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HomeMy WebLinkAboutMiscellaneous - 1 OAK AVENUE 4/30/20184 --� I* -- Date.... ............... TOWN OF NORTH ANDOVER PERMIT FOR WIRING ryv) P - This certifies thaLj-� (I -z- J ........................................................................... ..... fy A J. - has permission to perform ................. wiring in the by1ding of at ....... L ...... ...................................... . North Andover, Mass. ..... ..... ....... ... .......... Fee...... . . ........ Lic. No. I ... 54� .................................................................................... ELECTRICAL INSPECTOR Check 4 M SO Pp Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked ,M BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (ME, 5 27 CMR ) 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: I �'-4 11u City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) vAy- AN C Owner or Tenant -TIZ-0 CY F 2& 1 S (E7 -TZ Telephone No." - Owner's Address a SjC-,. eY 9,e-00 Is this permit in conjunction with a building permit? Yes [9'- No ❑ (Check Appropriate ]Box) Purpose of Building Q -s iA-O^ CQ Utility Authorization No. - Existing ServicelM) Amps i2U /2 q0 Volts Overhead [� Undgrd ❑ No. of Meters __ New Service ' Amps t1Q /a4Volts Overhead Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: -2,A- -c q %C>(- t -C R -L,--) e - U 1C.Q DCTE-etXA 1�,, j Cmmnletinn nfthe following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Cell: Susp. (Paddle) Fans ` s Total Trsformers KVA Tran No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above In -El Swimming Pool rnd. rnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Detection andInitiating No. of Switches No. of Gas Burners Devices No. of Ranges Tot No. of Air Cond. Tons No. of Alerting Devices Heat Pump Number Tons KW No. of Self -Contained No. of Waste Disposers P Totals: """""""""`"` Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Municipal Local ❑ Connection F1 Other No. of Dryers Heating Appliances Security Systems:Y No. of Devices or E uivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: TIN ! Attach additional detail if desired, oras required by the Inspector of S. Estimated Value o Ele trical Work: ? (When required by municipal policy.) (� Work to Start: ' 2& ( Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE CO GE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) 1 certify, cinder the ins and penalties perjury, that t1t information on this application is true and complete. FIRM NAME: eeS LIC. NO.:—1 U 9 oI Licensee: The c� ,"�rbAk A -_;J f Signature LIC. NO.: (If applicable, enter " xe,�ipt" - the lic se numper ine.) Bus. Tel. No., Address: DOAZ ��s +I A Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lie. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. B my signature kelow, I hereby waive this requirement. lam the (check one) ❑ owner Elowner's agent. Owner/Agent` (��, t a PERMIT FEE. $ Signature _ Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed p on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8—Permit/Date Closed:** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INS CTION: Pass 0 V Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature• Date: FINAL INSPEC ON: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: --610 tam DEB WEINHOLD ...TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com I The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 •`` www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name(Business/Organization/Individual): 1W-jV`A.S'��EVS Address: kl,k hAL- {,N I() Citv/State/Zip: C O&—L'"'`S F0'' Are you an employer? Check the ap�iopriaie box: Phone #: 1. ❑I a employer with _employees (full and/or part-time).* 2. I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.F1 I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4.❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.# 6.F1 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 required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submif 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:V TypMoJect (required): construction 8. [] Remodeling 9. ❑ Demolition 10 ❑ Building addition 11. ©ctrical repairs or additions 12. Plumbing repairs or additions 13. E] Roof repairs 14.0 Other Policy # or Self -ins. Lic. #: Expiration Date: ISwc 4\3E- w crt✓ i �`-� fl�vL�� City/State/Zip: kA Job Site Address: 1 � Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify der tli�Nnd penalties ofpetjury that the information provided above is true and correct. \h nate. Phone #: 9�La • 8, G - 1 Lka-�_ Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents fok confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should'enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia CONSERVATION DEPARTMENT Community Development Division NEGATIVE DETERMINATION OF APPLICABILITY SPECIAL CONDITIONS 1 Oak Avenue, North Andover At the March 23, 2016 public hearing the North Andover Conservation Commission (NACC) voted to issue a Negative Determination of Applicability to construct a deck with roof and open deck (both on sono -tubes) and replace an existing wood fence with a vinyl fence within the 100 -foot Buffer Zone to Bordering Vegetated Wetland (BVW). The project will conform to the following: Applicants/Owners: Tracy Frazier and Alan Bingel 2 Stoney Brook Lane Salem, NH 03079 Record Documents: Request for Determination of Applicability Form 1 and supporting materials, submitted: March 11, 2016 Plan dated March 10, 2016 Prepared by Scott M. Cerrato, P.I.S. 24 Pleasant View Drive, Exeter, NH 03833 Titled: Proposed Plot Plan 1 Oak Avenue North Andover, Massachusetts SPECIAL CONDITIONS: 1. Prior to the start of work the applicant will ensure that the site contractor has reviewed the Determination and is aware of the wetland resource area and the limits of the proposed work. 2. Wetland markers will be placed on the new fence spaced evenly at 30' intervals (5 markers — 3 round / 2 square). Markers are available from the Conservation Department ($2 round/$3 square). 3. Once the work is complete, all disturbed areas will be stabilized with loam and seed or other methods approved by the Conservation Department. 4. Upon completion of the approved project and site stabilization (grass growing and ready to be mowed), please contact the Conservation Department for a final inspection. 1600 Osgood Street, Suite 2035, North Andover, Massachusetts 01845 Phone 978.688.9530 Fax 978.688.9542 Web: http://www.townofnorthandover-com/Pages/NAndoverMA_Conservation/index Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. _ I� �I Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands WPA Form 2 — Determination of Applicability Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 A. General Information From: North Andover Conservation Commission To: Applicant Tracy Frazier & Alan Binael Name 2 Stoneybrook Lane Mailing Address Salem NH 03079 City/Town State Zip Code Property Owner (if different from applicant): Name Mailing Address City/Town State Zip Code Title and Date (or Revised Date if applicable) of Final Plans and Other Documents: Proposed Plot Plan 1 Oak Avenue March 10, 2016 Title Date Title Title 2. Date Request Filed: March 11, 2016 B. Determination Date Date Pursuant to the authority of M.G.L. c. 131, § 40, the Conservation Commission considered your Request for Determination of Applicability, with its supporting documentation, and made the following Determination. Project Description (if applicable): Construction of a deck with roof over and open deck (both on sono -tubes), and replacement of existing wooden fence with vinyl fence within the Buffer Zone to Bordering Vegetated Wetland. Project Location: 1 Oak Avenue Street Address MAP 59 Assessors Map/Plat Number North Andpver City/Town Parcel 27 Parcel/Lot Number wpaform2.doc • Determination of Applicability • rev. 12/14 Page 1 of 5 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands WPA Form 2 — Determination of Applicability Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 B. Determination (cont.) The following Determination(s) is/are applicable to the proposed site and/or project relative to the Wetlands Protection Act and regulations: Positive Determination Note: No work within the jurisdiction of the Wetlands Protection Act may proceed until a final Order of Conditions (issued following submittal of a Notice of Intent or Abbreviated Notice of Intent) or Order of Resource Area Delineation (issued following submittal of Simplified Review ANRAD) has been received from the issuing authority (i.e., Conservation Commission or the Department of Environmental Protection). ❑ 1. The area described on the referenced plan(s) is an area subject to protection under the Act. Removing, filling, dredging, or altering of the area requires the filing of a Notice of Intent. ® 2a. The boundary delineations of the following resource areas described on the referenced plan(s) are confirmed as accurate. Therefore, the resource area boundaries confirmed in this Determination are binding as to all decisions rendered pursuant to the Wetlands Protection Act and its regulations regarding such boundaries for as long as this Determination is valid. Wetland Flags WFA1-WFA3 and WFB1-WFB8 ❑ 2b. The boundaries of resource areas listed below are not confirmed by this Determination, regardless of whether such boundaries are contained on the plans attached to this Determination or to the Request for Determination. ❑ 3. The work described on referenced plan(s) and document(s) is within an area subject to protection under the Act and will remove, fill, dredge, or alter that area. Therefore, said work requires the filing of a Notice of Intent. ❑ 4. The work described on referenced plan(s) and document(s) is within the Buffer Zone and will alter an Area subject to protection under the Act. Therefore, said work requires the filing of a Notice of Intent or ANRAD Simplified Review (if work is limited to the Buffer Zone). ❑ 5. The area and/or work described on referenced plan(s) and document(s) is subject to review and approval by: Name of Municipality Pursuant to the following municipal wetland ordinance or bylaw: Name Ordinance or Bylaw Citation wpaform2.doc • Determination of Applicability • rev. 12114 Page 2 of 5 Massachusetts Department of Environmental Protection ILIBureau of Resource Protection - Wetlands WPA Form 2 — Determination of Applicability Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 B. Determination (cont.) ❑ 6. The following area and/or work, if any, is subject to a municipal ordinance or bylaw but not subject to the Massachusetts Wetlands Protection Act: ❑ 7. If a Notice of Intent is filed for the work in the Riverfront Area described on referenced plan(s) and document(s), which includes all or part of the work described in the Request, the applicant must consider the following alternatives. (Refer to the wetland regulations at 10.58(4)c. for more information about the scope of alternatives requirements): ❑ Alternatives limited to the lot on which the project is located. ❑ Alternatives limited to the lot on which the project is located, the subdivided lots, and any adjacent lots formerly or presently owned by the same owner. ❑ Alternatives limited to the original parcel on which the project is located, the subdivided parcels, any adjacent parcels, and any other land which can reasonably be obtained within the municipality. ❑ Alternatives extend to any sites which can reasonably be obtained within the appropriate region of the state. Negative Determination Note: No further action under the Wetlands Protection Act is required by the applicant. However, if the Department is requested to issue a Superseding Determination of Applicability, work may not proceed on this project unless the Department fails to act on such request within 35 days of the date the request is post -marked for certified mail or hand delivered to the Department. Work may then proceed at the owner's risk only upon notice to the Department and to the Conservation Commission. Requirements for requests for Superseding Determinations are listed at the end of this document. ❑ 1. The area described in the Request is not an area subject to protection under the Act or the Buffer Zone. ❑ 2. The work described in the Request is within an area subject to protection under the Act, but will not remove, fill, dredge, or alter that area. Therefore, said work does not require the filing of a Notice of Intent. ® 3. The work described in the Request is within the Buffer Zone, as defined in the regulations, but will not alter an Area subject to protection under the Act. Therefore, said work does not require the filing of a Notice of Intent, subject to the following conditions (if any). See attached. ❑ 4. The work described in the Request is not within an Area subject to protection under the Act (including the Buffer Zone). Therefore, said work does not require the filing of a Notice of Intent, unless and until said work alters an Area subject to protection under the Act. wpaform2.doc • Determination of Applicability • rev. 12/14 Page 3 of 5 LlMassachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands I WPA Form 2 — Determination of Applicability Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 B. Determination (cont.) ❑ 5. The area described in the Request is subject to protection under the Act. Since the work described therein meets the requirements for the following exemption, as specified in the Act and the regulations, no Notice of Intent is required: Exempt Activity (site applicable statuatory/regulatory provisions) 6. The area and/or work described in the Request is not subject to review and approval by: North Andover Name of Municipality Pursuant to a municipal wetlands ordinance or bylaw. North Andover Conservation Commission Chapter 178 Name Ordinance or Bylaw Citation C. Authorization This Determination is issued to the applicant and delivered as follows: ❑ by hand delivery on Date ® by certified mail, return receipt requested on Dat � � --- -- This Determination is valid for three years from the date of issuance (except Determinations for Vegetation Management Plans which are valid for the duration of the Plan). This Determination does not relieve the applicant from complying with all other applicable federal, state, or local statutes, ordinances, bylaws, or regulations. This Determination must be signed by a majority of the Conservation Commission. A copy must be sent to the appropriate DEP Regional Office (see http://www. mass.gov/eea/agencies/massdep/about/contacts/find-the-massdep-reg Tonal-office-for-your- city-or-town.htmD and the property owner (if different from the applicant). Date wpaform2.doc • Determination of Applicability • rev. 12/14 Page 4 of 5 Massachusetts Department of Environmental Protection ' Bureau of Resource Protection - Wetlands WPA Form 2 — Determination of Applicability Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 D. Appeals The applicant, owner, any person aggrieved by this Determination, any owner of land abutting the land upon which the proposed work is to be done, or any ten residents of the city or town in which such land is located, are hereby notified of their right to request the appropriate Department of Environmental Protection Regional Office (see http://www.mass.gov/eea/agencies/massdep/about/contacts/find-the- massdep-regional-office-for-your-city-or-town.html) to issue a Superseding Determination of Applicability. The request must be made by certified mail or hand delivery to the Department, with the appropriate filing fee and Fee Transmittal Form (see Request for Departmental Action Fee Transmittal Form) as provided in 310 CMR 10.03(7) within ten business days from the date of issuance of this Determination. A copy of the request shall at the same time be sent by certified mail or hand delivery to the Conservation Commission and to the applicant if he/she is not the appellant. The request shall state clearly and concisely the objections to the Determination which is being appealed. To the extent that the Determination is based on a municipal ordinance or bylaw and not on the Massachusetts Wetlands Protection Act or regulations, the Department of Environmental Protection has no appellate jurisdiction. wpaform2.doc • Determination of Applicability - rev. 12114 Page 5 of 5 I POU�m ,0 °r -40 r ol I ICA D Z is Tl Z T O m z I til C' I v 3 m IN j�e- m r m z 0 O O n ANc)ovE2 ST U. Rtow � d _° _ !n g w� O L J -In 70 C �a� � In o B 5G o� In • - -- - ��.� M sl O G 105.90 IL �N pD N-~ U. Rtow � d _° _ !n g w� O L J LP C �a� 5G o� In • - -- - ��.� M 76 D r '0 i Z 0 NnT ANDOVER p c N p .� u � w T � � ? � T o_ c D u, � a m r y z D a rn o , � 10 L L— �e �qrr s ter/ F. Adort� s til j% A v r N o� D m ul 920g 9z. tA — 2U.111io eo.N2i 5T /l9.52 '- �o n V ��. 77 t M R �3 FJ O b PLAIQ or A;"D 00 9p*l \.9 tji,`, �\ M012Tw APDOVEas MAss Esc PREPARED POP- JAME WHITEHILL SCALE, ("=50' �� \��' o QOV. 27, 198 40' e -Ili �j L_ 01, . 2. 2.3 ACRES , . 1-13 ;5 1 . I - 1.24 Ae-eas e7,4aw 'RD ; BOARD AMOVAL UNDER EMOMMON. CONTROL LAW NOT RHO'' IP00. BOARD OF TOWN OF NORM ANPOVs Agpovram i>j_AwNItj4c, 50,c;± To Jowmsam Gy. 00. C), V E P Locus f./ P PU E5LIc 0 4, sr z AME7 O Vol C; A, vA.ra%A.SLe f, "'?V, WFIrtWE RION INVE, im-, Q05E2-C (f'300DW1-4 p w $4.11- or �EMTQAL 9-1-62er.-f Nod. 27 1956 OI S O d% 100 Coro P�Iso M 50,c;± To Jowmsam Gy. 00. C), V E P Locus f./ P PU E5LIc 0 4, sr z AME7 O Vol C; A, vA.ra%A.SLe f, "'?V, WFIrtWE RION INVE, im-, Q05E2-C (f'300DW1-4 p w $4.11- or �EMTQAL 9-1-62er.-f Nod. 27 1956 OI S O Safety Insurance Wo Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Inspector of Buildings City Hall NORTH ANDOVER, MA 01845 RE: Insured: TRACY FRAZIER Property Address Policy Number: Claim Number: Date of Loss: Company: Board of Health or Board of Selectman City Hall NORTH ANDOVER, MA 01845 1 OAK AVE, NORTH ANDOVER, MA HMA 0408607 BOS00046792 12/9/2014 Safety Insurance Company Claim has been made involving loss; damage or destruction of the above -captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any n6tice under Mass. Gen. Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim number. Holly Coughlin Claim Examiner '12/19/2014 Safety Insurance Company Homeowners Claims Unit P. O. Box 55098 Boston, MA 02205-5098 Phone: (617) 951-0600 EXT 3026 Fax: (617) 531-6684 Email: HollyCoughlin@Safetylnsurance.com Location—/ e "122 No. (_ 11 Date "' '16 TOWN OF NORTH ANDOVER Check # lPe�9 5'1 57 Building Inspect6- Certificate of Occupancy $ C Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL s Check # lPe�9 5'1 57 Building Inspect6- TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING �0'1 IN s SCW o n f01' q f ri c i a i USC o gy Ll L-01 �=' -1 � I ONE 3 ffl N N �E-' 0 : ffl N.." -ggz N BUILDING PERMIT NUMBER: ISSUED - h SIGNATURE: 4a4&,Or Buildin Commissioner or of Buildings Date 1.1=M4 .1 Property Address: 1.2 Assessors Map and Parcel Number: &w:Z7,9- Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zonin District Aoposed Use Lot Area (sf) Frontage (R) 1.6 BUILDING SETBACKS (ft) Front Yard E- Side Yard Rear Yard Required I Provide I Reattired. 1. Provided I Required Provided "0 M X 0 ts. 0 M X z 0 z M 90 0 -n M z 0. 1.7 Water Supply UGLC.40. 54) Public 0 private 0 1.5. Flood Zone Information: zone - outside Flood Zone D Municipal 1.9 Sewerage Disposal System On Site Disposal System 0 p 2.1 Owner of Record ;jz6tt Name (Print) Address for Service Signature Telephone 2.2 Authorized Agent Name Print Address for Service: Signature Telephone MOM I MEN— 3.1 Licensed Construction Supervisor TAML� h , �AA)D Not Applicable D Address /01 --. License Number sedon Supprvi'sor: 171? 7 Expiration Date Signature;:: -T Telephone 3.2 Registered Home Improvement Contractor 1-4 -Qb�/ 7-/0/y Not Applicable 0 Company Name lc>i Registration Number dress Expiration Date Signature– Telephone "0 M X 0 ts. 0 M X z 0 z M 90 0 -n M z 0. 1' <-' A as Owner/Authorized Agent Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. r Signed under the pains and penalties of perjury Print Name Signature of Owner/Agent Item 1. Building 2 Electrical 3 Plumbing 4 Mechanical (HVAC) 5 Fire Protection 6 Total (1+2+3+4+5) Date (a) Building Permit Fee MWtinlier (b) Estimated Total Cost of Construction from (6) Building Permit fee (.) x (b) Check Number BASEMENT OR SLAB ' SIZE OF FLOOR TIIvMERS 1 ST 2- 3 RD SPAN DEMENSIONS OF SILLS DEMENSIONS OF POSTS DDAENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CIIDANEY r IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE C/) m m m m m m C/) m C/) 0 m 4 4 s 0 -01 10 10 W-1 0 CWD P" 7d CL'S: qia coW cr Go c, P)Ci 2 S- m y — dc CA CO) 10 0 CD a m IrA CD r M CL to 3 CL C.X COD CD so CL C) ac= -0 C -.P CD CD Cl CL Er cr =r Fn - CO) cb' Er y 0 CD CD CD CD� co) CL 1= CD co) C:j 0 0 CD Cos C2 C) I= co I m a cn C2 cn CD ==rr O CD 0 -01 10 10 W-1 0 CWD P" 7d CL'S: qia coW cr Go c, P)Ci 2 S- m y — dc 'lid 0 C** n Dr- 4 - CD R C/) n r M j;7+1 to 3 CL C.X COD CD 0 z M cn cn Er ML cL 0 — 0 0= Fn - CO) O y 0 O gr 6, CD a cn 0 0 go. z:s 0 !! C2 C.3 cn cn ==rr MCC CL =r E: CD COD: CD CO R r C7-0 COL Ccdcw -01 10 10 W-1 0 CWD P" 7d CL'S: qia coW cr Go c, P)Ci 2 S- m y — dc 'lid 0 C** n Dr- 4 - CD R C) r M CD to 3 CL C.X COD CD M Er ML cL 0 — 0 0= Fn - CO) CC y 0 1-0 0, gr 6, CD a 0 0 go. z:s 0 !! C2 C.3 cm caCD ==rr MCC CL =r E: CD COD: CD CO R r C7-0 COL GO M: CD H w I cr ' CL Im C) CO CD CC2 IE .;g Go C 0 fA CD co, .0 Fv CD A CD CA ol =r 0 C C, D CD 0 CD COP CD 0 • C/) 0 C/) 4 z CWD P" 7d CL'S: g, G70 Z 0 c, P)Ci 2 S- m y z 0 'lid 0 r. p n Dr- 4 - CD Irl 0 0 9L CA O r M C/) 0 C/) 4 z W c 0 P" 7d -x 0 g, G70 Z 0 cp 2 P)Ci 2 S- m y z 0 'lid 0 r. p n Dr- 4 - w ro OQ Irl 0 0 9L CA O r M oil d. O 0 North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: n of Facility) Signature of Permit licant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector } . -----`� . . R ,. ) t . . 0 .t } �§k 0 = N < . \ 0 G ■ � , !. 2 '® 0 &:� / , �. /0 \ƒ 0 .at 2 . / $ � / 2 | @ M00 « /. 2 4-) § / 2 E ¥@£ / c w # a k & $ 0 � 4 m & a � \ § ?\Z� f\ Z C) W // c/ / '| { p 2 E R R w 2 \- 3«§ @3} »\ ZZ7 2263 f 00 \� -j�0 ¢ \ ƒ k 0 4 ¥ @ Z . 2Iw ~ \ � \/\Z ! �' ok ems. . ,� � . ,. ) t .t } �§k � < . ■ � X222« . , LL z.\k &:� / , ■ Q:�>�2�» .at 2 . � / 2 Name: LAViU t l 0=72�,fG(%d -V Location: /d / i)d Z-5 DUO Jr � am a homeowner performing Gil work myself. ��am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Company name: Address City: Phone # Insurance Co. Policy # 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' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine 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 herby certiWnd4r the pains and penalties of pe 'ury that the information provided above is true and correct. Signature Date Print namePhone #k�7,52-5-3 Official use only do not write in this area to be completed by city or town official' ❑Check if immediate response is required Building Dept Contact person: FORM WORKMAN'S COMPENSATION ❑ Building Dept ❑ Licensing Board ❑ Selectman's Office ❑ Health Department ❑ Other