HomeMy WebLinkAboutBuilding Permit #679 - 96 BRIDLE PATH 5/19/2008BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO:
- 6 -If
Date Issued:_
IMPORTANT:
LOCATION
6 6 r)
Date Received
must complete all items on this
Print
PROPERTY OWNER �c� d L�G�.1 mt,I
Print
MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One family -
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
Others:
Repair, replacement -
Assessory Bldg
Demolition
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
ucatorar i IUN Ur VVUKK I U BE PREFORMED:
4- r
Identification Please Type or Print Clearly)
OWNER: Name: _ ���,hClj'�1 &IMme,, Phone: 6P y "
Address: q( �Drid�-1 Pa -� tJl�� %/1���� lt-!� �/� `��
CONTRACTOR Name: I- C Wi'I arV e ?OAA -`J) J(k Phone
Address: 'too 6AN Sf SO&P Z -bo { �`{-i~ %t CYdl1el- eft- fb l
Supervisor's Construction License: Exp. Date:
Home Improvement License: { d 4 S--(-09
ARCHITECT/ENGINEER Phone:
Address:
Reg. No
l4/di
FEE SCHEDULE. BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ 63V6. IN FEE: $
Check No.: /d ?00 Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the gu ran fund
signature of Ager►t/Owner Signature of contractor
Location �� ell t 4, _
No. 431 Date ✓ ��
NpRTq TOWN OF NORTH ANDOVER
��.• a pw r
9
Certificate of Occupancy $
J'•^° E<�' Building/Frame Permit Fee $ 9
ncwus
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
21 I r
2 `` Building Inspector
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/Massage/Body Art
Swimming Pools
Well
Tobacco Sales
Food Packaging/Sales
Private (septic tank, etc.
Permanent Dumpster on Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Drivewav Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
COMMENTS
DAVID CASTRICONE
CASTRICONE ROOFING & SIDING INC.
ROOFING, SIDING & REMODELING REPLACEMENT WINDOWS
HOME IMPROVEMENT CONTRACTOR REGISTRATION NUMBER 104569
200 SUTTON STREET, SUITE 226, NO. ANDOVER, MA 01845
In North Andover 978-683-3420 In Boxford 978-887-6147 In Haverhill 978-374-7314
Uwe the owner(s) of the premises mentioned below, hereby contract with and authorize you as contractor, to furnish all necessary
materials, labor and workmanship, to install, construct and place the improvements according to the following specifications, terms and
conditions, on premises below dqsmbed.
r
r.I
. .Owner's Name ..... &. . . ......IP 5..............................................lyep.h.one #....�
...........
Job Address ...... g4..... r :................... city .................
State..
Specifications:
.........................................................................................:..........................................................................................................................
trip existing shingles ply new drip edge to all edges. gl.., w,.. b'
...pp Y_.......:......................................................................... g........................................................................................................
i I feet ice and water shield membrane to bottom ed es of house. 3 feet ice and water shield membrane
in valleys and bottom edges of any unheated areas of house. F ) )
uli[
......................................................................................................................................
pply felt paper under a Vment. Install ride vent to o _ _ _' .. _ t1, /
Aeroof using
shingles with a 26 year warranty.
.................................................................................................. ............................
...................................................................................
-Counterflash chimney. 4ew vent pipe flashing. ✓foegal disposal of all debris.
....................................................3.':.. 3.!.................................................................
Area(s) to be worked on:
..........
.............................................r�,en.......� f,6,I' ....li .. .� ,l.aat r.. Ll�
Wr........�r,?..... ..................................... .�. — �3G 8d
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,{�
-
..Llzt:...........s.�.Ll`!•............. �.Gc........,� r. ......./..:G..sl':.-....rlltt..G�t�j/ .W.. ... .,,..�iff....� ,. ...
...`./. .........
...
...,.....Ce.......'......./...G Gd.
Roof board replacement if necessary @ e6o /sheet or = /foot.
........................................................................................................................................................................
Two Year Workmanship Warranty (Not Transferable) 11 M`anufacturer's Warranty as sped by ma facturer
The tractor agrees to perform the work ish the materials specified above for the SUM 5......
coMPa able .......t
Payable ...... ...— .............. on .......... — ...... ........... lance payable on completion of
Owner or Owners are not responsible for property Damage or Liability whu e�ob s m of on.
Contractor is not responsible for any damage to the interior of property, including pre-existing conditions (i.e. water stains, crumbling plaster, exposed nails) or
conditions resulting from application of materials specified above (i.e. objects coming loose from walls, crumbling plaster, exposed nails, dust in attic or other living
Spam). Items in attic may need to be covered by homeowner. All materials are property of contractor. Any dumpster placed bycontractor is for his use only. Upon
completion of above work, all undersigned agree to execute and deliver to contractor, their joint note in accordance with his (their) above obligation as requested by
contractor. Upon refusal to do so, contractor may at its option declare the entire contract price or so much as then remains unpaid, immediately due and payable. It is
agreed that, if permitted by law, contractor shall be paid by the owner(s) all reasonable costs, attorney fees and expenses, in addition to the amount due and unpaid that
shall be incurred in enforcing the terms and conditions of the contract and/or any lien in connection herewith. It is further agreed that this contract may be assigned by
contractor, and also that the obligations hereof shall bind and apply to their heirs, successors or estates of the parties. The undersigned warrants) that he is (they are)
the owners(s) of the above mentioned premises and that legal title thereto stands of record in his (their) names(s). There are no representations, guaranties of
warranties, except such as may be herein incorporated, if any, nor any agreements collateral hereto, nor is the contract dependent upon or subject to any conditions not
herein stated. Any subsequent agreement in reference hereto shall be binding only if in writing and signed by all parties.
All Home Improvement Contractors shall be registered and any inquiries about a contractor or subcontractor relating to a registration
should be directed to: Director, Home Improvement Contractor Registration, One Ashburton Place, Room 1301, Boston, MA 02108
Tel: 617-727-8598
Any and all necessary construction -related permits shall be obtained by the Contractor. Any Owner who secures his own construction -
related permit or deals with unregistered contractors is excluded from the Guaranty Fund to isfons of C. 1 2A.
!7 /7e /` J � � O. pm onion date
(��
Approximate starting date of work ................................................ Completion date.........................................................
Receipt of a copy of this contact is hereby acknowledged, and it is further acknowledged by the undersigned that the foregoing
provisions have been read and the contents thereof understood and that no representation or agreement not herein contained shall be
binding upon the parties and that all of the agreements and understandings of said parties are contained herein.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
Owner has three business days to cancel this contract and incur no penalty (see notice of cancellation).
IN WITNESS WHEREOF, the parties have hereunto signed their names this ..... day of ...cc t f 20...01.
Accepted:
Signed............ . ................... ..............._._ Owner
Signed....................... »..... »...................... .......... _.......... Owner
.... ............... ...... . ....
David Castricone, President
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Town of North Andover
Building Department
27 Charles Street
North Andover, Massachusetts 01845
(978) 688-9545 Fax (978) 688-9542
DEBRIS DISPOSAL FORM
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COC NTLI 1 WK M
A°p�rro �PKly.t�
SA C NU
In accordance with the provisions of MGL c 40 s 54, and a condition of.
Building permit # the debris resulting from the work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL c.l 1, s150a.
The debris will be disposed of in /at:
Szc I.
Facility location ,
Signature of Applicant
Date
NOTE: A demolition permit from the Town of North Andover must be obtained for this
project through the Office of the Building Inspector.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www Mass.gov/dia
pensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Busu7ess/Organization/Individual): 1AV t) CM-FtQ..I Co l) t lCpp r I NOn S I D iN 6
Address: 07W $uTTdI,�T 5o t-ra—
City/State/Zip: K. AN i o Jp n tw% Q i zqr Phone #:AV G U 3 `f -LQ
Are you an employer? Check the appropriate box:
1. Rr I am a employer with 8 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
ship and have no employees
working for me 'many capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
listed on the attached sheet.
These sub -contractors have
employees and have workers'
comp. insurance.$
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance
Type of project (required):
6. _❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition.
10. ❑ Electrical repairs or additions
I L ❑ Plutnbuig repairs or additions
12. ❑ Roof repairs
13. ❑ Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit 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 have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: �� (;UfJC Co 0' S i Pt'T. �%''
Policy # or Self -ins. Lic. #: VV C I al a l 2 Expiration Date:
Job Site Address: 70 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cert"n,40 the painsAndpena_ ¢' s ofperjury that the information provided above 4 true and correct.
Phone 7 0
./ X
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
TAE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOP. THE POLICY PERIOD INDICATED.
NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE
TZRMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TRW -AM-T
LT
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
POLICYNUMBER
POLICYEFFECTIVE
POLICYEXPIRATION
EACHOCCURREIJCE LIMITS$
CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO
GENE RAL LIABI UTY
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE 1-1 OCCUR
SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON
THE INSURER, ITS AGENTS OR REPRESENTATIVES.
A G
PREMISES Eaoocurema $
MED EXP (AnyonaPerson) $
PERS014AL A ADV INJURY $
}
GENERALAGGREGATE $
GENIAGGREGATE LIMITAPPLIES PER:
POLICY j RO LOC
PRODUCTS -COMPIOPAGG $
A
AUTOMOBILELIABILITY
ANYAUTOAUTO
07MMBBTNKT
8/1/2007
8/1/2008
COMBINED SINGLE LIMIT
(Eaaccitlenl) $
ALL OWNE D AUTOS
}(
SCHEDULEDAUTOS
BODILYINJURY $250000 (Per person) 2 5 0 0 0 0
X
HIREDAUTOS
}(
NON-0WIJEDAUTOS
BODILY INJURY
(Peraocidern) $ 500000
PROPERTY DAMAGE
(Per aockfera) $ 100000
GARAGE LIABILITY
AUTO 014LY-EA ACCIDENT $
ANYAUTO
OTHERTHAN EAACC $
AUTOONLY: AGG $
EXCESSIUMBRELLA LIABILITY
OCCUR CLAIMS MADE
EACHOCCURRENCE $
AGGREGATE $
DEDUCTIBLE
$
RETENTION $
B
WORKERS COMPENSATION AND
EMPLOYERS'LIABILITYSI
WC7222278
9/23/2007
9/23/2008
}{ WCSTATU- "H-
I ER
El. EACHACCIDENT $ 100000
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBEREXCLUDED?
E.L. DISEASE - EA EMPLOYEE $ 100000
Ilyyes desrrlbeunder
SPECIAL PROVISIONS below
OTHER
E.L.DISEASE - POLICY LIMIT $ 5 Q Q 00
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIALPROVISIONS
CFRTIFICATF Wx11 11F0
0 ACORD CORPORATION 1988
vrarw G66.n IJV IN
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER
WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE
CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO
SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON
THE INSURER, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATI
}
0 ACORD CORPORATION 1988
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 2 1 A —F and G min.$100-$1000 fine
NOTES and DATA — (For department use)
❑ Notified for pickup - Date
Doc.Building Permit Revised 2008
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
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
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
Revised 2.2008
CA
W
N21 U1, 7
9
Date ... .... -:P
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
"--// - a
This certifies that ......
....................................................................
,j
-4
has permission to perform ....—
.... ......... ......... I -C, .........
wiring in the building of
at.Z.:,n ..... .A ........... �71 ...................... . North Andover, Mass.
40
C -e/-
'.4
Fee ... Lic. N,,/�j
/.z-
. .............................................................
I ELEcmcAL INSPEMR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
F
e Com$nonweaIth of Massachusetts
ent of Public Safety
PREVENTION REGULATIONS S27 CMR 1200
O: i ice Use ,Onnn Only
Perrit No: ( V_ `
Occupancy & Fee Checked�_�
3/90 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All Work to be performed in accordance with the Massachusetts E)eetrical Code. 527 CMR 12:00
(PLEASE PRINT IN INR OR TYP ALL INFORMATION) Date cQb of 9l
City or Town of N0 A h C'o ve-r To the Inspector of Wires:
The undersigned applies for a permit to /perform the electrical work described below.
Location (Street & Number) h 3 r,
Owner or Tenant
Owner's Address
Is this permit in conjunction with a building permit: Yes No ❑ (Check Appropriate Box)
Purpose of Building f1t� Jtn+ral Utility Authorization NO.
Existing Service Amps Volts Overhead
A Undgrd ❑ No. of Meters_
New Service Amps / Volts Overhead ❑ Undgrd
❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work o f • i h i, w: ,.,•,, t o�
tfLm.'Aj I,<•t,�-k
No. of Lighting Outlets
No. of Hot Tubs
No. of Transformers Total
KVA
No. of Lighting Fixtures
Swimming Pool Above In-
grnd. ❑ grnd. ❑
Generators KVA
No. of Receptacle Outlets
No. of Oil Burners
No. of Emergency Lighting
Bat-tery Units
No, of Switch Outlets
No. of Gas Burners
FIRE ZTNo. of Zones
No. of Detection and
Initiating Devices
No. of Sounding Devices
No. of Self Contained
Detection/Sounding Devices
Local ❑ Municipal ❑other
Connection
No. of Ranges
No. of Air Cond. Total
tons
No. of Disposals
Heat Total Total .
No. of Pumps Tons KW `
No. of Dishwashers
Space/Area Heating KW
No. of Dryers
Heating Devices KW
No. of Water Heaters KW
No, of No. OT
Signs Ballasts
Low Voltage
Wiring
No. Hydro Massage Tubs
No. of Motors Total HP
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws
I have a current liability Insurance Policy including Completed Operations Coverage or As substantial
equivalent. YEX NO 0 -I- have submitted valid proof of same to this office. YEX NO
If you have checked YES,,please indicate the type of coverage by checking the appropriate box.
INSURANCEBOND OTHER ❑ (Please Specify)
Expiration Date
Estimated Value of Electrical Work S 3 O L)
Work to Start 3/;.-3 Inspection Date Requested: Rough 9J4 7 Final W.i( C4#
Signed u "
FIRM NAM
Licensee
Address
NO. %!6�
NO.
Alt. Tel. No.
014NERIS INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub-
stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit
application waives this requirement. Owner Agent (Please check one)
Telephone No. PERMIT FEE S
Signature of Owner or Agent
Dat63 . ' 14 ..
"o TOWN OF NORTH ANDOVER
p PERMIT FOR PLUMBING
,SSACMUSE� f
This certifies that .............. .......... .
has permission to perform .^.................... .
a
plumbing in the buildings of .............
atG................... North Andover, Mass.
Fe . ... Lie. No. .. .... f �
PLUMBIN"fNSPECTOR
Check x d
644.E
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Date 306--
06
S
06 Owners N�meBuilding Location
Permit # YsAf
Amount
Type of 0,e`cuvancv /!�",c
A
New 1:1 Renovation
11 Plans Submitted Yes 11
FIXTURES
No ❑
(Print or type) Check one: Certificate
Installing Company Name Corp.
Address �� m 16111 K-1�11111-1 111 E] Partner.
Tusmess a ep one —�-- Firm/Co.
Name of Licensed Plumber: •J a
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity 11 Bond
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 installati xjs performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachuseate Plumbing Co , C pter 142 of the General Laws.
BY'Signa oi i7icenseaum er
ype of Plumbing License
Title
City/Town icense um er Master Journeyman ❑
APPROVED (OFFICE USE ONLY
. r.-. ... -.... _,.. ._.. — - to ,� ..... ... .-
Date.
4109
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that.......................
has permission to perform_ ..........
plumbing int the buildings of,-�-:j ............
at .. � . �. _:!� -. `-/......... North Andover, Mass.
Fee'? .. Lic. Ne -4-: ��-
^' PLUMBING INSPECTOR"' ►�
1-1
08/10/99 14:51 45.00 PAID
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MAP
PARCEL MASSACI
S UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
NORTH-ANDOVER,MASSACHUSETTS -- Date9
Building Location s Name Permit #
Building A6LC)-Iy
Amount
Type of Occupancy
New
Renovation 1:1
Replacement 1:1 Plans Submi'tted. Yes ❑ No
FIXTURES
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(Print or type) Check ne: Certificate
Installing Company Name Corp.
Address Partner:
Business TeTephone.. L Finn/Co.
Name of Licensed Plumber:
Insurance Coverage: dicate type of insurance coverage by checking the: apprWat&.'bQN..
pfi P
icy
Other emnity
:.:.
Liability 'insurance policy Other type of irid&'..
Insurance.Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner Agent 0.
I hereby certify that -all of the: details -and. information I have. submitted (or entered). in abov.e..application, are,true andaccurateto the,
best of my knowledge and that all, plumbirig work ridins atio PeTfqrmedlun4�&pe=t.Issued,f6Lthis applica4gr(will,be in..
L- -47 A- State.Plumbing�Cd-Pi r 142 of d)P-51eneralLaw&
compliance with all pertinent provi s
Type of Pi in'!
Title
City/Town
1P-7TTiense -Number
gL
APPR--&VEDTmFCE USE ONLY
...............
License
jo-Lun
Location 0//p j? ldlLo 10AYX JA4),--
No. Date ? J.? I-, J? ?
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
0
Foundation Permit Fee $
CHUS
Other Permit Fee $
Sewer Connection Fee $
Water Connection Fee $
TOTAL
44 13008
r-- Building Inspector
1 1308",
/04/199 11:40 812.00 PAID
Div. Public Works
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• FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
****************APPLICANT FILLS OUT THIS SECTION******************"'
APPLICANT PWRIZEA1 1)94%Z7_11(1i PHONE 05--36 -77
LOCATION: Assessor's Map Number 14),10 PARCEL /7
SUBDIVISION 1� LOT (S) j
STREET 8/Z/J) A6 r 1W ST. NUMBER 94
*****************************************OFFICIAL USE
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RECOMMkNDATI NS OF TOWN AGENTS: /b X /i P. -Am, fb* Acla,
CONSERVATION ADMINISTRATOR DATE APPROVED
I A 1 j DATE REJECTED (�
COMMENTS aAA#%1 �O'� — S �e Ol �2'
vV D D► �/Or'�
[ VV
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TOWN PLANNER
COMMENTS
FOOD INSPECTOR -HEALTH
SEPTIC INSPECTOR -HEALTH
COMMENTS
DATE APPROVED
DATE REJECTED.
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED v`
w ► i_L. cbN,vECT -0 sFiJ6JC —( J�UJ
PUBLIC WORKS - SEWERIWATER CONNECTIONS vrA PNA3E 3c C-ro rye pa.E -rk(s Y64e)
DRIVEWAY PERMIT N /,-;- -' L") 5 -) 4 _%t
FIRE DEPARTMEN
RECEIVED BY BUILDING INSPECTOR DATE
Revised 9197 Jim
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L� PLs IOeD, O'
r� FOUn SEASONS ASSOCIATES, IIIC.
375 Common 8t. Inwrence,lhee. 018110
Telephones (617) 063-5671-
14071:
83-5671NOTE: TIIIS IS NOT A SURVEY AND imouLD BE USED FOR MORTOAOES PURPOSES ONLY. no NOT USE OFFSETS Fon ESTABIIfIHINO LOT LINES. FOR THE E11EC.
TION 0► FENCES OR CONSTnUCT1oN PUnposes. IF BUILDINOt sHOWN LESS THAN ONE FOOT FROM THE BOUNDARY LINES. IT IE ADVISED TO MAKE
IIURVEY TO VERIFY THESE MEAIUREMENT11.
I IIEnEBY CERTIFY THAT 114AVE EXAMINED TI1E PREMISE11, AND ALL BUILDINGS, EASEMENTS AND ENCROACIIMENTS Ant LOCATED ON THE GROUND AS
SHOWN. 1 FURTIIEn CERTIFY THAT THE BIIIIDINOB CON►OnMED TO TIEE ZONING LAWS AND AMENDMENTS OEWO.AuDOVEIL wHEN CON-
BTRUCTEO. 1 FURTHER CERTIFY THAT THIS PROPERTY IB HOT LOCATED IN THE ESTABLISHED FLOOD HAZARD AREA.
BUYR ..•�• ••.,
RIc+HARt�CAROL. TO THE AP—LIt�IG-rom TRUST COMPAtIV ,•P0%UFM
BA LM. AS AND TITLE INSURERS
BooK: .1427 MORTGAGE INSPECTION PLAN WA- rn
PAGE: 34G o , �ARRY
LOCATED #16572
PLAN NO.: 7x74 B nn //�� FQ/STE��
SCALE: I11=dol- 00" (6 �R IU LE T{{�� ATm k1O. A w -D O VER F M !-t q" R
SUR
TO BE USED FOR MORTGAGE PURPOSES ONLY
DATE: 3/z s f s(o I I
j
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Name Please Print —
_e
Name: ��, ,�/1��AMAO
Location: 7,4 1?%? -140& � 7�
City AV` 4AILAIDI / MA Phone # UOS 36?
7 1 am a homeowner performing all work myself
FAI am a sole proprietor and have no one working in any capacity
F7I am an employer providing workers' compensation for my employees working on this job.
Comoanv name:
City:
Insurance Co. Policv #
Comoanv name:
C
Phone #:
Insurance Co. Policv
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00
and/or one years' imprisonment as well as civii penalties in the form of a STOP WORK ORDER and a rine of ($100.00) a day against me. I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
/do hereby certiy under the pains and penalties of perjury that the information provided above is true and correct.
Signature
Print name J�J�iTL%L��N `i'1��/1Lj,L% Phone #
Official use only do not write in this area to be completed by city or town cfficiaf
City or Town Permit/Licensinc
❑Check if immediate response is required
Contact person:
Building Dept
Licensing Board
Selectman's Office
Phone #: ❑
Health Department
Other
<
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 i�:
Z, L , � S CC viv7/���ti
(Location of Facility) 'J
Signat e 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
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