yJjIZ� I I i'• '. � � �I f � �I a l /� �� i"ne I ' I \ � �/� � I \� � ,/ I I I I`•\ I ' i I j � i I I I ' I '� I 1 'I I � � � - � • \\�Y �, II!j I ' oI'; III j �I � ' I Ii ' �, �I I i I' I � �� - jl I 3'o�c r I f I i I I II f i I I I f I i I I I i I _ I I -- � ;Ii LL _ - -Eli xj I I. "j I ��I I r: I I , I I I I I I I I I I I I I I I to TH Town of C'% - LAKE 0 dover, Mass., A 'o�/•D�/ T O � C OC MIC ME WICK V �.9 40 ATED 9'P5 `S V BOARD OF HEALTH PER D Food/Kitchen Septic System • • BUILDING INSPECTOR THISCERTIFIES THAT..... ...... .... ................................... ....................... �............... Foundation has permission to erect........................................ buildings on ..to... . .,.......;p Rough to be occupied as ...... ................................................... Chimney ............................................................................... provided that the person accepti his permit shall in every respect conform to the terms of the application on file in Final this office, and to the provision the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North dover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION S Rough ............................................. ervice BUILDING INSPECTOR Final Occupancy Permit Required t® 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.