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Building Permit #656 - 846 CHESTNUT STREET 4/14/2006
I-- Ei NORTFr ° p TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION ,SSACMUSE4 Permit NO: Date Received: c2 7- L.� Date ISSUCII: IMPORTANT: Applicant nlllSt complete all items oil this LOCATION— y (� C��S�n�\ ST, Print . PROPERTY OVa'NER SC3.n�po. Print MAP NO.: jO�l C. _PARCEL_A-'CA ZONING DISTRICT: r�r r■ r�r�r �s Mere Dlf MQTDIf T vF.s n I Y CC Hl`Ill UOG - - ---- — -- TYPE OF IMPROVEMENT PROPOSED USE -- Residential No Residential New Building _ One family /Addition = Two or more family Industria;. Alteration No. of units: i Repair, replacement _ Assessory Bldg =Commercial Demolition Moving (relocation) r Other _:, Others: Foundation only DESCRIPTION Oli WOKK 10 LSt FKrruKlvir,u \A In Rir1 t Fam,Iy QMj 6060(-, Identification Please 'rpR or Print Clearly) OWNER: Name: 0 �o -3FI 5ign'ture Address: f¢`�,L' f�/ x'� �2G(� �'r )-)elz,-f1 he euepi2 6)honc: c C iI CONTRACTOR Name: Qv,�Pss r\G ( 49`7300 Address: Supervisor's Construction License: I (,, _Exp. Date: Hunte (nlprovcment License:_ Ex Date: Io11b I°% N.anle: Phone: 97� '&Y3 11 _ Address: ;� &-c-kelev U , Reg. No. FEE SCHEDULE: BLLDLNG P R,1IM 510.00 PER $1000.00 OF THE TOTAL EST1;11A TED COST BASED O,V S 12.5. 00 PER S. F. /0' Total Proiect Cost :$ 2)-S"00 x10.00 FEE:$ Check No.: 3 C6 � 7 Receipt No.:. I C/_� 0 -5;"(, ("17e--SY'�ve Location 4 No. Date _Illello TOWN OF NORTH ANDOVER 14 Certificate of Occupancy $ Z. S cmust Building/Frame Permit Fee $ 72 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # V5? A 2 Building Inspector 14 0 0 41 CHU ��Ikle) R Date... , . ............... TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,TC''L- C/I d a Thiscertifies that ...... ...................................................................................... /z-( 4 P �. has permission to perform ....... wiring in the building of ......... .... .. . ............................................. at ......... ......... ........................... . North Andover, Mass. Fee .... !�5 ...... Lic. No. -.1031) �� ........ J.- ....... .. ... .. ...... Check # 13-)3 CAL INSPE�OR 4771 TYPE OF SE\kARGE DISPOSAL j Public Sewer Well Private (septic tank, etc. i Tanning/1vtassage Bod) Art Tobacco Sales Permanent Dempster on Site Swiniming Pools - Food Packaging. Sales NOTE: Peri ilN eonlrm-tin; witlr nrrregivererl conlrrrclurs- du not /nrve arreti'sh► the Si.411Mature ofAgent,Owner f ' �� �! 2� Signature of Contracto Plans Submitted 11 Plans Waived ❑ Certified Plot Plan 17 g THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS DATE REJECTED U Li Water Shed Special Pen -nit Ll Site Plan Special Permit ❑ Other rrrrr r I,fnr l Stamped ans DATE APPROVED t TE REJECTED DATE APPROVED CONSERVATI T � 2917 COMMENTS DATE REJECTED DATE APPROVED %HEALTH�� �� 1���'� `/� �/ �� XA , COMMENTSSOS�--'�-��� «�, 1_onin�- Board ot-1ppcals: Variance. Petition No: Lonlnu Decision, receipt submitted yes Plannin,, Board Decision: Conservation Decision: Ccmunents Comments A E Water & Sewer connection siunature & date _ Temp Dempster on site yew no Fire Department sivnature'date 2116 Building Permit Approved and Issued by: i Building Setback (ft.) Front Yard Side Yard Rear Yard Required Provided RcqLlii-cd Provides Required Provided I DIMENSION N Umber of Stories: Total land area, sq. ft.: NOTES and DATA —I For denartincni asci Total square feet of floor area., based on Exterior dimensions. Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Rooting, Siding, Interior Rehabilitation Permits Building Permit Application u Debris Removal Form u Workers Comp Affidavit u Photo Copy Of H.I.C. And/Or C.S.L. Licenses j 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) u Building Permit Application u Form U j Certified Proposed Plot Plan j Photo of H.I.C. And C.S.L. Licenses u Workers Comp Affidavit u Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract u klass check Ener y Compliance Report In all cases if a 1 ariance or special permit was required the To11 n Clerks office ,oust 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 cope and proof, of recording must be submitted with the building application Doc: I\SPECTIOV,1E SE10 R ES DEPARTN1E\T:BPFOR1105 02/23/2006 12:04 FAX 978 794 0313 S.J.DLiRSO INSURANCE AGCY 4003/003 AC -08Q, CERTIFICATE OF LIABILITY INSURANCE C,�° 1 °A02/23/06( PRODUCER Samuel J. Durso insurance Agcy Charles S. Randone 198 Massachusetts Avenue THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLIER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. TYK OF INSURANCE North Andover NA 01845 Phone: 978-682-5175 Fax:978-754^0313 INSURERS AFFORDING COVERAGE INSURER A: Guard Insurance Group MAIC INSURED GENERAL LIABILITY 15024 INSURER B: Prg>'ox"d Netual Insure" C6. (NSLIRERC Saf@t insurance C 33618 CJI4 Builders Inc. INSURER O: $50000 PO Box 545 Wilmington MK 01687 INSURER E: X_ COMMERCIAL GENERAL LIABILITY THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED YO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONYFACT OR OTHER DOCUMENT WITH RESPECT TD WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, 51(CLUPAONS AND CONDITIONS OF SUCH _ POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.FNw LTR TYK OF INSURANCE POLICY NUMBER M P 00131 MY DATE M LWITS GENERAL LIABILITY EACH OCCURRENCE $ 500000 PREMISPs(Eeoewrence) $50000 B X_ COMMERCIAL GENERAL LIABILITY CPP0100578608 01/15/06 01/15/07 MED EXP (Any ate Person) $ 5000 CLAIMS MADE F-� OCCUR _ $500000 B X Business Owners CPP0100578608 01/15/06 01/15/07 PERSONAL BADV INJURY GENERAL AGGREGATE $ 1000000 PRODUCTS-COMPIOP AOG GEN'L AGGREGATE LIMIT APPLIES PER: S1000000 POLICY 7 JECT LOC AUTON OBILE UADILITY ANY AUTO COMBINED SINGLE LIMIT (Ea WddmQ $ C X ALL OWNED AUTOS SCHEOULE13AUTOS 1604351 05/20/05 05/20/06 BODILY INJURY (Per person) $ 100000 BODILY INJURY (Por wmdeni) _ $ 3Q0000 HIRED AUTOS NON -OWNED AUTOS $ PROPERTY DAMAGE (Per aWdenl) _ GARAGE L MIJ1TY AUTO ONLY - EA ACCIDENT S_ — - 07MR THAN EA ACC AUTO ONLY: AGG ANY AUTO $ B "CESSIUMBRELLA LIABILITY EACH OCCURRENCE S AGGREGATE $ OCCUR ❑ CLAIMS MADE DEDUCTIBLE RETENTION S $ WORKERS COMPENSATION AND TATU TORY LIMITS ER EL, EACH ACCIDENT - $500000 -- A EMPLOYFW LIABILITY ANY PROPRIETORIPARTNERlEXECUTIVE OFFICERlMEMBEREXCLUDED) CJWC702751 02/22/06 02/22/07 E.L. DOME EMPLOYEE 3500000 IF ye& dasalt* under_ SPECIAL PROVISIONS Delaw $ 500000 E,4, DISEASE. POLICY LIMIT OTHER DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Re: 846 Chesnut St., N. Andover, Ma_ 01845 acct T rrlw+r a nvwerc Vr��V�+�-�—�v� NoRTH13 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE tMING INSURER WILL ENDEAVOR M FAAR 10 DAYS WRITTEN NOTICE To TME CEIMFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO 00 SO SMALL Town of North Andover IiPOBE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENT$ OR 384 Osgood street North Andover M& 01845 Armon or 19n 4Mal 0ACORD CORPORATION 1988 REScheck Compliance Certificate 2000 IECC REScheck So$ware Version 3.6 Release 2 Data filename: CAProgram Files\Check\REScheck\No Andover Skelton.rck PROJECT TITLE: Addition CITY: North Andover STATE: Massachusetts HDD: 6322 CONSTRUCTION TYPE: Single Family WINDOW / WALL RATIO: 0.05 DATE: 02/23/06 DATE OF PLANS: 8-25-04 PROJECT DESCRIPTION: 2nd floor remodel New front 2 story addition DESIGNER/CONTRACTOR: CJM Builders Inc. COMPLIANCE: Passes Maximum UA = 869 Your Home UA = 772 11.2% Better Than Code (UA) Permit Number Checked By/Date Gross Glazing Area or Cavity Cont. or Door Perimeter R -Values e U -Facto UA Ceiling 1: Cathedral Ceiling (no attic) 1716 30.0 0.0 57 Skylight 1: Vinyl Frame:Double Pane with Low -E 32 0.370 12 Wall 1: Wood Frame, 16" o. c. 2368 13.0 0.0 182 Window 1: Vinyl Frame:Double Pane with Low -E 108 0.360 39 Door 1: Solid 42 0.370 16 Floor 1: Slab-On-Grade:Unheated 729 19.0 466 Insulation depth: 4.0' COMPLIANCE STATEMENT: The proposed building design described here is consistent with the building plans, specifications, and other calculations submitt , with the permit application. The proposed building has been designed to meet the 2000 IECC requirem s i RES k Version 3.6 Release 2 (formerly MECcheck) and to comply with the mandatory requirements list in th check Inspection Checklist. Builder/Designer / - jCtJ /'- Date North Andover Zoning Board of Appeals Regular Meeting Town Hall Top Floor Meeting Room, 120 MainStreet, P Stree, North Andover, 30 Iif _ WW*6 WHIP - May 12, 2005 OLD/NEW BUSINESS: Massachusetts 01845 Five minute address by Rosemary Smedile, BOS Chair & Mark Rees, Town Manager. Approval of April 4 & 8, 2005 minutes. Discussion of Campion Hall Regulatory Agreement, Deed Rider, and decision modification. Request CONTINUED HEARINGS: (*Requested continuance until May 12, 2005 meeting) Richard S. Else Special PE For District -0 _ T # = Member�6yhofve hea>evidence * = Voted continue MOM *JP/EM/RB/TI/D W *EM/RB/TI/RV (*Requested continuance until May 12, 2005 meeting) #JP/EM/JL/RB/AM/TI/RV/DW Bell Atlantic Mobile d/b/a Verizon S ectal Permit & FindingVR * Jp/EM/JL/RB/AM/TI/RV/DW Wireless for premises at: *JP/EM/RB/AMMIDW 5 Boston Street (*Requested continuance until May 12, 2005 meeting) #EM/AM/RB/TI/RV Cin lar Wireless LLC Vanance R-3 — *JP/EM/RB/AM"fUDW For premises at: *EM/AM/RBiTI/RV 300 Chestnut Street (*Requested continuance until June 7, 2005 mee4ag) #EM/JI /RJ3/Aiyl/TURV/DW Peter Pribhu Hin orani Trustee Com rehensive Permit B-4 *EM/AM/DW One Hundred Fourteen Trust *EM/JL/RB/AM/TI/RV/DW For premises at: Turnpike Street (Map 106.D Parcel 63 (*Requested continuance until May 122 2005 meeting) R-4 #EM/AMIRB/TURV Saraceno Construction LLC Variance, *EM/AM/RB_/_TI/_R_ V For premises at: 0 High Street (Map 53 Parcel 24B) Page I oft May 12, 2005978-688-9541 fax 978-688-9542 North Andover Zoning Board of Appeals, 400 Osgood Street, N. Andover MA 01845 phone North Andover Zoning Board of Appeals Regular Meeting Town Hall Top Floor Meeting Room, 120 Main Street, North Andover, Massachusetts 01845 Time: 7:30 PM Tuesday May 12, 2005 OLD/NEW BUSINESS: Request for 6 -month extension of Variance 2004-006. Request District # = Members who have heard evidence * = Voted to continue CONTINUED HEARINGS: (*Requested continuance until May 12, 2005 meeting) Richard S Else Special Permit GB #EM/RB/TI/RV For remises at: *JP/EM/JL/RB/TI/RV/DW 85 Main Street *EM/RB/TI/RV/DW _*_JP/EM/JL/RB/TI/RV!QW — *JP/EM/RB/Tl/DW *EM/R13/TI/RV (* Requested continuance until May 12, 2005 meeting) Bell Atlantic Mobile d/b/a Verizon Special Permit & Finding VR #JP/EM/JL/RB/AM/TI/RV/DW Wireless for premises at: *JP/EM/JL/RB/AM/TI/RV/DW 5 Boston Street *JP/EM/RB/AM/TI/DW (*Reguested continuance until May 12, 2005 meeting) Cingular Wireless LLC Variance R-3 #EM/AM/RB/TI/RV For premises at: *JP/EM/RB/AM/TI/DW 300 Chestnut Street *EM/AM/RB/TI/RV (*Requested continuance until June 7, 2005 meeting) Peter (Pribhu) Hinp_orani Trustee Comprehensive Permit B-4 #EM/JL/RB/AM/TI/RV/DW One Hundred Fourteen Trust *EM/AM/DW For premises at: *EM/JL/RB/AM/TI/RV/DW Turnpike Street (Map 106.13, Parcel 63 (*Requested continuance until May 12, 2005 meeting) Saraceno Construction LLC Variance R-4 #EM/AM/RB/TI/RV For premises at: *EM/AM/RB/TI/RV 0 High Street (Map 53 Parcel 2413) May 12, 2005 Page 1 of 2 North Andover Zoning Board of Appeals, 400 Osgood Street, N. Andover MA 01845 phone 978-688-9541 fax 978-688-9542 Ib North Andover Zoning Board of Appeals Regular Meeting Town Hall Top Floor Meeting Room, 120 Main Street, North Andover, Massachusetts 01845 Time: 7:30 PM Request PUBLIC HEARINGS: District # = Members who have heard evidence * = Voted to continue Karen & David Perry Variance & Special Permit R-4 21 Parker Street Belford Construction, Inc Variance R-3 for premises at: 249 Marbleridge Road Sandra Skelton Variance & Special Permit I-1 846 Chestnut Street Hollis A. Curtis, Jr. Variance R-4 178-180 Water Street Microwave Engineering Corporation Variance I-1 1551 Osgood Street Note: Matters may be called out of order and not as they appear on the agenda. Deliberations and vote on any issue taken under advisement may take place later in the meeting after the conclusion of the hearing and other matters listed on the agenda. "All interested parties are invited to remain to the end of the meeting". May 12, 2005 Page 2 of2 North Andover Zoning Board of Appeals, 400 Osgood Street, N. Andover MA 01845 phone 978-688-9541 fax 978-688-9542 w BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 059169 i Birthdate: 09/05/1.969 Expires: 09/05/2006 Tr. no: 3685. i Restricted: W CHARLES J MULlk .4 10 YORKSHIRE kb,G- WINDHAM, NH 03087 Comipissloner erazir^ 120003 �z[oti: i0i16i2007 i.ndividuai CHARLES J MUL; CHARLES MU',-; 28 Redmond Aj 1, North Reading-- CjM BUILDERS, INC. PO BOX 545 Wilmington MA 01887 978-649-7300 PROJECT CONTRACT 2"d Story Addition Table of Articles 1. Contract Payment 2. Scope Of Work 3. Changes 4. Warranty DATE: February 2, 2006 This agreement is made this 2 day of February 2006, and effective the 2 day of February 2006 by and between CJM Builders, Inc. (Contractor) and Mr. & Mrs. Skelton (homeowner) to perform the work identified in Article 2. PROJECT: 2"d Story Addition (aprox. 1000 sqft) New 2 Story addition attached OWNER: Mr. & Mrs. Skelton 846 Chestnut St. North Andover MA 01845 CONTRACTOR: CJM BUILDERS, INC. PO BOX 545 WILMINGTON MA 01887 ARTICLE 1 HOMEOWNER PAYMENT. The Homeowner agrees to pay the contractor for satisfactory performance of contractors work the sum of $310,000.00 Three Hundred Ten Thousand dollars Based on the Schedule of Values contained in attachment B herein, Progress payments shall be made to the Contractor for work performed and completed as described. $2,500.00 at signing of contract $25,000.00 at start of job $25,000.00 after foundation $50,000.00 after framing $45,000.00 after roof and side $45,000.00 after rough electric and plumbing $35,000.00 after blue board plaster $25,000.00 after trim $25,000.00 after paint $20,000.00 after tile $12,500.00 at completion ARTICLE 2 SCOPE OF WORK. Contractor agrees to perform and complete such work in accordance with Contract Documents. See attachment "A" ARTICLE 3 CHANGES. Homeowner, without nullifying the agreement, may direct contractor, in writing to make changes to contractors work. Adjustment, if any, in the contract price, shall be paid in full at the time of signing extra work order. ARTICLE 4 1 YR WARRANTY. Contractor warrant its work against any defects in any of the workmanship. All materials supplied by homeowner will be warranted by the manufacture not by the contractor. If materials supplied by homeowner are defected, the contractor is not liable to supply the labor to disassemble and reinstall materials. In witness whereof, the parties have executed this agreement under seal, the day and year first written above. CJM BUILDERS, INC. MR.&Mrs. Skelton ATTACHMENT "A" SCOPE OF WORK: SITE WORK: Scrape up existing loam on site and leave in pile for later use. tca;,. Dig trenches to accept new frost walls. �F -e"'�'� — Install perimeter drains around new addition and run out to day light. �14(1� Linc Backfill foundation with on site material. -ro cr".1r Rough grade yard and spread existing loam down. Dig trench to cabana to accept new 4" drain pipe. Run electric for 1 post light. Run new electric line for pool heater DEMO: Demo existing roof and 2nd floor walls. (Floor to remain untouched) Demo entire interior of 2"d floor leaving floor. Demo first floor half bath and walls to accommodate new entrance to Dining Room. FOUNDATION: Install a 24" x 12" footing per prints dated 2/25/04 Install a 10" x 4' concrete wall. Install 3 foundation vents. SLAB: Pour rat slab 1 1/2" concrete over vapor barrier. FRAMING: New addition Floor to be BCI series 500 9 11/z" 16" O.C. with 3/4" Advantech Plywood Walls to be 2 x 4 x 8' with 1/2" fir plywood Ceiling joist to be 2 x 8 Rafters to be 2 x 10 with5/8" plywood 2 x 6 collar ties @ 32" O.C. Tray ceiling in Dining room. All framing to be MA building Code. ROOF: 30 Year asphalt shingle Harvard Slate. CHIMNEY: Extend 2 chimney's through new addition. Color to match as close as possible. Install zero clearance fireplace in mister bedm m on side wall. Tank to be supplied by USA gas. �—A- HARVEY WINDOWS & DOORS: 23 Double hung tilt -in windows for new addition and second floor. 5 Picture windows in front and 1 half circle Windows out front will be mulled together. Windows to have grids between glass and screens. Install 4 skylights Install 1-5' french door to balcony deck. Install front entrance door with side lights as shown on drawings. Install 1 solar tube SIDING: Strip existing siding on main house. Install new vinyl siding with 4" Exposure on new addition and on existing house. Metal coverage on Fascia boards and rake boards. Shutters installed on front of house. Fluted white corner boards. Vinyl raised panels with Aztec around them on front bay bump out. GUTTERS: Install gutters on front and back of house including down spouts. Front of house to drain into perimeter drains. FRONT ENTRANCE: Install bead board on ceiling with 2 recessed lights. Install brick steps on risers and treads. BALCONY DECK: Install a 6'x 9'6" deck. Pt frame, and posts, composite decking and vinyl rails (builders choice) ELECTRIC: Outlets to code Smoke detectors to be to code in new addition fps (Price doesn't include upgrading existing house if need) Bedrooms - 1 light in each Lbs 1: kS Master and Main to have light/exhaust fan/heat combo, 1 - light over each vanity. 2- flood light. Run new line for pool heater, and post light.. All work to be done by a licensed electrician. Lighting allowance $600.00 5 -phone and 5 -cable jacks Price includes 12 recessed lights. All wiring to be done off existing panel. HEATING: Add forced hot water to new addition and second floor. The system will be by-dro air off existing boiler. �.r g„511�.� • Install AC to entire house. (2 condenser needed) Install Aprilaire filter with hepper filter and fresh air intake. 1 -10-D PLUMBING: Main bath to have 1 -toilet, sink, and 4' fiberglass shower. Master bath to have 1 -toilet, double bowl sink, Steam shower, And Jacuzzi. Half bath to have 1 sink and 1 toilet.. Toilets to be reused. Faucets will be chrome builders choice. INSULATION: To MA building Code. WALLS & CEILINGS: '/z" blue board with skim coat plaster. Light texture on ceilings and closets. FINISH TRIM: 21/2" colonial casing around windows and doors. pv' l l0w1 57u «c 6 panel Masonite doors for rooms. 5 1/4" colonial base molding 1 - 3' Oak Vanity for Main bath 1- 3' Oak vanity for Half bath 1-4' and 1-5' vanity for Master bath 2 -pocket doors in master bedroom Railings at top of stairs Oak rail with white balusters COUNTERS: Granite counters in Master bath and half bath. Formica in Main bath. PAINT: 1 coat primer and 1 coat finish 8 different colors 2 coats semi gloss on trim and doors. FLOORING: Allowance of $20.00 per yard for carpet in back bedroom and exercise room.. $8.00 per sqft for tile in 3 Baths and foyer. Master bathroom gets tile in steam shower. Hardwood installed in Master bedroom, study,hall,familyroom, and dinning room. Red oak sand in place natural finish. Refinish 1" floor kitchen hardwood to match new. SHELVING: Wire shelving in all closets. Master bedroom closet gets double row on one wall. ALTERNATES: Attachment "B" Schedule of Values The Stock and labor for addition and 2 n floor TOTAL BASE PRICE $310,000.00 ALTERNATES: a -S3 e No p +-Ustc $ 0 TOTAL COST OF ALTERNATES TOTAL COST OF JOB $ 310,000.00 (,5-00,00 16 30'x, S o0 , c v i SO - 00 � ► sas.� �f1 E(rc44 c r, 6&x Pt�r s� e'-Mvt 05 co Fj O z o ca u �°. a U) w Or- e w° ' o°G v U c w O a o w c w" H U a w o a: co x AG ,� o Q� " E� Z x w W o z cin L� 0 cn c c �c om ts .off ' ta H C vV O.� CL C �L O m Ea � c CD s t5 net.. "r c. N C OD o� «c0 `m c E :mm � y C h r... cm m y cc o tr cri :Em ID mo N m C Z O Of SCM 5 CL. m o101 m VN O oZ wCO C C Q m O. : y m C •O C O 1 N .6- N m w m t 'vd'i 'D li nz a° c 2 a'vs O ci m UA o g h a •� o'C = W m ` H = O 1-- 40-d_... m F. z O U T I-IL96 O Om I O� y O O m m CL = O� �3 O 0 O CL Ca occ = c ) 'v 'c Z t5 CD CL V y O C C C y 0 0 N LLI U) W ce W U) �+�_"°•"•": + Town of North Andover Town C'lerkTime Stamp Community Development and Services Division Office of the Zoning Board of of Appeals f � � E. CLF YU/ OsgoodStreet 1 - ': A C i L i . it North Andover, Massachusetts 01845 D. Robert Nicetta Telephone (978) 688-9541 2fiih PAY 2b P 4: ( � Building Commissioner Fax (978) 688-9542 Any appeal shall be filed within (20) days after the date of filing ofthis notice in the office ofthe Town Clerk, per Mass, Gen. L, cr. OA, §17 NAME: Sandra Skelt" Cbennat his is to certify that twenty (20) days have elapsed from date of decision, filed Notice of Decision without filing of an', nppeai. Year2M Date Joy . Bradshaw Town Clerk Pro at: 846 Chestnut Street I]EARI NGM: May 12, 2005 PETITION: mNorth Andover Board of Appeals held a public hearing at its regular meeting in the Town Haff top floor meeting room, 1 0 Main Street, North Adel, MA em Tuesday, May 12, 2005 at 7:30 PM treet, North Andover upon the application of Sande Skelton, 846 Chestnut S requesting a dimens-iow Variance from the repnine� of Section 7, Paragraph 7.3 and Table 2 of the Zoning Bye for relief of the rear setback of the existing structure setback of flu; proposed frard addition, and a Special Permit for a pre -egg, n structuand the right side from Section 9, Paragraph 9.2 of the Zoning Bylaw for an addition to a residenW str-o ucttim Said' lot & use ply with frontage on the S side of Chestnut Street within the 1=I � he P �� is mailed to all abutters and published in the Fogle-Tn'bume on April 25 dtlegal notice was May 2, 2005. The following members were present John M Panone, Ellen P. McIMM Joseph D. LaGrasse Albert P. Manny IM The following non-voting members were , Richard J Byers, and and David R. Webster. e� Thomas D. Ippolito, Richard M Vaina�oott, `Upon a motion by Albert P. Manzi, III and a by Richard J Byers, the Board voted to GRANT a dimensional Variance from Section 7, Paragraph 7.3 and Table 2 of the Zoning Bylaw for relief of 24.1' from the ri setback for the proposed two-story Groat addition and 20.2' fent the rear setback of the t; side motion by Albert P. Mam III and a by Richard J. Byers, the Board vexed to ng and � a Section 9, Paragraph 92 of the Zoning Bylaw in order to allow a a Spear! Permit from be extended by a two-story front addition aihacdled B' �IIg lot, dt use to VmMm Plan, 846 Chestnut Streit, North Andover, MA Assessor on a Parcel ting, e'00� °g lot per 846 Chestwt Sheet, North Andover, MA 01845, April 13, 2005 107C, Parcel l9, prepared �, Ske ftM aWneern Services, Inc., 60 Beechwood Drive, North Andover, MA 01845 �j Residence for vid Ahes #4,5454, a' ��, g�46 N Andover MA 01845, Date 8-25-04, [byj G J Brum Associatm Residential Desi Andover MA 01845. with flee Berkeley Road, N. following eom�dition: 1. The ground to roof peak elevation of the pnoposed addition shall be no Vmterthan o29� MW m p P Joseph D. LaCaasse, Richard Byersand Albert P Maw,, � The Board finds that the lot and pre -1941 dwelling existed before the I-1 zoning end and the lot cannot be used for I-1 unless other residential lots along the access are redistricted to 1-2, and that the applicant has satisfied the Provisions Of Section 10, paragraph 10.4 of the Zoning Bylaw in that the gran mg of this Variannce win not adversely affect the neighborhood or derogate from the intent and purpose of the applicant has satisfied the pro was of section 9, Paragr i 92 of the `". Also, the >3owd finds that then or alteration shall not be �8 bylaw and that such change, extension wally more detrimental than the existing structure to the neighborhood. Pagel of2 A True Copy Board of .appeals 978- 688-9541 Building 978-688-9545 Conscn ation 978-688-9530 Health 978-688-9540 Plannine 97RT Clerk � 4 n� • � i Town of Noah Andover Office of the Zoning Board of Appeals Community Development and Services Division 400 Osgood Street North Andover, Massachusetts 01845 D. Robert Nicetta Telephone (978) 688-9541 Building Commissioner Fax (978) 688-9542 Furthermore, if the rights authorized by the Variance are not exercised within one (1) year of the date of the grant, it shall lapse, and may be re-established only after notice, and a new hearing. Furthermore, if a Special Permit granted under the provisions contained herein shall be deemed to have lapsed after a two (2) year period from the date on which the Special Permit was granted unless substantial use or construction has commenced, it shall lapse and may be re-established only after notice, and a new hearing. Town of North Andover Board of Appeals, a Ellen P. McIntyre, Chair Decision 2005-010. M107,CPM Page 2 of 2 Board of Appeals 978- 688-9541 Building 978-688-9545 Conservation 978488-9530 Health 97&688-9540 Planning 978-688-9535 TOWN OF NORTH ANDOVER pf "ORT" 1 Office of CONINIUNITY DEVELOPMENT AND SERVICES ,r, HEALTH DEPARTNMENT 100 OSGOOD STREET NORTH ANDOVER, MASSACHUSETTS 01815 �,SSAc An. tt4, Susan Y. Sawyer, REAS/RS 978.688.9540 - Plione Public Hcalth Director 978.698.9542 - FAX healt lidept,Fi;toNanofnorthaudover. coin tiv-1«v. tovvuofnorthandovcr.com Sandra Skelton 846 Chestnut Street North Andover, MA 01845 Re : Building permit for addition April 4, 2006 Dear Ms. Skelton, Thank you for responding to the March 22nd request for additional information in regard to your building application. The information submitted on March 27th has been reviewed and the health department has the following comments in relation to the previous letter. 1) The Title V report for the second subsurface disposal system has been properly submitted. 2) A professional engineer, Steven Eriksen, of Norse Environmental Services, Inc. has submitted a written opinion as requested and a supplemental opinion on April 4,2006. Mr. Eriksen was contacted to confirm the size of the existing home. The drawing submitted by you on March 13d', identified the current home as a 3 -bedroom, however Mr. Eriksen has personally confirmed that this home is currently a 4 -bedroom home therefore the sketch drawing is not precisely accurate. The North Andover Subsurface Disposal Regulations state that by definition 1.07 "Cesspools are failed systems and shall be replaced with a system meeting these regulations and 310 CMR 15.000" a cesspool is a failed system". This letter is to inform you that the cesspool/ laundry drywell system must be abandoned and the internal plumbing be rerouted to the piping to the subsurface disposal system. In addition Part F 17.06 states that if the leaching area has not received usual effluent it shall require a second inspection conducted 6 months later by a MA and N. Andover licensed system inspector and a report must be submitted to the Health Department. In regard to tying the laundry into the subsurface disposal system, the report submitted by Norse Environmental states that he does "not think that this would be beneficial" in this case. Therefore, if you wish to request a variance to the Board of Health regulations, allowing you to continue the usage of your laundry system, you may do so by submitting a written request addressed to the Board of Health, to be heard at the next regularly scheduled Board of Health meeting. Please refer to the regulation section listed above in your request. At the meeting, the board members will review Mr. Eriksen's findings and, if you wish to do so, you may present any additional evidence to the three board members as to why this variance should be granted. If you choose this option, please submit your request in writing at least seven (7) days prior to the board meeting. The next scheduled meeting is on April 27, 2006 at 7:00 PM, in the Town Hall 2nd floor selectmen's meeting room. This letter will be forwarded to the Building Department. It is common practice that this office approves a building permit for an addition to a structure, while concurrently, the corrections to septic system is being done. Failure to comply with these stipulations could result in further action. Therefore, in good faith, this office has signed off on the building permit with the stipulation that the septic system issues will be corrected prior to issuing any Building Department final occupancy permit, for the completed addition. Thank you for you cooperation. Sincereli, 01 SSawyer, REHS/RS ./ blic Health Director Cc: Building Department a2 T� 0 U %2 6 %�Id Obs6•>i8"L6 "H 06C6Bti?tiL6 uotte.-unw:) CbC6-" �[ 9•eL62+rot.ne trc6-as9•tic6=I�da�1�9 �x n Adoa anal V Do I aged pOOgmgqglpa a p ol "'W Iia MWP stout *XMITO 00oo PW aogeaalle m ` Wo Pae A"RAq *Pm QW Jo L'6 q `6 teop*ag do =oopt"oad M aq 1a�ldtfe a� >� � aeOH � `oilV '"►ep(g �[aoZ aq� � atiodnad Poe >� aql mai OIdouap JD Ap "Pe 3m IIF e°°e!ieA:gypto ftXW Mp 1eg1>q Mggg VUM agtP 4 OI * '0 P aaoisuMW Mi P*m aq in ago 1olaol ap poe > prp Nam I -I am awpq pp�O gu.qpmp � �( ' I -I 461 lot "wag Pm a KL t: 'III `!'SII 'd uagry Pm %wAg •r PAVT INMX •Q gda=or �PoA — an aq PW a P9" Pnodoad alp 1s nop�tNp .ao"eg tai gapoA xtd�ooa o4< p aqy 'i N ` e gz'traogwQ , MAOPUV ,X,=, � *p• ma s" t� xx ` 948 '°0lf�lS eaPmts a�p[pg Pa sNTQ vpq aanopav qwN s cr•� PaaftII `bsKiN iV p!" a IAW WK EI LSV P4gi0 VY1I ` g1aoN No 948 wa ,6� sa ooI &f�i V vHi `sa�opav quox ><C9a `aqd A n••i � ao<t yol �A R � � �iq PVBM= aq N M$ *nAd t s av PPA P=ff e�el'IH �IaoZ MPJo Z'6 d 6 taolt*as C= e soda Pa'Sta p gagm *WJo ]PW stlp�t °� �g f P 6q WZ PW M I '4'1m9IY.(q ollom ap!s 1q$n aqt � ami.. 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Robert Niceita Telephone (978) 688-9541 Building Commissioner Fax (978) 688-9542 Frr&ermore, if the rights authorized by the Variance are not exercised within ane (1) year of the date of the grant, it shall lapse, and may be re-established only after notic% and a new hearing. Furthermore, if a Special Permit granted under the provisions contained herein shall be deemed to have lapsed after a two (2) year period from the date an which the SpecW Permit was granted unless mhbstamtW use or construction has commenced, it shall lapse and may be re-established only of notice, and a now hearing. Town of North Andover Board of Appeals, IIIIAi /Y P v Ellen P. Melatyre, C hai Decision 2005-010. Mh07.CP19. Page 2 of 2 ESSEX NCAR`tN REO'ISTAY 4F DaDb LAWRENCE, MASS. A TRITE COPY: ATTES 04 REGC,'SR OF DEED %tio4 R -1/6 Lod n No. Date Ot OORTH .4 TOWN OF NORTH ANDOVER ,,so " - S Certificate of Occupancy $ L) Building/Frame Permit Fee $ S A""U Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ Building Inspector C> HP!5 Div. Public Works PER .tIT NO 00 APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1 MAP 4qO. I LOT NO. -Z_ C� 2 RECORD OF OWNERSHIP IDATE BOOK ;PAGE ZONE SUB DIV. LOT NO. �— LOCATION/n n� S PURPOSE40F BUILDING OWNER'S NAME 7� , IJ ��NO. OF STORIES Z SIZE OWNER'S ADDRESS e G BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST Z)e�19 2ND x/G 3RD V a ' BUILDER'S NAMEr.,o� C' .. 1 �j YV Ute, �OS SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES — SIDES REAR GIRDERS AM - AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION if //'1THICKNESS a /y �1//') IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION ?�'y/a I/a IS BUILDING ON SOLID OR FILLED LAND yl f WILL BUILDING CONFORM TO REQUIREMENTS OF CODE ��/��Jfs l IS BUILDING CONNECTED TO TOWN WATER / BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER /lo IS BUILDING CONNECTED TO NATURAL GAS LINE A/O INSTRUCTIONS SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED' BY BUILDING INSPECTOR DATE FILED Z 7 , 7 &,,,�..r L.rG SIGNATURE Ott OWNER OR AUTHORIZED AGENT FEE PERMIT GRANTED i IC/ 19 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST �0 EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BUILDING INSPECTOR &07 - OWNER TEL. N i CONTR. TEL. if CONTR. LIC. # H.I.C. # / 0 7 r _ . BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY _ STORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES _ LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA - APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH _ 8 1 2 13 PINE CONCRETE CONCRETE BL'K. BRICK OR STONE HARDW'D PIERS PLASTER DRY WALL _ UNFIN. 3 BASEMENT AREA FULL FIN. 8'M'TAREA _ 1/4 l/_ � FIN. ATTIC AREA NO 8M'T FIRE PLACES _ HEAD ROOM MODERN KITCHEN _ 4 WALLS ( 9 FLOORS CLAPBOARDS B 1 2 3 _ DROP SIDING WOOD SHINGLES CONCRETE EARTH ASPHALT SIDING ASBESTOS SIDING VERT. SIDING _ HARDW D COMIAGN ASPH. TILE STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY BRICK ON FRAME ATTIC STRS. & FLOOR I_ CONC. OR CINDER BLK. WIRING STONE ON MASONRY _ STONE ON FRAME SUPERIOR I� POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE HIP BATH 13 FIX.) GAMBRELMANSARD TOILET RM. (2 FIX.) _ FLAT 11 SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY _ WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER ROLL ROOFING MODERN FIXTURES _ _ TILE FLOOR TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. & COLS. STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING _ RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ 1st 13rd ELECTRIC NO HEATING i 4p O z ill oo o� .c v N b � a a A a w a v a a a a CdW w a U u w z 000 c4° u C7 dao a w A cx � cn o � co i ae 0 cn w- o F c WC3 � cc o p vv Cm ^ so sc (`j� ► 0 Cc ` s Ets a :.. o a E CA c z . [-•-c t; CD o N W ` Q No �( Ccc N C OO Em U Amo ID CD `!,CLCJ m N W �• wof m' C93 .7 N cc c �. •«' C=Mc o C a timc x :ago S Vi "" N y ~ .c tL. Nm it W ++ O CLs W .E 'a cros N z L3 o 0-0 c H x c0 aoy=D 5 � G M cm o •- ca Q 'a 'E m LM 0 CD O Q O e_cd v o a M C Co 0 cc C 3 C. 0 � C ca z C3 ID CL V y O C•— '� C _c 0. H Q Y ... Town of Orth Andover BK 9603 PG 155 Community beveloptn# and Servic c , Town Clerk Time stamp Office df the Zorn Board es Divieion�," F,,, (, �j yip S of Appeals ,.pP 'J r�E 6;t,�tDS;tAW 400 ood Street r�',y CORK North Andover, assachusetts 01845 }; - ;�;Cr., D. Robert Nicetta Telephone ' (978) 688-9541 ZOOS PAY Building Commissioner Fax (978) 688-9542 6 P 4� i This is to M* that twenbr (20) days ''may eppeW shag be filed within have elapsed *M date d deoalon, filed (20) days ager the date of film have of Qpey without }Illnp a f of this notice in *0 oifiia of the Year 2006 a+b L Jradshaw Town Cleric, per Mass, pm, L oh. Town Clock 40A, 117 Prone �.�: . r'ty at: 84 The North Ando w Board of Appeals held a PW)Rc at roam,120 Main hut, Norm Andover MA m � is the Town � gm M s>�, W North zum*, May 12, 2009 at 7:20 PM upon the moa cfs —.. Pmgmph 7.3 4 d MMdood variaice selbad of the popmed &W f�rtliefatthe rearsalbact of tLe °deHnB °fthir � 3eWan 9, iagraph 9.2 tithe . OW i Sperm limit for a premo& ft � g struckm � MdC pay amu► t1aadition to a reddeati� mallet! to an ebtom md � �0°'� aitk a[Cheatnug �t a� �ixm»aea wed ie� Pied in the Fogle-Tn'bmte � � ` c� fo 8 be I Were Peamt: Aft M AlmP. >h icing n°avo ft bat rl e p Joseph D. Laf , �cbard J. By 'k afldv mai D. 18a1h0. Rid�ard M Vaillastooure Upon a motion by Albert P; Mmu, III Md 2" by Richard 1. Byerty tib Baatd voted to GRANiT a V&rbm fiW 861 100 7, Pfsragtapb 7.3 ad Table 2 oP fhO. selbadc for tik patsposed t� "Oly � addidon aid 20.21 -ham the f 4.1 the rigirt o motion by A16ert A Maui; M aW 2-r b9 Ridtaad J. Bylem de Boats v to dam& upon a SOWN 9 92 of the GRANiT a N ?�angBrla*►1noMer to> a spm Pertatk E� be extmdod �' ate'dition atbdied g MF110Valiance PIIA �° ' � las: tit rue m�"' 946 ChcgftNorth Andover, MA AdlsatM p a° uigg lot ga WW 19, cn =j, MA 01845, APM 13, 2003 (byl DOW Ahm A1434S4, New E AmmerPOPOW for So* SIMUM qwhwaw 844 North Ardovrr, MA 41813 and Rcsidmcx for Sandra nSWA a8"� Andover MA Ol W� Owing 1 ► Rdidm�bl DedgOet� d,N► 1• candWm- The d to roof qak ekvador of the Voting is livor: MiJoegth D d sitaR be so gateater t M 291. otutg agnini t:� P B3'ba, card Alban P. Masi, IQ. The Board Quds the lot and`pnp-1941 dwelling exceed be fm the I-1 I-1 UWM other dunks M the lot carrot be used for lob ttloog the totxo arc ro � 1.2. aid thN theofd& ba pVada=edsBwined the affect the a of Secft 10, pnagl O 10.4 of the Zoning Bylgw is that the Plating aPP&t hes ad" the pen w4bbabood Or ��g� � � PRP= of the Zonis Bylaw. Alm Bomd $lads do y Of altendon shell nos he wbodilillty moue deWmen WIVMjh � ��o and that suds dtao extension 8 n tto the ieigbborhood. Page 1 of2 ATTEST: A True Copy Board of Appesh 978.688.9341 Bujld 9 g78.688,9343 Comtcnation 978.6889330 Heahti 97 &4".9540 PIM 9 �T�v �SClerk BK 9603 PSG 156 Town of North Andover Office of the Zoning Board of Appeals Community Development and Services Division 400 Osgood Street North Andover, Massachusetts 01845 D. Robert NicM Building Commissioner Telephone (978)688-9541 Fax (978)688-9542 Fw1bermore, if the rights authorized by the Variance are not exercised within one (1) year of the date of the grant, it shall lapse, and may be m4stablished only after notice, and a new haring. Furtham^ if a Special Permit granted under the provisions contained herein shall be deemed to have lapsed after a two (2) year period from the date on which the Special Permit was granted unlas substantial use or construction has commenced, it shall lapse and may be re-established only after notice, and a nese hearing. Town of North Andover Board of Appeals, NI- . P v , M%A2,L- Ellen P. Mclrltyre, Chair Decision 2005-010. 61107.CP19. Page 2 of 2 Board of Appeals 978- 688-9341 Building 978688.9543 IConsc"k n 978.684.9330 HeaM 978.688-9540 Planning 978-688-9333 SEX NWTH REGISTRY OF D DS A T f ur- copy: ATTEs ECS, t3Ft OF DEED Location No. / 7,-� Date TOWN OF NORTH ANDOVER L 0 jsj�.�� Certificate of Occupancy $ Building/Frame Permit Fee $ CHU Foundation Permit Fee $ Other Permit Fee $ TOTAL s Check # 6744 Building Inspecirof -t TOWN OF NORTH ANDOVER I BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUH,DING PERNUT NUMBER: , -IT AO DATE ISSUED: le- 6-3 It. A Al /// a4w SIGNATURE. Building Cornrnissi2EEIor of Buildings Date i - SECTION I- SITE INFORMATION 1.1 Property Address: 1.2 Assessors X* and Parcel Number /07 C- ®off e? Map Number Parcel Number 1.3 Zoning Information: 1.4 Dimensions: Property 3K7 5 Zoning District Proposed Use Lot Area (sf)Fronts ft 1.6 BUILDING SETBACKS 00 Front Yard -� r ' i:� � I - Side Yard Rear Yard Required Provide Provided 'red . Provided 7 1.5. Flood Zoot hdonnation: 1.7WAff SupplyM.GUL-C-40; f54) Zone 0owde Flood ZDW' MMILipl 11- Sewerap D*m&!,Syi4enr 0 Qwgi*� bkposgsy.e. )g(, Public —A Private . 0 SECTION 2 - PROPERTY -OWNERSEEW/AUTHORIZED AGENT 2.1 Owner of Record. Name. 00. Address for Service :,, -gignature- Telephone 2.2 Owner of Record: Name Print Address for Service: Siaturc Tele hone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor,: Not Applicable' 0 Licensed Construction Supervisor. - License Numbet Expiration Date Signature Telephone 3.2 Registered Home improvement Contractor Not Applicable 0 Company Name Registration Number Address Expiration Date -Signature Telephone SECTION 4 - WORKERS COMPENSATION (It/iG.L. C 152 § 25c(6)-1 Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will i in the denial of the issuance of the building permit. Si ned affidavit Attached Yes .......0 No ........ I? f £, f �r . t } _, ; �;• SECTION 5 Description of Proposed Work check all applicable) New Construction 0 Existing Building ❑ Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. 0 Demolition ❑ Other 0 Specify `} Brief D/e'scription of Proposed Work: SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be- Completed eCom leted by permit a licar 1. Building 2 Electrical Oo 3. PlumbingQ O 4 Mechanical HVAC 5 Fire Protection (a) Building Permit Fee Multiplier (b) Estimated Total Cost of Constiiiction Building Permit fee (a) x (b) 6 Total -P ' t3+4:t5.- r :,F.%; j,:. QeJ.. Check Number SECTION 7a OWNER Al TIT ORIZA ON TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ir J,' r, 1> vu.iuvv �. v1v1vL,\. 11:11 1v as Owner/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 71b OWNER/AUTHORIZED AGENT DECLARATION Owner uthorized Agent of subject property `as Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledg( and belief Prin ame ,.�:' _ 3 'Si ature of Owner/Agent /ZPo- Date SIM NO. OF STORIES SIZE ' S" BASEMENT OR SLABti SIZE OF FLOOR TINMERS I mo ; 2ND 3 SPAN l DIMENSIONS OF SILLS DIMENSIONS OF POSTS r.- �v _ DIMENSIONS OF GIRDERS IiTIGFIT OF FOUNDATION TIIICKlv'ESS SIZE OF FOOTING _ X [MATERIAL OF CHIMNEY [L',:13UILDING ON SOLID OR FU -LED LAND 114tH UPlt l7N0 Lily r. :,. / ; , I04 � 04 O z ca O w ' u , u. cn u or. tiul G O w O rx G .0 U � G w" O U W i a a x O c�: G w" . O W U a W x O w y cn —cdo G u". p H .G rx w w w v cn z cn Q v cn Q S H W_ LL P Lr LU v h : C C c O L C y O C COA C-3 CL. C O A tccC O O L N � Ea CF _ is CL N O :oma CD c CL= N R m m L N 3 m C a Cn N C A E a w N O N C cm W m ac C" c m L O CM C �C Cl m t 0 Z co O co O O L co v � Z p_ O H C O cm CO2 O ;� D _ OCO2 co •— •g m CD co = O � �3 O CD L O O d M:ca c 4 cCc .CJ J 'D O C Z G) V CO) c C C CL - ■ C GO LLJ 0 U) U) IrW W crLU LLJ U) A dV L N O � C S c ' ate= 6i0y O � C O d m : N m C 0 CD aw 0 N lD y0.1-- .� O� O N L n v O .— cm "M O-S zoo m •O R 0y ZZa0m E a w N O N C cm W m ac C" c m L O CM C �C Cl m t 0 Z co O co O O L co v � Z p_ O H C O cm CO2 O ;� D _ OCO2 co •— •g m CD co = O � �3 O CD L O O d M:ca c 4 cCc .CJ J 'D O C Z G) V CO) c C C CL - ■ C GO LLJ 0 U) U) IrW W crLU LLJ U) A TOWN NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING „ •..: 4Y .. _ a"m C 5 �KJ�'�,"3s"x �4Hi' VVb .. �� §� 1V1��M�Vin. �I�I i iks �� ,`�rq "�s"'"m' �z"'p'a°t•� �F BUILDING PERMIT NUMBER: l` DATE ISSUED: 9-10-6-3 it 11 /� SIGNATURE: Building Commissionerfl for of Buildings Date r/o 03 SECTION 1- SITE INFORMATION ' 1.1 Property Address: 1.2 Assessors Map and Parcel Number: /07 C, .� Map Number Parcel Number 1.3 Zoning Information: pl�,; Qe$14W�11% zcn�mg bistrid Proposed Use 1.4 Property Dimensions: 3r, -A r �C?— Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide R redProvided ReqWred Provided ®'21b t 3O SO 71L, 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public ')K Private ❑ Zone Outside Flood Zone 59� 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes _„_ No 2.1 Owner of Record Name nt) Address for Service ignature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Tele hone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address 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......:�P SECTION 5 Description of Proposed Work(check all applicable) New Construction ❑ Existing Building Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. ❑ Demolition 0 Other ❑ Specify Brief Description of Proposed Work: SDC 1�(1 h 5 i'�"4li✓l �'rz� !^ c,vY���L /l{ �./ I i SECTION 6 - ESTIMATED CONSTRUCTION; COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant Oi+FTCj.z;USE QNLY 1. Building �J p ©� (a) Building Permit Fee Multiplier 2 Electrical per, (b) Estimated Total Cost of Construction 3 PlumbinE Building Permit fee (a) X (b) 4 Mechanical HVAC Al 5 Fire Protection 6 Totalw 1+2+µ3+-4+5 -, 30i T �• i - ' :220 Check Number SECTION 7a OWNER AUTHORIZATfON TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/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 SECTIIO'N' 7bOWNER/AUTTHORIIZED AGENT DECLARATION I, �G�jI�X �"e �� L ! ��Yl as Owner uthorized 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 S Prin aIn i ature of Owner/Agent Date s .. ..�..,... ,... wr3 sT y. NO. OF STORIES SIZE BASEMENT OR SLAB �v SIZE OF FLOOR TIMBERS 1 sr,�� 2ND RD � 3 SPAN DIMENSIONS OF SILLS , DIMENSIONS OF POSTS DE�ENSIONS OF GIRDERS ' HEIGHT OF FOUNDATION / THICKNESS SIZE OF FOOTING f -' X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND £ IS BUU DING CONNECTED TO NATURAL GAS LINE NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-95, 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 properly licensed solid waste disposal facility as defined by MGL Chapter 111, S 150 A. The debris will be disposed of in: (Location of Facility) Signature of Permit Applicant 3 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector 0 ' Town of North. Andover Building Department 27 Charles Street �Hus�t�y North Andover MA 01845 Tel: 978-6889545 HOMEOWNER LICENSE EXEMPTION Please print. DATE_ o_ JOB LOCATION-. Number '.'HOMEOWNER 9 Number PRESENT MAILING ADDRESS �1!-�, (/ f1/Lr�01/�- City Town P&W4I/ Street Address Home Phone/— Je�lhv� ST State Section of Town Work Phone Zip Code The current exemption for "Homeowners" was extended to include owner -occupied dwellings of six 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 109.1.1) 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 to six family dwelling, attached or detached structures ac- cessory to such use and and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) 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 Building Department minimum inspectic comply with said procedures and requin HOMEOWNER'S SIGNATUR understands the Town of No. Andover s and re%Ai r�ents,#nd that he/she will APPROVAL OF BUILDING OFFICI Note: Three family dwelling 35,000 cubic feet, or larger, will be required to comply with State Building Code Section 127.0 Construction Control. MORTGAGE /INSPECT/ON PLAN AT Z 846 CHESTNUT STREET �~ NORTH ANDOVER, MA: NO. ESSEX REG/STRY OF DEEDS.' K 3,223 PG. 255 PLAN: NO. 0533 CERTIFIED TO.' NORTHMARK BANK SCALE.' / = 50' DATE.' SEPTEMBER 3, /993 PoveO D�ivecroy Gar.. PARCEL / 35,165 s f. Wood POOL TWO Shed r. LJ l WOOD ` GARAGE > ` LOT A CERTIFICATE N0. 3,747 NOTES.' vDD NOT USE OFFSETS TO ESTABLISH PROPERTY LINES OR TO ERECT ANY STRUCTURE 21PROPERTY LINES ARE DETERMINED FROM COMPILED INFORMATION TO BE USED FOR MORTGAGE PURPOSES ONLY. CERTIFICATIONS: -Fvvvv ' BASED ON MY KNOWLEDGE, INFORMATION AND BEL/EF, / HEREBY CERTIFY THAT THE PERMANENT STRuCTURES IND/GATED ARE LOCATED ON THE GRaIND APPROXIMATELY AS SHOWN AND ARE CONFORMING TO THE ZONING SETBACK REa11REMENTS OF THE TOWN OF N0. ANDOVER WHEN CONSTRUCTED AND THAT THE STRUCTURE SHOWN Is NOT LOCATED IN A FLOOD HAZARD ZONE AS PER F. E.M.A. MAP, COMMUNITY N0. 250098 EFFECTIVE DATE.' 06-02-93 ZONE.' X ✓OHN ASAG/S 8 ASSOCIATES, PROFESSIONAL LAND SURVEYOpR$ 137 CHANDLER ROAD, ANDOVER, MA. (508) 688- 4699 I�k cd � w w O La. In v co ° w � z C o p w O w v U C u. 0 w a Q+ SOD O a C is x a � a U a W O w u v UOw" C a O a z d ADD O w C w z F+ A w a w v C 7. co C z cn Q L C cn Oi �i .11 O O E O i � O v z CLO O y � C CD I Com_ ca Q (D .� Ma O •E m � O.a Cc CD 0 Q L cmQ ca S O � env v J-0 'FL O CD co C Z co 0 CL V H Q C Cr ■ C !O H LU 0 U) Lli U) crW W wLLI 1 o m c o � c ` : O y MCC 0 V ACL CLc ev m o �= o y L"' :Ea . L w c o c. y EO = c m E CLcc L mCD a 0 L m3 z cm m y c c � _m o y A O E m mo :aC.3 m y co ; A-= O � cm� c m CD O r y O Z Occ O c C O O. c Q toO O•O = m m o N ~ O .=• of-- m CO3 W ... CAU. O Cc CD _ O«�= ..• .. F- y .E CL= m •y Z W v 'p v p1 O SO c 0.00. O0 c 4 co a mO C4 :2 2 eyv O H w Qm � Oi �i .11 O O E O i � O v z CLO O y � C CD I Com_ ca Q (D .� Ma O •E m � O.a Cc CD 0 Q L cmQ ca S O � env v J-0 'FL O CD co C Z co 0 CL V H Q C Cr ■ C !O H LU 0 U) Lli U) crW W wLLI 1 ,ORYH 0 "SACHUS Date ............. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING -- -e'e W A to � ( � This certifies that ... ... ......... 00) has permission to perform .................................... plumbing in the buil ings of .'5 �'e ( � a &q(,, C �' "� OL: * * ... at ... * * ' . iJ .......... .................. North Andover, Mass. 9 1 '/' - AA C-1, Fee . ...... Lic No. . �C? -�t It! . .. ...... Check # — I Lk 5 1 . PLUMB SPECTOR 5776 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date /()- aq-03 Building Location Owners Name4iSg-Permit # _ Amount Type of Occupancy I�FJ New Renovation Eff Replacement Plans Submitted Yes' No #• MIN Will (Print or type)Check one: ,n 1 ^ Installing Company Name P�f A �-re--e—maz ❑ Corp. F1Partner. Firm/Co. Name of Licensed Plumber: A�y� V1C. d n Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: ❑ Liability insurance policy E1 Other type of indemnity ❑ Bond Certificate Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner El 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 Mas etts Stat lumbing Code and Chapter 142 of the General Laws. IBy: I Title OVED (OFFICE USE ONLY Type of Plumbing License �( icense I m er Master Journeyman E Date. b) 7.7. ....... 40RTH 6 6 6 6 TOWN OF NORTH ANDOVER -- it PERMIT FOR GAS INSTALLATION N. -,""A This certifies that .. ............ has permission for gas installation in the buildings of .(.: ............................... at ...... North Andover, Mass. Fee ... Lic. ..... &S INSPECTOR Check # &2 / 4954 MASSACHUSETTS UNIFORM (Type or print) NORTH ANDOVER, Building Locations TO DO GAS FITTING Date Permit # 1( / J"OW, Amount $ v, Name fo ), New ® Renovation Replacement Plans Submitted (Print or type) Icak one. Certificate installing Company Corp. 0 Partner. D Firm/Co. Name ofLicensed Plumber or Gas Fitter /4-( .n pi—r -P INSURANCE COVERAGE i have a current liability Insurance policy or it's substantial equivalent. Yess�. No;Q ,)f you have decked yes, .please indicate the type coverage by checking the appropriate box Liability insurance policy Other type of fixe zmuty 0 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 an this permit application waives thi§ requirement Check one. . Signature of Owner or Owner's Agent Owner Q Agent 13 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 Massachusc77att Gras Code and Chapter 142 of the General Laws. // /l Ui,►r.e Ann .�/loL (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter El Plumber -D3gY/ Gas FittericeL" nseTum 0 Master ® Journeyman IN D. 0-0 R (Print or type) Icak one. Certificate installing Company Corp. 0 Partner. D Firm/Co. Name ofLicensed Plumber or Gas Fitter /4-( .n pi—r -P INSURANCE COVERAGE i have a current liability Insurance policy or it's substantial equivalent. Yess�. No;Q ,)f you have decked yes, .please indicate the type coverage by checking the appropriate box Liability insurance policy Other type of fixe zmuty 0 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 an this permit application waives thi§ requirement Check one. . Signature of Owner or Owner's Agent Owner Q Agent 13 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 Massachusc77att Gras Code and Chapter 142 of the General Laws. // /l Ui,►r.e Ann .�/loL (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter El Plumber -D3gY/ Gas FittericeL" nseTum 0 Master ® Journeyman o cation e ",!;P4 �0. Date - V - 6 IV 6810 25.00 PAID Div. Public Works TOWN OF NORTH ANDOVER 0 Certificate of Occupancy Building/Frame Permit Fee $ $ AcmU Foundation Permit Fee $ 19-)�� Other Permit Fee $ Z) Sewer Connection Fee $ Water Connection Fee $ TOTAL $ 2 AV Building Inspector - V - 6 IV 6810 25.00 PAID Div. Public Works PERMIT NO. APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. ,w PAGE 1 MAP d-40'(67 C LOT NO. AZ(' 19 I 2 RECORD OF OWNERSHIP iDATE,,;�ab_J IP/�+iE o \ ZONE SUB DIV. LOT NO.i LOCATION irq C r c5D p T- STS 1. l 1�/�V✓ PURPOSE OF BUILDING _ OWNER'S NAME'Tj m Ifow W NO. OF STORIES 2 SIZE /��d (C ��t-pse �+N — OWNER'S ADDRESS '�q16 �p�esT-`�rs� O� BASEMENT OR SLAB ARCHITECT'S NAME Gc,v�ye�e_ SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAMEn .M6UlldiUk-h 4R—c-modeIik&- SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES - SIDES REAR " GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION S�tFI-r�CCKC� IC�d j� �� �µYYOI�F•IICODE IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR l� kttED SIGNATURE OF OWNER OFfAUTHCWIZEWAGENT FEE -mss"'a 0 PERMIT GRANTED - L�� - d t? , . /�-, y d,z;e��y 6 el 6 OWNER TEL. #_ CONTR. TEL. # b6 CONTR. LIC. # - 7 MCI-! Rej 167sa3 C/ 3 PROPERTY INFORMATION LAND COST EST. BLDG. C EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY DOARD OF HEALTH PLANNING BOARD DOARD OF SELECTMEN mum"INFA gmur6GToR BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY STORIES MULTI. FAMILY OFFICES APARTMENTS _ CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH 3 1 2 13 PINE CONCRETE CONCRETE BL'K. BRICK OR STONE HARDW D PIERS PLASTER DRY WALL _ UNFIN. 3 BASEMENT AREA FULL FIN. B M'T' AREA _ '/. 1/7 1/1 FIN. ATTIC AREA N_O B M FIRE PLACES _ HEAD ROOM MODERN KITCHEN _ 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 �_ DROP SIDING WOOD SHINGLES CONCRETE EARTH ASPHALT SIDING ASBESTOS SIDING VERT. SIDING _ HARDW D COMMON ASPH. TILE STUCCO ON MASONRY _ _ STUCCO ON FRAME _ BRICK ON MASONRY BRICK ON FRAME CONC. OR CINDER BLK. ATTIC STRS. 8 FLOOR I_ WIRING STONE ON MASONRY STONE ON FRAME SUPERIOR I- I POOR—A_ ADEQUATE NONE 10 PLUMBING 5 ROOF GABLE I HIP BATH Q FIX.) GAMBQEL MANSARD TOILET RM. 12 FIX.) _ FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY _ WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING TAR 8 GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR _ TILE DADO 6 FRAMING 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. 8 COLS. STEAM STEEL BMS. 8 COLS. HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING _ RADIANT H'T'G UNIT HEATERS GAS 7 NO. OF ROOMS OIL B'M'T 2nd _ tat 13rd I ELECTRIC NO HEATING THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. 120 Main Street North Andover. Massachusetts 01845 (617) 6854775 . r N. In accordance with the provisions 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 c 111, S 150A. The debris will be disposed of in: �zoc /bk"c/ 2f (Location of Facility) Signature d Permit A licant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. TOwU*: Of OFFICES OF: ; _ NORTH ANDOVER APPEALS BUILDING ;iW; DIVISION OF CONSERVATION . HEALTH & COMMUNITY DEVELOPMENT PLANNINGPLANNING KAREN H.P. NELSON, DIRECTOR 120 Main Street North Andover. Massachusetts 01845 (617) 6854775 . r N. In accordance with the provisions 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 c 111, S 150A. The debris will be disposed of in: �zoc /bk"c/ 2f (Location of Facility) Signature d Permit A licant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. 10 mo x t> w a a dD o y 2 MW :R s' a Z 5W c ••l. :� o m o+ °z s z ; `# $ N .. v y O m �• a _. -- QO _ T _ ( _ -. -O .-,t m O 2 -T z c i ?-•-�-,v l.l_,�,s cl f o a00 � 3 s j� W to m m ti T 2 v O cso m m m O � m i[:) =1 rXl Pr O f• ZOO ` O Da t O O i N rTt f ,2„ 2 \ G mZ O iYi J c -6� oag G� N o ZO-1 O m~ n - 0- -n tic X,"O m 0 z 00 00 oo z DSD -+ < m —1 L C7 D Nf \ 70 it is z} Z Pry � �Q Dr H f A`..-. > m > ° O� � m yn N rtl ...? - _ n I o 'moi a •7 _ fi Z"Z -0 Z Dr �T r..m Mm � a =•+� it { ° c ..• N hr r n F•1 r ipw_yi O O Q'T r� o m A m N 00-4 W z y ,e cD co A jp W ! o a s A A=� N CD K � F. y m < W ;• uCi % P.0 o to i m ®!; •SON 9 • � a m ev7om '� g O m r; o � Fye ' m - —;W" -M m .�NZ '° m O t� ^ • �' T O m m D y (� m • c O° �• M I r; n z —1 •-1 r� m 3 n z z D t (fl i pq 9 z D v < z r O r ,� *)K 1, A c O� '>3' I m m m O p N (n ' Roo r m0O m m m m .z r S In 0 v R m o r` m 0) m O D D c m H r Z T D 31 ^ Al C)m • v n m m my 3 O m m 00 m to { v's, _� •O D D O M Tom Angela, Prop. 508-664-3364 Building and Remodeling 42 Tower Hill Road Construction Company North Reading, MA 01864 PROPOSAL SUBMITTED TO ri _im & Sardy.Skelton PHONE 68? -9' DATE 12-20-9? STREET 846 Chestnut St. JOBNAME second floor renovations CITY, STATE AND ZIP CODE N.Andover, Puss. JOB LOCATION ARCHITECT DATE OF PLANS JOS PHONE We hereby submit specifications and estimates for: Tb.e removal of all plaster and wall material in the second floor area including casings, doors & jambs and base moldin s;but not including framincr material of structure. ATA will supply a licensed electrical contractor to work along with n-reliminary dismantling of second floor area. ATA as well as our subcontractors are licensed & insured. Job area will be 'cert neat and orderly with all debris removed from job site by contract hauler. Any unforeseen work needed to complete the scope f worl,, described or additional reguirements by local insnectors will be brouc�ht to customer attention and may if neressary become a cost abnve estimated cost of i Me j'Jroposc hereby to furnish material and labor—complete in accordance with above specifications, for the sum of: Two Thousand and Eicrhty &00/1.00 . .dollars($ 2080.00 Payment to be made as follows: All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from above specifications involv- Authorized ing extra costs will be executed only upon written orders, and will become an extra charge over Signature and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our . control. Note: this proposal may be withdrawn by us if not accepted within days. kreptattre of jho o5tt� The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as Signature specified. Payment will be made as outlined above. Date of Acceptance: Signature W W x w q a 0 w° E U)]v P cit a w z z A 000 w° U is w a w �' ap' m w a UC4 c U W Q > v) m w O U �w., to w is w a w A a w G co cn v p cn ui O z o a 1'R o L co c � O o : 9� E No Z a CO) H 1 a`, c ^� O cm s y: boa z y o ca � o U co O O a� �� �cm t o Z. m c E CL c y C2 m3 C aO rd `� H �' O — c p p) O O CL.E CD c W tcc cm :cyQ W^� y Z V .CL CO3 ;H o o` U V H Z o c O R o c _ VCL. o N C c Z W c=a c Z CO) oc �E v � � C.2 mm a g C* = co, 2 m C40 O E- r I. CL,— Co �1, J z LL J Q z_ J � Z W co z � z cr z LU W (I- U) lJ� MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO 00 GASFITTING � (Print or Type) NORTH ANDOVER Mass. Date • lk 4uilding Location ke5t 6 Permit #b-c)X�► ---j 33.6 c^'T�A Owners Name-fijY� • - New '7 Renovation Replacement �] Plans Submitted �] �-s FIXT'UPC:c G (Print or Type) //}}�� Installing Company Name LJ Address Check one: Certificate Q Corp. Partner. \VVq� Firm/Co. C Business Telephone: Name of Licensed Plumber or Gas Fitter qjk OVe oiz, Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Q Other type of indemnity Q Bond Insurance Waiver: 1, the undersigned, have been made aware that the licensee of 6thhel appiica i does not have any one of the above three insurance coverages. natyl, of owner/agent of property Owner Agent 1 hereby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of my knowledge and that sll plumbing wort and installations performed under Permit issued for this application wW be in compliance with al! pe=tlnent provisions of the Massachusetts Slate Cas Code and Qtiaptes 142 of the General lAwa. /X// �' /"ol Al TYPE LICENSE: Plumber Glufber Signature of Licensed Master Plumber or Gasfitter Journeyman g g_5-7�1 License Number N •' � W N a ¢ o Z s as U3 a� 0 = t�- W wW co C m is F- a >• a x o = O w d Q to w w 00: Q W >. t - N WW cc N B O E t) d: ul l:: at tt W 0 „C tc a: W D W U w x 0 = t7 2 t- Z W h G z tt: t-• -� W f• W }- N O try= > W O t•• .� W -1 O 1- rA to Z d 4 u> O C c W = aL 2 `f A < O d .1 O U O tz W > Q O a W H H O Q x StJ$—BSTMT. r BASEMENT IST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR TTH FLOOR STH FLOOR (Print or Type) //}}�� Installing Company Name LJ Address Check one: Certificate Q Corp. Partner. \VVq� Firm/Co. C Business Telephone: Name of Licensed Plumber or Gas Fitter qjk OVe oiz, Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Q Other type of indemnity Q Bond Insurance Waiver: 1, the undersigned, have been made aware that the licensee of 6thhel appiica i does not have any one of the above three insurance coverages. natyl, of owner/agent of property Owner Agent 1 hereby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of my knowledge and that sll plumbing wort and installations performed under Permit issued for this application wW be in compliance with al! pe=tlnent provisions of the Massachusetts Slate Cas Code and Qtiaptes 142 of the General lAwa. /X// �' /"ol Al TYPE LICENSE: Plumber Glufber Signature of Licensed Master Plumber or Gasfitter Journeyman g g_5-7�1 License Number 1715 Date ..................... 'LORTH TOWN OF NORTH ANDOVER 0 PERMIT FOR GAS INSTALLATION SA HUS This certifies that... -t ............. ......... "I "e has permission for gas installation ... ......... in the buildings o� ...................... �i//'/ at .... ...... North Andover, MaSE, �j 1r) Fee..b.'.-.-. Lic. . ........................ GASINSPECTOR WHITE: Applicant CAN�RY': Building Dept. PINK: Treasurer GOLD: Fl�'-' Installl Addre ��-���-�•�-�•-....+ urssrvnlvs r1r"r'L.JVMIIvI�e PVI7 f CriM/1 Iv vv iLN1Y1L7uty (Plinio Type) NORTH ANDOVER, -Mass. Date /� .lo ?% Bullding - Permit 3 Location _ Owner's Name New O Renovation Replacement p Pians Submitted: Yea ❑ No. ❑ �1xTuAes Business Telephone0 �%& Name of Licensed Plumber Check one: ❑ Corp. ❑ Partnership 0 Firm/Co. INSURANCE COVERAGE: Check one I have a current liability Insurance policy or Its substantial equivalent. Yea 0 No If you have checked jM, please indicate the type coverage by checking the ippropriale bo; A IlabiRy Insurance policy OM�If. Other type of Indemnity ❑ Bond O Cadvicate OWNER'S INSURANCE WAIVER: I am aware that the licenses dogs not have tho insurance -coverage requIred by Chapte 112 of th Mass. a ent ws, and that my signature on this permit application waives this requirement. Check one: Owner Agent O SIgnatme oftmu or OwnN a Agent I hereby certify that all of the detafis and Information i have submM*d for entered! In above q*fi atlon an bus and socurate to the best of my krwwiedge and that all plumbing wak and Installations performed under the permit I to this be In pertinent provisions of the Massachusetts Slate Plumbing Code and Chapter 11Z of � plana with all By Title +t" of Ucensed Plumber �q,D cy City/Town License Plumber 1" `f ! 7l Type of Plumbing License: Mailer 91 lir 110VED (OFFICE USE ONLY) Journeyman 0 at w s w M } OZ >ts < « .08u J el � 0 w aL q = s< s` s s U s xsc r O o s s s{ y e O<< aI a o 16 s w Le °s i o sus—�aYT. . •Ae[M[NT IST FLOOR IND FLOOR bex- IND FLOOR 4TH FLOOR ITH FLOOR ITH FLOOR. ITH FLOOR ITH FLOOR — Business Telephone0 �%& Name of Licensed Plumber Check one: ❑ Corp. ❑ Partnership 0 Firm/Co. INSURANCE COVERAGE: Check one I have a current liability Insurance policy or Its substantial equivalent. Yea 0 No If you have checked jM, please indicate the type coverage by checking the ippropriale bo; A IlabiRy Insurance policy OM�If. Other type of Indemnity ❑ Bond O Cadvicate OWNER'S INSURANCE WAIVER: I am aware that the licenses dogs not have tho insurance -coverage requIred by Chapte 112 of th Mass. a ent ws, and that my signature on this permit application waives this requirement. Check one: Owner Agent O SIgnatme oftmu or OwnN a Agent I hereby certify that all of the detafis and Information i have submM*d for entered! In above q*fi atlon an bus and socurate to the best of my krwwiedge and that all plumbing wak and Installations performed under the permit I to this be In pertinent provisions of the Massachusetts Slate Plumbing Code and Chapter 11Z of � plana with all By Title +t" of Ucensed Plumber �q,D cy City/Town License Plumber 1" `f ! 7l Type of Plumbing License: Mailer 91 lir 110VED (OFFICE USE ONLY) Journeyman 0 TZ - 3213 Date ... �/g TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING //' �' / C( - ( This certifies that ... 10 ............................ has permission to perform .... 9. . �. f. - ". '5 .............. plumbing in the buildings of 5�1. t tj '( , ( 1'�( ( Si at .... ..... ................ North Andover, Mass. 'F V Fee Lic. No. P��? 7/r ...... ............. ................ PLUMBING INSPECTOR C 14 a 01/24/97 11:52 29.00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 3 k/ Mo�M Zoning Bylaw Denial • r O Town Of North Andover Building Department 4W OsgoW St. North Andover, MA. 01845 Phone 87 545 Fax 971114=4542 Street: y C.: +oS I/V 1/7-= / 0 1 Cl kpplicanlr. 5 i4� v`A S ^�10SA Date: L11 / / Please be advised that after f your Application and Plans dW your Application is DENIED for the following Zoning Bylaw reasons: tonin .1- heat A Lot Area 1 Lot area Insufficient 2 Lot Area Preexists Notes -I<f S F 1 2 item Frontage Fro a Insufficient Frontage Complies Notes "� s 3 Lot Area Complies Lot Area Variance 3 preexisting frontage Conr Housing Special Permit 4 Insufficient Information Special Permits Zoning Board 4 Insufficient Information Large Estate Condo Special Permit B Use Special Permit Use not Listed but Similar 5 No access over Frontage R-6 Density Special Permit — 1 Allowed G Contiguous Building Area 2 3 Not Allowed Use Preexistiij 1 2 Insufficient Area Complies 4 Special Permit Required Q 3 Preexisting CBA 5 Insufficient Information 4 Insufficient Information C Setback H Building Height 1 2 All setbacks com Front Insufficient 1 2 Height Exceeds Maximum I e S 3 Left Side Insufficsent 3 -Complies Preexisting Height 4 Right Side Insufficient 4 Insufficient Information 5 Rear Insufficsent Building Coverage 6 Preexisting setback s 1 Coverage exceeds maximum 7 Insufficient Information 2 Coverage Complies �° 5 D Watershed 3 Coverage Preexisting 1 Not in Watershed Lf e 4 Insufficient Information 2 In Watershed j Sign /v A 3 Lot prior to 10/24/94 1 Sign not allowed 4 Zone to be Determined 2 Sign Complies 5 Insufficient Information 3 Insufficient Information E Historic DWWd K Parking 1 In District review required 1 More Parking R uired 2 Not in district Lfe 5 2 Parking Compiles S 3 Insufficient Informabon 3 Insufficient Information 4 Pre-existing Parking Remedy for the above is checked below Item * Special Permits Planning Board Item 4 Variance Site Plan Review Special Permit C-ya Setback Variance Access other than Frontage Special Permit Parldng Variance Frontage Exception Lot Special Permit Lot Area Variance Common Driveway Special Permit I Height Variance Conr Housing Special Permit Variance for Sign Continuing Care Retirement Special Permit Special Permits Zoning Board Independent Elderly Housing Special Permit Permit Non-Con1drming Use ZBA Large Estate Condo Special Permit 'Special Earth Removal Special Permit ZBA Planned Development District Special Permit Special Permit Use not Listed but Similar Planned Residential Special Permit Special Permit for Sign R-6 Density Special Permit — Special Permit prewdsting nonconforming Watershed Special Permit The above review and attached mplenstim of such is basad on rtrs plans and 'mtormstim submitted. No definitive review and or advice shW be bmw on verbal sr1Mnatiora by the appfcnt nor d W such verbal esphnetiorrs by the appicent serve to Previte definitive wwmrs fo the above reesorre for DENAL Any inaowecia, niha V 9 Rine on, or atlrer subsequent d%e nges to the Marnstion suA -by urs applcart slid be grants far itis review to be voided d the disaation of the Building DaPEbnert. The attedrs ' docrarwrt tOod •Pien Review Narrative• ehW be attad»d hereto and Mncmpmeted herm by reference. The building deparlmarnI will rehin W piens end downenistion for the above fife. You must file a new buldbg POft OPPIcOm form and begin to p a tltlrp pnogeas. lEfuildinb Department Official Signature I y /// /,� Al // L//O j ppi Received Ap Denied Plan Review Narrative The following narrative is provided to further explain the reasons for denial for the application/ permit for the property indicated on the reverse side: � i -1I lam• Fire Health Police Zoning Board '0 e c J �/'�r it �. ne tE� yrSM 44 rtn "of Public Works oma, - copOr ml /n0c��r� �o USle._. Historical Commission v BUILDING DEPT 1 S7 ry Gov r -e /v c,4 N R, C - j4 L141,1A NVe,. �� ��r-- s-e4,4c & 6ti c i5 a/ 5n�c�Pi.�`� rvp� Rr ,4 51' S le �a C O ry `E n D D S ro of /loilJ! D� (dt N �i'd 2�v1 6 oa rW ® / 4 eijs %.4 TA6 e � i -1I lam• Fire Health Police Zoning Board Conservation rtn "of Public Works Planning Historical Commission Other BUILDING DEPT //-6 TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING i r , BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioner/I for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area Fronts ft 1.6 BUILDING SETBACKS 00 Front Yazd Side Yard Rear Yard Required Provide Required Provided Required Provided 1 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zane Inbrmstion: Public 0 Private 0 Zone Outside Flood Zone 0 1.8 Sewerage Disposal System: Municipal 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record r attf 1--m > jy Iee (Print) Address for Service 78— Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address 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 it. Signed affidavit Attached Yes .......0 No ....... 0 SECTION 5 Description of Proposed Work check aU applicable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: Ito xis: ;,Ij ,r SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY .._ 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN -T OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, ! z � c"mu i4lrn - C Qs �2- e7o—O a/2— , as Owner uthorizedAgent of subject prope Hereby authorize to act on My behalf; in all matters relative to work authorized by this building permit application. k mature of ner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, 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 Si ture of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR nNIBF.RS I 2' 3 SPAN DM ENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHDANEY 1S BUILDING ON SOLID OR FILLED LAND IS BUU DING CONNECTED TO NATURAL GAS LINE NEW ENGLAND ENGINEERING SERVICES INC April 11, 2005 Mike McGuire North Andover Building Inspector 27 Charles Street North Andover, MA 01845 Re: 846 Chestnut Street, North Andover Dear Mike: Enclosed is a Building permit application for the above referenced property. The application is being submitted in order to receive a denial so that a Board of Appeals application can be filed this week. The proposed structure is located 24 feet from the side lot line. The required lot line setback is 30 feet. If you have any questions please do not hesitate to contact this office. Sincerely, Benjamin C. Osgood, Jr., P.E. President 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 c\i co cv 10. PROPOSED 846 CHESTNUT STREET ASSESSORS MAP 107C, PARCEL 19 1.24± ACRES CHESTNUT STREET THIS PROPERTY IS LOCATED IN THE *-12- ZONING DISTRICT EXISTING DWELLING Shr. *- 1 - U ti- r,\. S Ss.-+ SKETCH PLAN 846 CHESTNUT STREET NORTH ANDOVER, MA PREPARED FOR SANDRA SKELTON SCALE: 1"=40' DATE: APRIL 11, 2005 NEW ENGLAND ENGINEERING SERVICES 60 BEECHWOOD DRIVE NORTH ANDOVER, MA (978) 686-1768 (PLAN #: 940—S [By: VYA SGB IBY:LIAZL B.C.O. ]r. I } THECOiY MONWF.ALTH.OFMASSACHUSE77S Office Use only DEPARTAfiMOFPUBIJCS4FL7Y Permit No. 7 t BOARD OFFIREPREVEMONREGaMONS527CMR12- O �- Occupancy &Fees Checked ILL— APPLICATIONFOR. PERMIT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date k ld _6 'd .3 Town of North Andover To the Inspector of Wire: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) ?" (e C4 (2 5 f OOT 157 - Owner Owner or Tenant 74,u b -1 S Ike* 1-M A.J Owner's Address 1:5 - Is Is this permit in conjunction with a building permit: Yes M—No r7 (Check Appropriate Box) ` 7 78,67 - Purpose of Building LrJ /N.) Utility Authorization No. _ Existing Service 7,00 Amps./L�Volts Overhead 'Underground No. of Meters / New Service Z O D Amps /la / 240 Volts Overhead r --J Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical WorkfCi °�-� �voV zap/ --. uA)!/ eZ— MAji) 3e e(/!GC No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA rou ground No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges ' No. of Air Cond. Total Tons No. of Detection and No. of Disposals / No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW / No. of Self Contained Detection/Sounding Devices Local Municipal _ Othe No. of Dryers Heating Devices KW Connections � No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER• ItmnanoeCovaage. Rua>atrttottletegttitelrtatlsofMassacYa�.sC�a�eralLaws Ibaveawna>tLmb&yyhnuz=PohcyincktdalgContlll&, Co�ageoritsstlbst�alecprivalent YES ED—NO ID Ibavestlbntit�dvandptoofofsametothe011im YES [—G� r—T F)uuhaveclleckedYES plea9ei &*dietypeofcovaageby WodctoStatt to /D —o iWectimDateReWesed signed underTrPb Aesofpmii)� O CA lz- FIRMNAME (Sly) G G - ° `f EViratimDale Esl mwedvalueofDect<icalwodc $ M • J Licensee t o e '� �4 Signatute\�C��`-'E . LimmNo BusinessTel.Nb. 979'`f7 Al,,-?'- ge'#+ SC #I r- 0-((2,AL)e,0 H,4 o f F 4q AITUNo. g 6 gJ �O�So OWNER'S INSURANCEWANFR;Iamawatetha &Lic mdoesnotbaysetheffwmlceeoverageoritswbsMtdeytrivalentastequiredbyMassadntsettsCcrteralLaws and thatmysigtimmonthispemritapphcabmwaivesthisregt onmt (Please check one) Owner Agent Telephone No. PERMIT FEE $ Signature o . wner or Agent The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print Name: Location: City Phone .# I am a homeowner performing all work myself. aI am a sole proprietor and have no one working in any capacity. 0 I am an employer providing workers' compensation for my employees working on this job. Company name Address City: Phone#. Insurance. Co. Policv # Company name: Address City 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' imprisonmentas weti.as_civil.penaltiesinlhelxm4aBTOP WORK ORDFRand afore-d.($1D0.OD)atlay.against_me I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. t do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature Date Print name Phone.# Official use only do not write in this area to be completed by city or town officiary City or Town Permit/Licensing. Building Dept pcheck if immediate response is required Licensing' Board F1 Selectman's Office Contact person: iP�.one;#• - ❑ Health Departmen Other , i