HomeMy WebLinkAboutMiscellaneous - 10 JOHNSON STREET 4/30/2018TOWN OF NORTH ANDOVER
Office of the Building Department
Community Development and Services
400 Osgood Street
North Andover, Massachusetts 01845
Telephone (978) 688-9545
FAX (978) 688-9542
September 26, 2014
Michael C Donovan
10-12 Johnson Street
North Andover MA 01845
Dear Mr. Donovan
It appears that you porch post are bending under the weight of the structure they support. The North
Andover Building Department is requesting these supports be evaluated by a licensed structural engineer
or replaced by a licensed contractor, with new structural columns rated to carry the 2nd floor load.
Please feel free to contact the Building Department or office hours are between 8-10 and 1-2 daily.
Sincerely Yours,
Gerald Brown
Inspector of Building.
i
TOWN OF NORTH ANDOVER
Office of the Building Department
Community Development and Services
400 Osgood Street
North Andover, Massachusetts 01845
Michael C Donovan
10-1.2 Johnson Street
North Andover MA 01845
Dear Mr. Donovan
Telephone (978) 688-9545
FAX (978) 688-9542
September 26, 2014
It appears that you porch post are bending under the weight of the structure they support. The North
Andover Building Department is requesting these supports be evaluated by a licensed structural engineer
or replaced by a licensed contractor, with new structural columns rated to carry the 2°d floor load.
Please feel free to contact the Building Department or office hours are between 8-10 and 1-2 daily.
Sincerely Yours,
Gerald Brown
Inspector of Building.
M 6) ej q�61Iq
9800 Fredericksburg Road
San Antonio, TX 78288
USAW
04664.1K1QZ.JSS924415683.01.01.446
CITY OF NORTH ANDOVER
ATTN: BUILDING COMMISSIONER
120 MAIN STREET
NORTH ANDOVER,MA 01845-2420
Reference: MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B
Dear Sir or Madam;
I am writing regarding the claim referenced below.
Policyholder:
Peter H Anderson
Reference #:
005606657-20
Date of loss:
September 6, 2014
Location of loss:
North Andover, Massachusetts
September 23, 2014
A claim has been made involving loss, damage or destruction of the property referenced above,
which may either exceed $1000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143,
SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS, CHAPTER 139,
SECTION 3B is appropriate, please direct it to my attention and include the reference #.
You may submit correspondence or questions to me. My contact information is:
Address: P.O. BOX 659461
SAN ANTONIO, TEXAS 78265
Fax: 1-800-531-8669
Phone: 1-800-531-8722 ext 44238
Sincerely,
Jamie B Parries
Property Unit 6
USAA Casualty Insurance Company
P.O. Box 659461
San Antonio, TX 78265
Phone: 1-800-531-8722 ext 44238
Fax: 1-800-531-8669
005606657 - DM -04664 - 20 - 8023 - 08
54577-0914
Page 1 of 1
Date ..... 2-9-0 7
...........................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ................... ?� ...... z'-5. ZZ.. TR.
56 fll,/, Ce
has permission to perform ......................................................................... -. f��
wiring in the building of ....... /V ................ N ......................
at ......... ......... JgHIUS-041 ...... North Andover, Mass.
Fee .... !�� Lic. NoAIIO� ............... . r.'. .......
?3o?o RICAL INSPECTOR
Check
7936
a � V
Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No. �Z�- ,
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527f MR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: Z 7 G
City or Town of. NORTH ANDOVER To the Inspe for oy Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) 10 - `-K 3-p�,k5 0.A
Owner or Tenant YA i` C h 0. ` w ►1 ec U Ct Telephone No.
Owner's Address 6)2� yt/k�=
Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box)
Purpose of Building P,'e 51 d-evt .T t ct ` Utility Authorization No.
Existing Service Amps / Volts
New Service aoo Amps Leo / alb Volts
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
1, s +CL L ( tq ec.v C' cA&cec, ► ( s
Overhead ❑ Undgrd ❑
Overhead ❑ Undgrd[
W un
K` Lf�g LF
C'mmnletion nftl.o i:,ll,
No. of Meters
No. of Meters 3
>2fyic�
Pho�t�
No. of Recessed Luminaires
No. of Ceil: Susp. (Paddle) Fans
—wul Vvu uy the lns ecror oj n'Zres.
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑ In- ❑
o. o Emergency Lighting
rnd. rnd.
Batter Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
o. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Number
Tons
.KW
"'
No. of Self -Contained
Totals:
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances Kms,
Security Systems:*
No. Devices
No. of Water
No.KW No. of No. o
Signs Ballasts
of or Equivalent
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER: �..e I .. i _ _
1 Aitacn aaartionai detail j desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE'BOND ❑ OTHER ❑ (Specify:)
I certify, under thepains andpenalties ofperjury, that the information on this application is true and complete.
FIRM NAME: �cv� wQ, �C G_� ri C-CLi ' CSA LIC. NO.: N\ It, C1 t
Licensee: ,5Jk Qui � T Nqydrow4tSignature—A-/,,—.-.,, LIC. NO.: IN1k W:�
(If applicable, ent r "exempt'; in the license number line.) Bus. Tel. No. 781' 3 5 /' 7e1-1
Address: c3 0 W ► n G •e tfA -I CA cN G - Alt. Tel. No.: _'M -395 - 7 6,30
*Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner'sa ent.
Owner/Agent
Signature Telephone No. �PERMITFEE: $ J
r"I "
Date. :t� ... . . . ........
... . ... .....
,AORT#1
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
Thiq certifier that
has permission to perform-... .................................................
wiring in the building of ...................... ................................
................ .....
at................................................... t7e..,A.. ................... North Andover, Mass.
F& . ............... Lic. No . ............. ................
VLE**CT'R*I*C*A*'L* INSPECTOR/
Check #
86,,4
4
J
Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No. �y
Occupancy and Fee Checked 3S
r BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (NEC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: ���o y
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) /D ,Ja /,lii/SOIJ S'fiL P e
Owner or Tenant 1211e-44611 L Telephone No.
Owner's Address /cg T /{,,./ .SOiJ .942e e 7'
Is this permit in conjunction with a building permit? Yes ,K No El(Check Appropriate Box)
Purpose of Building �C1?,0 Vel / ##tLi Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ 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:
Completion of the following table may be waived by the Inspector of Wires.
No. of Recessed Luminaires
No. of Ceil: Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑ In- El
rnd. rnd.
o. o Emergency Lighting
Battery Units
No. of Receptacle Outlets S
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
o. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Number
I Tons
............... .
KWNo.
of Self -Contained
Totals:
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water KW
No. of No. of
Data Wiring:
Heaters
Signs Ballasts
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of lectr'cal Work: (When required by municipal policy.)
Work to Start:�� Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains andpenalties of perjury, that the information on this application is true and complete.
FIRM NAME: LIC. NO.: 315 751'
Licensee: �� (I�- 5fQ SignatureAa,-JA.__ LIC. NO.:
(If applicable, enter "exempt" in he license umber line.) (—, Bus. Tel. No.• 7$ /– 0�3 – %/90
Address: 3t., "� i�rGc� w o 6UyA , 41� • Alt. Tel. No. • _
*Per M.G.L c. 1.47, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature be4pw, I hereby waive this requirement. I am.the (check one)Wowner ❑ owner's agent
Owner/Agent
Siunature i!z� � if"'t'`� Telenhnne No. ��!!'��'�%�� PERMIT FEE. $ �'
RC9-c^,y� gq-4=8-C:g742
�7- T. A-2-7
ok
m
dt-, t t t,==dT==dq qa@* Lj I „S y==dzil2a7,] X==dAAiviV:V7,6d „a113330y ���
lb
Date.
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This.certifies that . 1;114A 11.r ...
has permission to perform A� q-1es ...................
plumbing in the buildings of ....................
at ... JC4!-� f . ......... North Andover, Mass.
Fee. Lic. No. C .. ....... . . 17.Z
PLUMBING INSPETCO
Check
8057
0
i
I
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS �`��/
,j Date % — a 7-
Building Location l U ��yy��/ Owners Name �'%it�,f'�/��/ Permit #_y
Amount
Type of Occupancy
New 1:1 Renovation 5C
Replacement 0 Plans Submitted Yes No ❑
o'
1
'
•
-----..------.-...------.
�.�----------------------
i . .'
------------------------1MMMMMMMMMM=M
-
MM
1 '
------------------------
t,'
-------------------------
-----.-..------.-t--m----
(Print or type) , C Check one: Certificate
Installing Company Name j 11 Corp.
Address Ot%/
El Partner.
Business Telephone , — Firm/Co.
/° A
Name of Licensed Plumber: //'dP//
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity ❑ Bond ❑
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
threeinsurance
c—�
signature Owner Agent ❑
I hereby certify that all of the details and information I have submitted (or7en ered) 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 Massachusetts State Plumbing Code and 42 of the General Laws.
By:
Signature o icense um er
e of Pl ing Licen
Title � t
City/Town �14 um er Master ❑ Journeyman
APPROVED (OFFICE USE ONLY q
L
The Commonwealth of Massachusetts
k� I Department of industrial Accidents
j
Office of Investigations
600 *i zyhington Street
Boston, MA 02111
r : www-nuus.gov/dia .
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians�ptnmbers
A Iicant Information
Please Print Legibly
Nanne (Business/Organization/individual):
Address: S�
city/state/zip: / �r/ ���d� Phone
Are you an employer? Check the appropriate box:
I.❑ I tion a employer with 4Type of project (required):
❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors 6. []New construction
2. I am a:sole proprietor or partner-
ship and have no employees listed on the attached sheet t ? J&Remodeiing
These sub -contractors have
working for .in 8• Q Demolition
g any capacity, workers' comp. insurance.
A
[No workers' comp, insurance 5. ❑ We are a corporation and its 9' ❑Building addition
3. ❑required.) officers have exercised their l0.❑ Electrical repairs or additions
I am a homeowner doing all work right of exemption per MGL } I.�] Plumbing repairs or additions
myself. [No -workers' comp, c. 152, § 1(4), and we have no
insurance required.] t em Io ees. 12.[] Roof repairs
P Y [No workers'
comp, insurance required..] t3•7_0ther
'Any applicant fiat checks box # t must also fill out the section below showing their workers' bompensstion policy information.
r Homeowners who submit this affidavit indicating they are doing all work ,and then hire outside contactors must submit a new affidavit indicating such
jContractors that check this box must anaeb sn add•tioas] chest siw;vitrg the name of the sub-cotrtrtictors and their workers' comp, r�li�i irtnrmadon.
t ant an employer that is provi4ng:workers' compensationirrsuranre a !a ee� Below information. or f m' mp Y po hcy and job site .
Insurance Company Name:
Policy # or Self -ins. Lie. #:
T j Expiration Date: /0 --/'Q
Job Site Address: �ci lJ�%il.�SC� S
Attach a copy of the workers' eomnencatir.n .,..f:..- sa..c...Y..!__ ,. City/state/Zip:/e-, 4��4,e
Failure to secure coverage as - r�b- ` s "l` punct' number and expiration date).
g 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.
! do hereby certify under the pains and penalties of perjury that the information provided above is true and rotred
OiNciat use only. Do not write in this area, to be completed by city or town offriai
City or Town;
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 9-
6. Othe'r
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 Ceensing agency shall withhold the issuance or
renewal of 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 'coverstge required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'- compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificates) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of industrial
Accidents for confirmation of insurance coverage.. Also 'be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the .application for the permit or license is being requested, nofthe 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 nurnberlisted 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 permitAicense 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 futum permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit
The Office of lnvestigaations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
Revised 5-26-05
The Commonwealth of Massachusetts
Department of Industrial Accident
Office of Investigations
600 Washington Stmt
Boston, MA 02111
TeL 9 617-7274900 ext 406 or 1-8.77-MASSAFE
Fax 4 617-727-77491
www.mass.gov/dia
N
Date ... �. 11-7-5� I'll .......
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that.. ...................
has permission for gas installation . . .
in the buildings of .... T) ........................
at .......... North Andover, Mass.
Fee. . Lic. No. . ...... \
, X. . � �(. ; I
GA� INSPECTO��-
I
Check # 7
57U7
A
IASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
-Od� A w oyy EYE Mass. Date 5 E oT , 7 ZUa Permit #
Building Location 16-/2- JoHuSpO s)
Owner's Name MlGNk�L
DI'N6VAj
ND• AfJ06v6jz,
Type of Occupancy_ let=S/p,�FLL7IAI-.
d
gr1l L�
New ❑ Renovation ❑ Replacement ❑ Plans Submitted: Yes❑ No ❑
Installing Company Name BAY STATE GAS COMPANY
Address 55 MARSTON STREET
LAWRENCE, MA 01840
Business Telephone 7 !B-68,7 '1105
Check one:
DC7 Corporation
❑ Partnership
❑ Firm/Co.
Certificate #
1862
Name of Licensed Plumber or Gas Fitter Francis X. Corkery ,..
INSURANCE COVERAGE:
I have acu renntt liability insurNo ance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
If you have checked yes, please Indicate the type coverage by checking the appropriate box.
A liability Insurance policy P< Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: 1 am aware that the licensee does not have the Insurance coverage required by
Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner❑ Agent ❑
I hereby certify that all of the details and information 1 have submitted (or entered) in abo pplication are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under the permit iss f r this application will n mpliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s. (/
T e of License:
Plumber Signature of censed Plumber or Gas
Title Gasfitter
City/Town
Master License Number 3745
Journeyman
APPROVED O FIC SE ONLY
■�����������A�t�t�1����ME
Nonni
012101
MENNEENREMEMENNE
min
EK
Installing Company Name BAY STATE GAS COMPANY
Address 55 MARSTON STREET
LAWRENCE, MA 01840
Business Telephone 7 !B-68,7 '1105
Check one:
DC7 Corporation
❑ Partnership
❑ Firm/Co.
Certificate #
1862
Name of Licensed Plumber or Gas Fitter Francis X. Corkery ,..
INSURANCE COVERAGE:
I have acu renntt liability insurNo ance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
If you have checked yes, please Indicate the type coverage by checking the appropriate box.
A liability Insurance policy P< Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: 1 am aware that the licensee does not have the Insurance coverage required by
Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner❑ Agent ❑
I hereby certify that all of the details and information 1 have submitted (or entered) in abo pplication are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under the permit iss f r this application will n mpliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s. (/
T e of License:
Plumber Signature of censed Plumber or Gas
Title Gasfitter
City/Town
Master License Number 3745
Journeyman
APPROVED O FIC SE ONLY
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Location
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in " ""i
Date 5// �/g
Check # 0
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee
Other Permit Fee
TOTAL
-,)A /�, ( 6'
Building Inspector
I
r
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
nk Set" for i�I0
BUE DING PERMIT NUMBER: ' DATE ISSUED:
SIGNATURE: 4
4 (CA^4MOO,
Building Commissioner/Insnector of Buildings Date
SECTION 1- SITE INFORMATION i
1.1 Property Address:
1.2 Assessors Map and Parcel
Map Number
Number:
Parcel Numb
j� A-0 So n �
`t%
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Areas
Fronts ft
1.6 BUILDING SETBACKS 00
Front Yard
Side Yard
Rear Yard
Required Provide
Required Provided
Re
red Provided
1.7 Water Supply M.G.I .G.40. X54)
Public ❑ Private ❑
1.5. Flood Zone Infonnation:
Zone Outside Flood Zone ❑
1.8
Municipal
Sewerage Disposal System:
❑ On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT ' " "kA it; Ll i='T(tCT:
r.o _
2.1 Owner of Record
Name (Print) Address for Service
728 =&1 `l72 i A"',
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Superv'sor,
5��4
Licensed
`Construction Super isor:
cj /
o � i /�✓L 4 �Xw� c / - t
Address
4
3.2 Registered Home Improvement Contractor
ompany Name
72-S S
Telephone
921-Z6-3 -?z
Not Applicable ❑
0j---9f3y
License Number
C, ~/�- —a&
Expiration Date
Not Applicable ❑
C ( 2 7
Registration Number
z- 0�5-
Expiration Date
4 X ,
SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 §
Workers Compensation Insurance affidavit must be completed and submit
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes .......0 No ....... ❑ _
SECTION 5 Description of Proposed Work check as applicable)
New Construction ❑ ., Existing Building ❑ 1 Repair(s)
Accessory Bldg,
Brief Description of Proposed Work:
t
with this application. Failure to provide this affidavit will result
❑ Other ❑ Specify _
t' L
I WrTInN R - F.CTIMAWn rn1VCT101TfTrnN rnVre I �—
❑ I Addition ❑
3
i
Item
Estimated Cost (Dollar) to be
Completed b permit applicant
OFFICIAL USE ONLY
1. Building
Lz>
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) X tbl
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5
/z>
Check Number
111V1�1/JAliVl\ •v DE 1,V11Lr JU JLM" WrIA11V I
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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 7b OWNER/AUTHORIZED AGENT DECLARATION
r
as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are Lrue and accurate, to the best of my knowledge
and belief
Print
ZR ?/ -11
Date .
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 3
SPAN r"
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIItDERS ;
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING - x
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED I:AND
IS BUILDING CONNECTED TO NATURAL GAS LINE
f
North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
Number is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c11,S150A.
The debris will be disposed of in:
(Location of Facility)
--- 6, --1111k-
ignature of Permit Applicant
M111,5 -
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
tvd W f.3
7 �-n����'OrJ�
Sold TO:
City: -
Job site Address (If different)
9. d'
10.
11.
12.
13. 'fes
14. ❑
15. ❑
16. Q/ ❑
HIC Registration #129774 Federal ID #04-3277886
Pella Windows & Doors of Boston
"Viewed to be the Best"
TRY SYSTEM CONTRACT
Pella Windows & Doors
45 Fondi Road
Haverhill, MA 01832
PH: (800) 866-9886
Service: Ext. 124
Fax: (978) 556-0394
Sales: (866) Pella06
L Date*
Phone (Home) C` `�f �'b-'
State: Zip: Phone (Work) —
Siler Phone (Cell)
E-mail:
_. _...- .__...-... ...y....� .......o.�wro a.. uatn 10 at wn 1plutiulI ul JUU site
Remove and dispose of door in existing opening
All workman's compensation and liability insurance maintained
Warranty mailed to customer upon completion when full payment is received.
Total Project Amount $_ a �v
Financed If Yes: Amount Financed $ (Reference # )
Deposit Received $ _C5_""
Balance on Substantial Completion $ (Payment Is payable to Installer at completion of job)
Additional Comments:
PELLA IS NOT RESPONSIBLE FOR ANY EXISTING SECURITY SYSTEMS.
PLEASE REMOVE ALL SHADES,VERTICALS, BLINDS, CURTAINS, DRAPES
OR WINDOW MOUNTED AIR CONDITIONERS, PRIORTOTHE INSTALLATION
OF YOUR NEW ENTRY SYSTEM. INSTALLERS ARE NOT RESPONSIBLE
FOR THE REMOVAL OR INSTALLATION OF THESE TYPES OF ITEMS.
CONDENSATION INSIDE THE HOUSE DOES NOT INDICATE A WARRANTY
PROBLEM.
SALESMAN HAS NO AUTHORIZATION TO CHANGE ANY ITEMS OR MAKE
ANY REPRESENTATIONS OTHER THAN CONTAINED INTHIS AGREEMENT
AND "OWNER" REPRESENTS THAT NONE HAVE BEEN MADE TO OR
RELIED UPON BY "OWNER". YOU ARE ENTITLED TO A COMPLETELY
FILLED IN DUPLICATE OFTHIS AGREEMENT.
CONTRACT SUBJECTTO FINAL INSPECTION BY PELLA CONSTRUCTION
DEPARTMENT.
This contract Is a legal document. Your Pella products will be specially made-to-order for you. UNDER NO CIRCUMSTANCES WILL REVISIONS OR
CANCELLATION BE POSSIBLE BEYOND THE THIRD BUSINESS DAY AFTER THE CONTRACT HAS BEEN SIGNED AND DEPOSIT PAID BY SIGNING
White - Original Yellow - Customer Pink - Store
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
'�M' O, www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information / Please Print Legibly
Name (Business/organization/Individual): pe l � W lyxd�.1 S a'xc� Do o i�.s
Address: '15-�vr'1 c� �,
City/State/Zip: V& -h*, I
Phone #:
Are you an employer? Check the appropriate box:
1.;Rf I am a employer with 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- listed on the attached sheet t
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
These sub -contractors have
workers' comp. insurance.
❑ 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.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. F-1 Electrical repairs or additions
11. E] Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
*Any applicant that checks box X31 must also fill out the section below showing their workers' compensation policy information'
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
(Contractors that check this box must attached an additional sheet showing the name ofthe subcontractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. 10,,
Insurance Company
�� (ns urnttnCr-
Policy # or Self -ins. Lic. #: OR (SNL 5 7q *2- Expiration Date:?
Job Site Address: 11] �60-1 s ->e,-, City/State/Zip:/I/,-
1/06
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 certify un&rlg pains and penalties ofperjury that the information provided al ove is, true and correct
Phone #: cl -2 6 5 ' 7 2 SC
Official use only. Do not write in this area, to be completed by city or town offtciaL
City or Town:
Permit/License #
` 1mss
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 #•
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