HomeMy WebLinkAboutMiscellaneous - 10 STONECLEAVE ROAD 4/30/2018 (2)aoloodsul 6uiplm8
$ -ivioi
$ aad Iivaaad Jay}p
$ aad I!WJOd uoijapunod
$ . aad I!wJOd auaaad/buipl!n8
$ Aouadnoop jo apaoilpeo
a3AOaNd HIHON =10 NMOI
o l !. ^ T
-ON
S -
TOWN OF NORTH ANDOVER t
PPLICATION FOR PLAN EXAMINATION l wt att 14 t. V ,:�
Permit NO: _ Date Received Z
Date Issued: ` t
IMPORTANT: Applicant must complete all items on this page
LOCATION I U_ t<�,/
KIYLI
nnf.PROPERTY OWNER')
,,00;..11,
zc�� Print 100 Year Old Structure
MAP NO: d� PARCEI-Ob / > ZONING DISTRICT: Historic District
Machine Shop Village
yes o
yes no
ves , no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
❑ New Building
One family
❑ Addition
❑ Two or more family
❑ Industrial
❑ Alteration
No. of units:
❑ Commercial
❑ Repair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
❑ Septic ❑ Well
❑ Floodplain ❑ Wetlands
❑ Watershed District
❑ Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Identification P}easet Type or Print Clearly)
OWNER: Name: I.►r,:YL I� t v b
Address:
5
CONTRACTOR Name: flynaZok Phone: tL DO 725 b
Address:
Supervisor's Construction Licensee (og 1 Exp. Date: 5 - I
LHome Improvement License: 1 Exp. Date:
ARCH ITECT/ENGINEE
Phone:
-Sigi
Address: Reg. No.
FEE SCHEDULE: BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ �n, o`�-C7� FEE: $
Check No.: o Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund
Signature of Agent/Owner Si- mature of contractor ,
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF7 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
PLANNING & DEVELOPMENT
DATE REJECTED. DATE APPROVED
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
a
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
Comm
Water & Sevier Connection/Signature & Date Driveway Permit
DPW Toiv;: Fngineer: Signature:
FIRE DEPARTMENT - Temp Dumpster on site yes
Located -at 124 Mair, Street
-Fire Department signature/date
COMMENTS
Located 384 Osgood Street
no
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 21A -F and G min.$100-$1000 fine
NOTES and DATA — (For department use
® Notified for pickup - Date
Doc.Building Permit Revised 2010
Building Department
The fol:13wing 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 apw-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be subm.tted with the building application
Doc: Doc.Buhding Permit Revised 2012
•
H
Q
LLI
LL
O
pC
O
m
C
L
j[
O
LL
ecu
?
N
v
O0 a).
N
O
W
CL
Z
Z
m
m
a
7
LL
s
d'
N
c
E
U
LL
o
W
CL
Z
C7
m
t
mto
0C
d'
LL
0
W
CL
Z
Q
U
F-
W
s
7
v
u
N
C
LL
oc
O
d
Z
H
Q
s
7
d'
C
LL
z
W
cc
LLIa
0
W
ti
i
v
i
CO
O
Z
..
G1
+
(%
v
Y
0
N
uj
LL
o 0
p : (�
W
•� L Q.
a°' :m
:Z
¢ :c9
�.. _ Z
'o° :o
E n
L N m
..c am �
0
tm
� � •a Z �
0 i O cul)
r d a
N J E
L a as Z H
> _
0-0 NU)
a'Z
'a cn Q =
�. s .c ,wt O Lu
Q C C t C Cl)
o w
mn
•'> 3 c W J
o Z
o D a
CL •�
r o
Q L c
2 d Q (D N
2 m O
N .r
w
W C 'a— O O ,F-
LL.(Dto= O
.y •� O
'E V V O
W L V d
cnF.Q 0,0d w Q
N N .O w.. _
w
U
E
O
Z
O
C
CD0
N
.E m m
CL E_
m
O �+
v D O
m O
� Q
O
ca
J
.v = O
U) Z �
O
V N
m
m
CL
U)
G
v+
U)
W
W
19
W
witenca, ma u-raci rnone: vio-otu-oeuff
Fax: 978-362-3102
e— Customer
Name
Laurie Kirby
Job Site
10 Stonecleave Rd
City
North Andover Ma 01845
phone
781-316-5485 J
Install tarp from roof to ground to protect siding & landscape.
- 'p existing 1 -2 -layers -down to -roof deck & re -nail where
necessary. Any broken or rotten plywood will be
replaced up to 1 sheet 1/2" CDX. Any extra
replacements will be at an additional cost of time and material.
Install 6' ice & water shield undertayment along all eves.
Install 15lbs of felt paper on remainder.
Install 8" white aluminum drip edge around entire perimeter.
Install LTD Lifetime GAF Timberline or CertainTeed Landmark
architect roofing shingles(color and manufacture chosen by
homeowner).
Counter flash and caulk chimneys where necessary.
Install one new 4" pipe flange.
Cut in and install new shingle over ridge vent.
Remove all roofing debris.
Remove antenna, clean gutters & re -secure back main gutter.
This is a labor, materials, dump and permit proposal.
Ten vear warrantee on all workmanshi
rayment uetans
Cash
• Check
Deposit of $ 2,200.00
Check to be made out to
Dem se Roofing LLC
Proposal —
Date 8/15/13
Order No.
-------- ---------------- ------------
----------------------------
Rep
FOB
[Office Use Only
i
-- — --- -- - - - -- -;-- --_.
The Commonwealth of Massachusetts
Department ofIndustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA. 02111
U1 www massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): f 1,in
Address: �z
City/State/Zip&"tlV a 6- pt�i Phone #: q gnC)
Are you an employer? Check the appropriate box:
1. W I am a employer with 3
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ 1 am a sole proprietor or partner-
listed on the attached sheet. #
ship and' have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11. ❑ Plumbing 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.
t Homeowners who submit this affidavit indicating they aie 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 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. _
Insurance Company Name:. A 1A L- lV I O
Policy # or Self -ins. Lic. #: ,G� b SCC -7 6,) -7 y 9-70 1 �/O 1 �A Expiration Date}: )2 - 1 - � )J � j
Job Site Address: i) ,6a o AaA � V� . City/State/Zip: uov4 �f U', �/l t .
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requiredunder 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 certo uldIr Ili SpaNs and penalties of perjury that the information provided above is true and correct.
Phone #: q ) 9` L 1 O d L�
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License
- .2 - i07
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 #:
0712512013 14:20 Prescott &;Son insurance Agency �WIA61i[rin��
CERTIFICATE OF LIABILITY INSURANCE
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE C
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMBNO, EXTEND OR ALTER THE COVERAGE AFI
BELOW. THIS CERTIFICATE OFA INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THF ISSUING
REPRESENTATIVE OR PRODUCER, ANb THE CERTIFICATE HOLDER,
IMPORTANT: If the corUflcw ate holder lo, an ADDITIONAL INSURED, On pollcypesj must be endorsed, It SUBROGA
the terms and eondltlent of the policy, 66rtaln policies may require an endorsement A statement on this eartifieate
Certificate holder in Him of s�911drom06l en a .
PRODUCER` A Conm►erai9l I.a
Prescott and son Ynsur f ee ;Agency, Inc. IjSPHO1 , (761,3 322-2950
963 Eastern AvenueI ADDRESS!
BY
not eonffr Mghts to the
INSURRIUXII APP DING COVERAGE NAIC
Malden MA 02148 IN URNR - tai.n Speciialty Ins Co i
INSURED iwaugnpAIK Mutual IDS CompanyImo+
Dempsey Roofing LLC ( NBua C: 1 _
PO Box 383 I• I
IN a !
Billerica MA t 011,321 [INSURERPi
QAVRROeRA 'CER7,791CATE NUMRRR!CLi372516871 REVISION NUMEIER!
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHS'T'ANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ASUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONGITIONB OF F !SUCH FLOLICIPS, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TYPE OF INBIiRANOE
IDOL
FUPR
POLICY NUMBER
FOLIGY EFF
} LIMITS
GENERAL LIABILITY
EACM OCCURRENCE+ S 1,000,006
i 100,000
MED EXP My ane , i 5,()00
A
X COMMERCIAL GENWA'L LIABILITY j
G7 OCCUR
ZP%44492
/3/4014
/3/2013
PERSONAL A AOV INJURY ! 11000,000
GENERAL A RELATE i 2,000,000
r
GEN'L AGGREGATE LIMIT APPU S PER:�
X POLICY 7R , Loc
PRODUCT& • COM PR)P AGO i 1,000, OOO
:
AUTOMOBILE UAB(UTY
COMBRED SINGLE
ANY AUTO
BODILY INJURY (Mr I)ORM) i
SCC EEE ULEO
ALOOs OWNED AO
MIRED AUTO& AAUTOS
BODILY WARY (Aer"wakmp &
i
p i
UMBRELLA UAB
Ed
OCCUR
EACH OCCURRENCEL _
EXCESS UAB
CLAIM&LOCE
AGGREGATE i
CEO I I RETEtTI
I =
$
WORKERSCOMPENSATRIN
AND EMPLOYERS! UABIL"n'
ANY PROPRIETORMARTN:RIMCUTIVE Y®
OFFICERIMEMBER EXCLU2E97
(Mandalery in NN)
li yes, eeeelke unser
ES IPTIO O,, OPERArK)NSBelow
IN /A
9PC702748101-20331
a ted free C
4�e �eeY
/1/2019
/1/2014
wcsTA OTN-
EL OACHACCIDEM !
ELL CISEASE • EA ERIPLOYEE i
B.L DISEASE . POLICY LIMIT i
16
I
I
DESCRIPTION OF OPERATIONS I LOCATIDNsi V6MICtdiE (Aeeeh ACORD 707, AddlUonal Relnerks Behedule, Ir roma epeae Ie reRUWI
f
K
LiA1VGCI.LA�! ION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIIIS BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS, f
AUTNORIZO REPRESENTATIVE j
J 8 8oholn ck/FJR �' ' � -'d° -fie- �'c-���►%
®1988.2010 ACORD CORPORATION. All rights reserved.
re'reglatered marks of ACORD 1
IL
I{
�I
II
�I +
it 1
Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor Specialty
License: CSSL-099681
� 4 ! 5 t • `
ERIC DEMPSEY
7 RICHARDSONSTM��. (
BILLERICA MA=0184,
A
,! +" Expiration
commissioner 05/23/2014
�i% �onrnconcvea/.b� c�'../�faaars�d
Office of Consumer Affairs 8c Bflarnees Regulation
C` 7MOYE i,."1PROVEV.EHT CONTRACTOR
Re&trzfion: :1150272 Type:
lExpirittlon:. 3r2V2014 DBA
DE SEY CONST i itG4Okk6� -
ERIC DEMPSEY
7 RICHARDSON ST'
f BILLERICA, MA 01821': Unders"reta
rY
i
No. 4-7 Z Date 9 1z,(,1
°"7F1
TOWN OF NORTH ANDOVER
3? ' 0
Certificate of Occupancy $
} �D
Building/Frame Permit Fee $
�ssc►wS
Foundation Permit Fee $
Other Permit Fee $
Sewer Connection Fee $
<
Water Connection Fee $
u;
TOTAL $
4
Building Inspector
CU
m
'- 8830
•
Div. Public Works
PER111T NO.
It
i
4-7 Z APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS.
PAGE 1
MAP K40.
LOT NO.
I
2 RECORD OF OWNERSHIP iDATE
BOOK 'PAGE
ZONE
SUB DIV. LOT NO.I
LOCATION D� L ����
t
PURPOSE OF BUILDING e-gee�q
5 potch
OWNER'S NAME
NO. OF STORIES SIZE
OWNER'S ADDRESS netft
BASEMENT OR SLAB I
ARCHITECT'S NAME
SIZE OF FLOOR TIMBERS 1ST 10 2ND 3RD
BUILDER'S NAME
SPAN
DISTANCE TO NEAREST BUILDING L
1
DIMENSIONS OF SILLS avA'� ---
'" "' POSTS �
DISTANCE FROM STREET %_) ^ IF-
DISTANCE FROM LOT LINES - SIDES )O� REAR
/
GIRDERS
FRONTAGE `'1� C�
AREA OF LOTL 6z�)
HEIGHT OF FOUNDATION THICKNESS
699
IS BUILDING NEW
N
SIZE OF FOOTING
IS BUILDING ADDITION W-11"
MATERIAL OF CHIMNEY Al
IS BUILDING ALTERATION"
IS BUILDING ON SOLID OR FILLED LAND 56 Lea"o
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE
IS BUILDING CONNECTED TO TOWN WATER �/ O
BOARD OF APPEALS ACTION. IF ANY _ (� ^
I
IS BUILDING CONNECTED TO TOWN SEWER
IS BUILDING CONNECTED TO NATURAL GAS LINE A
INSTRUCTIONS
SEE BOTH SIDES
PAGE 1 FILL OUT SECTIONS 1 - 3
PAGE 2 FILL OUT SECTIONS 1 - 12
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
DATE FILED ?/-) 0
SIGNATURE OF OWNER OR AUTHORIZED AGENT�'�',�Bv
my
FEE -v\
PERMIT GRANTED �f
l 19
3 PROPERTY INFOF
LAND COST / v
tft
EST. BLDG. COST 'T
EST. BLDG. COST PER SQ. FT.
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
TION
OWNERTEL.M ''C)4?4 7757 0
CONTR. TEL. # z
CONTR. LIC.
H.I.C. # A -I^ Fr -A
*88, Qm4
BUILDING RECORD
1 OCCUPANCY 12
SINGLE FAMILY
THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM
LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA-
RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN.
3 BASEMENT II
AKtA FULL
STORIES
I FIN. B -M -T - ARIA
MULTI. FAMILY
OFFICES
APARTMENTS
N_O B M T
CONSTRUCTION
2 FOUNDATION 8—INTERIOR FINISH
CONCRETE d 1 2 13 ,
CONCRETE BL K. PINE
BRICK OR STONE
_
HEAD ROOM
4ARDW D
MODERN KITCHEN
_
PIERS
PLASTER
I FLOORS
CLAPBOARDS
DROP SIDING
WOOD SHINGLES
ASPHALT SIDING
ASBESTOS SIDING
VERT. SIDING
_
DRY WALL
B
_
1
_
CONCRETE
EARTH
HARDW D
COMMCN
ASPM. TILE
_
UNFIN.
3 BASEMENT II
AKtA FULL
I FIN. B -M -T - ARIA
_
1/1 '/r
fiIN. ATTIC AREA
N_O B M T
FIRE PLACES
_
HEAD ROOM
MODERN KITCHEN
_
4 WALLS
I FLOORS
CLAPBOARDS
DROP SIDING
WOOD SHINGLES
ASPHALT SIDING
ASBESTOS SIDING
VERT. SIDING
_
B
_
1
3
_
_
CONCRETE
EARTH
HARDW D
COMMCN
ASPM. TILE
STUCCO ON MASONRY
STUCCO ON FRAME
_
BRICK ON MASONRY
BRICK ON FRAME
ATTIC STIRS. 8 FLOOR
_
CONC. OR CINDER BLK.
WIRING
STONE ON MASONRY
STONE ON FRAME
SUPERIOR I�POOR _
ADEQUATE NONE
5 ROOF
10 PLUMBING
GABLE
GAMBREL
I
I HIP
BATH 3 FIX.
MANSARD
TOILET RM. 12 FIX.I
FLAT
SHED
ATER CLOSET 7_
ASPHALT SHINGLES
LAVATORY
WOOD SHINGES
KITCHEN SINK
SLATE
NO PLUMBING
_
TAR 8 GRAVEL
STALL SHOWER
_
_
ROLL ROOFINGMODERN
FIXTURES
TILE FLOOR
_
TILE DADO
6 FRAMING
I 11 HEATING
WOOD JOIST
PIPELESS FURNACE
FORCED HOT AIR FURN.
TIMBER BMS. & COLS.
STEAM
STEEL BMS. & COLS.
W'T'R OR VAPOR
WOOD RAFTERS
_y6T
Lel_
AIR CONDITIONING
RADIANT, H'T'G
UNIT HEATERS
GAS
7 NO. OF ROOMS
OIL
B'M'T 2nd _
Int O 1 -3rd
ELECTRIC
NO HEATING k
V
T
Lq
e
CN
P
x
ao
w
x
N
Cf)
o
W
z
z
Q
ca
-%
c
0
W
z
z
s
°
c4
[
w
z
U
F
W
°
n:
v
U)
w'
a
w
z
°
C4
C
ii
z
a
w
w
cq
z
cn
o
E
cn
uj
Q
z
1
G�
0
E
CD
°C o
o �
Z Of
C.
O CO)
� C
�O Cm
C
co
y 0 �
•E m m
CL -
Co
O L co
OL
!C O a
�Q
CO) C
O O O
'a. o ,?
co
o Q
V C
m
m
CO)CL
Z
0
F—
LU LLI
U)
z
0
U
cc
LU
d
cr
z
Lu
Q
w
0
J
Q
z
LLI
Q
LLI
W
U)
0
�a�
c
c v
o c
O N
:Ro
v t.3
:Cc
i o
181:
Ea
:o
a' m o
{81
aoQ
z��N
E=
1�
Cc
Q
O
:;
fl.
E
CA cuN
o
i
m
C
3N
®J
r"'
N
T
O
— m
>
clO
• N O
C
m
E.3
N m >
vt
Cf
5F
m o
m
.9.
VN O
C3 Z
ev
i
o
�C
v
(J o
s
m
co
a o
N
C, CD L m
LL
C
e
cc
�
c
o �.. m N
Z
O
LLI
Q
N
_
CL
03
m� O�
2 O H -
O
cc
G�
0
E
CD
°C o
o �
Z Of
C.
O CO)
� C
�O Cm
C
co
y 0 �
•E m m
CL -
Co
O L co
OL
!C O a
�Q
CO) C
O O O
'a. o ,?
co
o Q
V C
m
m
CO)CL
Z
0
F—
LU LLI
U)
z
0
U
cc
LU
d
cr
z
Lu
Q
w
0
J
Q
z
LLI
Q
LLI
W
U)
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 local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: Phon<6_0 �_ 7y�
LOCATION: Assessor's Map Number Parcel
Subdivision Lot(s)
Street IS�I11�C/•eott/p �� St. Number
************************Official Use Only************************
RECOMMENDATIO S OF TO AG S:
Date Approved
Conservation Administra or Date Rejected
Comments
Town Planner
Comments
/Food Inspector -Health
Septic Inspector -Health
Comments
Public Works - sewer/water connections
- driveway permit
Fire Department
Date Approved
Date Rejected
Date Approved
Date Rejected
Date Approved
Date Rejected
Received by Building Inspector Date
_;
V
O8o mrm
mJO
O
y8D
Aa
DC)
0
T-.im
Vm
n%
NNmD
D
Dtl(
Z��D
O00
n
_
z
cti
v
rA
m
o xv
m
m
z
nneOD
n
TDOc
vm
AZZ
NA
n n
10
r
D
yo
NN
00
Z Z
O
AZ
OO
006-
O
o
O
0
6 ro
O
my
TK
Z
ZNN
ZG)O
Z
y
00
N;K
a '
N
O
�
S
DZDn;Z
T O
NO
30a
`
O
Tw
=
N
OrN
3i
xD
Z
O
Nx
^
30.ON
=
A
ZC
!
I I
I I
I I I
I
I
rPJo1
Zm'_'�
O
O
ZyDN
DOZz
O
mD
O
O
Zv
D ~R
DDD
T
O
Z
Z
O
C
2
o
v
m.�n
Nx
N
tipA
D
;�Z
Dy
O
Ta
;Z
K
Zm
DAm,
CO
n
m20
Z -i
O
OZ
x
.
A
Z
Y
O
NOT
NO0p
m
°
TOmO
WM
Z
0
0
O
O
o
DyDZ
G
r
T
O60z
'm
II W_
I I I
>
zZ0
0
O
TZmO
I
i
IIIII°'
1111!111
Illill!�
M-1
Pcy /O'!
"-L C77
7,N )C, .
on
>01
C) -r N N
yrm
Z
D0
NZZ
COi
�XN
V
D
(1
0(0
was
ini
p
mx
=Nn
aoo
MZ_
N
;OZ
"nN
mW0
NCN
9r20
�y0
a �
Z�z
• �O
=o
0-4
fel z
xn
rm
m
0m
00
3
Town of North Andover
OFFICE OF
COMMUNITY DEVELOPMENT AND SERVICES
146 Main Street
KENNETH R. MAHONY North Andover, Massachusetts 01845
Director (508) 688-9533
HCMEOWNER LICENSE EXE-MPTION
Please priMr(-15?
"DATE r
OB LOCATION
Number
'--_HO�, IEOWNTER"
PRESENT MAILING ADDRESS
City/Town
^Imvf Rd4c/
Street address
97s=rya
Home phone
S tate
o
Section of town
1330-410
Work phone
Zip code
The current exemption for "homeowners" was extended to include owner -occupied dwellings
of six units or less and to allow such homeowners to engage an individual for hire who does
not possess a license, provided that the owner acts as supervisor. (State Building Code Sec-
tion 109.1.1)
DEFINITION OF HOMEOWNER:
Person(s) who owns a parcel of land on which heshe resides or intends to reside, on which
there is, or is intended to be, a one to six family dwelling, attached or detached structures ac-
cessory to such use and/or farm structures. A person who constructs more than one home in a
two-year period shall not be considered a homeowner . Such "homeowner" shall submit to
the Building Official, on a form acceptable to the Building Official, that he/she shall be
responsible for all such work performed under the building permit. (Section 109.1.1)
The undersigned "homeowner" assumes responsibility for compliance with the State Building
Code and other applicable codes. bv-laws, rules and regulations.
The undersigned "homeowner" certifies that he. -she understands the Town of No. Andover
Building Department minimum inspection procedures and requirements and that he/she will
comply with said procedures and requirements.
& HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING OFFICLA L
Note: Three family dwellings 35,000 cubic feet, or larger, will be required to comply with
State Building Code Section 127.0, Construction Control.
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
Julie Parrmo D. Robert Nicetta Nfichacl Howard Sandra Starr Kathleen Bradley Colwell
TOWN of NORTH ANDOVER
AFFIDAVIT
I3e b7umwnt Gmtcactcr law
aFpieuntt to Rpt tgAlcatim
Ila 0—:11-4 1t4IIs1q�,l*K4-:II* ■ • 111weINK60 114lilles 61mrs r 1 .••� ■ • �• • �� ■ • •rr n :• • •
41 .1 11 4 oil 0, 11-1101slatell wro-3-1018,1
• S.Y • s Y • 1 41 •- • • • o.� a• r• 1■►: u w ro: Y.1 orSY■ • . • 1 ••
Type of Work: Est. Cost
I -Address of Work 10
t -Owner Name:
L
ewe of Permit Application:
I hereby certify that:
Registration is not required for the following reasou(s): Fcr office Use Q11y
Work excluded by law Fam t No.
Job under $1,000 nate
Building not owner -occupied
_Owner pulling awn parmit
Other (specify)
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED ODNTRACM.RS:
FDR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRA-
TION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A.
Signed tater pa-alties of perjury:
I hereby apply for a permit as the agent of the owner:
Date Contractor Name Registration No.
OR:
Notwithstanding the
7ner o t above p
1
!F
DataO
above notice, I hereby apply for a permit as the
O.
�;
�'
a° ;
�.
x �� �,
__.
--- -- _
o� `�`�
_�_- . __._ .____--- ��-...__---_--___.. ? c�
r
9
a
i
i
I
I
r,
�a
NJ
e
v
a
i
i
I
I
r,
h`
Ts.
a
a
TO: NORTH ANDOVER, MASS : 19ZY
BOARD OF HEALTH
FROM: DESIGN ENGINEER Re: Soil Absorption Sewage
System Inspection
This is to certify that I have inspected the construction/ of the said disposal system at
ZG, jr -:2I :57-C'/I�,1`(2Z,6, V.E led North Andover, Mass.
SITE LOCATION
The grades and construction are as specified in my plans and specifications dated
19
t NORTH a?MVM. BOARD OF HEALTH
�IN8TALLA ION CHMK LIST
APP ED DISAPPROVED ��EXCAVATION OK
Data,Date: _( „ -7-/;--i
Reason,.
1. As Built S�.ibmitted 9g1L � ..9�2�
Chec ocation, dimensions.of system, location in regard to
percolation tests, depth of system, Crater table
2. Di ce to Wetland Areas, Drains, Street & House, Drainage Easement and Wells.
3. W er Line Location
4. No Pile
5. tic Tank - Tees, Cement -Pipe to Tank -Joints on both side of Tank.
Distribution Box - No cracks in box or cover, all lines flotir erually from boy.
7. ach Fields - Dimensions, Stone Depths, Capped ends, Clean double-vashed stone
8. Leach Pits - Dimensions, Depth of Stone, Splash pad4 tees, Cement -pipe to tank -
joints on both sides of tank, Clean double -washed stone
. No Garbage Disposals
Final Grading 4;barricading of sub -surface system
A
NORIIE ANDOVER .BOARD OF HEALTH
SUBSURFACE DISPOSAL SYSTEM CHBOK LIST
PROVED PROVIDED AP ROVED
WIZ
General Information
leg. 2.5 Fail
OE The submitted plan must show as a minimum:
e lot to be served (area,dimensions, lot #, abutters)
ocation and dimensions of system (including reserve area)
ign calculations
culations showing recui,red leaching area
14
�ela sting and proposed contours
location and log of deep observation holes -distance to ties
ocation and results of percolation tests -distance to ties
ocation of any wet areas within 1001 of the sewage disposal
system or disclaimer
r ace and subsurface drains within 1001 of sewage disposal
system or disclaimer
tion of any drainage easements within 1001 of sewage
di osal system or disclaimer
own sources of water supply within 2001 of sewage disposal
s stem or disclaimer00 '
location of any proposed well to serve the lot (1001 from leaching facilit
ocatian of water lines on property (101 from leaching facilities)
ma3dmum ground water elevation in area of sewage disposal system
ocation of benchmark
(p) plan must be prepared by a Professional Engineer or other
• professional authorized by law to prepare such plans
veways ,
Barba a disposers
profile of the system (elevations of basement, plumbers pipe
septic tank,..distribution box inlets and outlets, distribution
field piping and any other elevations)
PVC is to be used in construction
Septic Tanks
Reg. 6.1
�ities - 150% of,flow
Reg. 6.7
table
Reg. 6.$Reg.
r
6.9
of tees
Reg. 6.1
Reg. 6.1
g_
Wean
Seg 3.7
om cellar scall or inground swimming pool
rom subsurface drains
Pumps
Seg: 9.1 '
a Approval
Seg. 9.6
(b) Stand-by power
Y�
North Andover Subsurface disposal system check list -Page 2
Fai stri u ion Boxes
Reg.10.2
a ., a greater than 0.08
Reg.10. It
Sump
Leachina Pits
Leaching pits are preferred where the installation is possible
Reg.11.2
(a) Calculations of leaching area (minimum 500 S.F.)
Reg.11.4
(b) Spacing
Reg.11.10
(c) Surface drainage 2%
Reg.11.11
(d) Cover material
�eaching Fields
Reg -15-1
a) Gre.ter than 20 minutes/inch
Reg.15.1
Area (minimum 900 S.F. )
Reg.15.4
Construction of field
Rei;.35 8
Ieg..'�
) Surface drainage 2%
�e)"70't from cellar wall or inground swimming pool
Downhill Slope
a) --Slope y/x = (to be shown)
(b) y/x X 150 = (to be shown)
Ll
d
r
f �
5- o
t
4
t;
4
,i
e
Y
t,et
t
t_4
kL
Qj Lu
aL
-,j 04Q Q
2
a
i
Wk
C�
m
1
Q
v
�•
v
lu
"V
w.
j
Q
M
2
a
Wk
C�
1
Q
v
�•
�V 4
lu
"V
w.
j
Q
r•
2
a
Wk
C�
1
v
�•
w.
r•
1