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HomeMy WebLinkAboutMiscellaneous - 10 WALKER ROAD 4/30/2018N Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Inspector of Buildings 1600 Osgood Street North Andover, MA 01845 RE: Insured: Property Address Policy Number: Date/Cause of Loss File or Claim Number: Joanne Mueller 10 Walker Road YT0035 11/22/2012, Water Damage 27371-R Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 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 the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Ryan Werner On this date, I caused copies of this Notice to be sent the persons named above at the addresses indicated above by First Class Mail. , Sigr6toire and Date ANDERSON ADJUiSTMENT CO., INC. 50 Nashua Road, Suite 303 PO Box 1098 Londonderry, NH 03053 All - Location No. e �'r) Date TOWN OF NORTH ANDOVER ! 9 . , Certificate of Occupancy $ o • Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee TOTAL ° Check # �`- I -7 vl Building Inspector low • TOWN, OF NORTH ANDOVER BUILDING DEPARTMENT I. APPLICATION TO C'ONSTR REP JtENOVA OR •DnKKM A ONE OR WM FAMMY DWUJ&G BUII,DIATGPERMTTrfiJMIDER:DATE-19SUED: D� SIGNATURE: B Commissioner r of SECTION i- SITE INFORMATION z i.t Prapaty Address: 1.2 Asaessara Map and Pwod Number: O pp 11 noat l Ctrl oy 1��. Map Number Parod.Number N - 1.3. Z4ninrnfurmatian: ��•-- 1.4 ` Zaaia District PfqwW Uae Ld Area - g 1.6 BUILDING SETBACKS M. Front Yazd . ReTkred Side-Yard _ _ Rear. Yard .. . Provide Prawided _ ._ _....RequiredProvided . 1.7 waren sgglyM.al.aao.. sal - i.s. >?>oo� 7me Lda�tioe_ .. -.. t.a- - Dupw�1 sem.... _ zone Pabrw ❑ Pdnto ❑ 0awdeFlood zow ❑ rw�i� o, .. on sse t>epa.a► sy:<ew ❑ , SECTION 2 - PROPERTY OWMUMP/AVMORiZED AGENT m 2.1 Owner of Rleoord r : Name (Print) Address for Service: ���a��c-6 a, 418,4 Signatutri Telephone 2.2�w�ewf•Rorord: e� :: . Qy L 4K - Name Address Ser Service . j wo CA m 3' store a hone SECTION 3 - CONSTRUCTION SERVICES go 3.1 Licensed Construction Supervisor:- - Not Applicable ❑ Licensed Conshuctinn Supervisor . License Number . _.. . Address +� Signatwe Takphone F* -fan Daft - .. 3.2 Registered Home Improvement Contrpctor. _ q.. Not Applicable ❑ v . PAA- Aob�e ru c " ... _. .� Company Name *� � 7_L��3 � � `S C ► - r� I r r u 6 - ° 1 60 7 - z Exp,ratwn Date S ire r. (- 'SECTION 4 - WORKERS COMPRNSATION n1T_G-T_ n u2 a 241m Workers Compeasetion Insurance affidavit mus0e completed'ead stibinitted with: this eFOiati'dn, Failure to provide this affidavit will result in the denial of the issusaoe of tbuilhe ' , ed affidavit Attached Yes ...... No ... :.::0 7`7777777 ,�:•. : . 7 sEcnON 5 Desc tion of d Work' etteelc all p t New Construction ❑ .Existing Wilding-, 0 '; Repair(s) '. 0 ` ' -,IU teciitions(s)' :. Addition 0 , .. . Accessory Bid& b-' Demolition ❑ .. Other ; 0 Specify Brief Description of Proposed Work ` nn—sl i✓ci, r .3 SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar) to be C b ` 1 `' t licant MY 1. Building (a) Building Permit Fee.. - Multi HE(b). 2 Electrical Estimated Total.Cost of. Construction 3 Phmn Building Permit fee -(•),x (b) 4 Mechanical ACF_ 5 Fire Protection . 6 Total 1+2+3+4+5 �j Check Number SECTION 7a -OWNER AUTHORUAIION TO BE COMPUTED WHEri. , OWNERS AGENT OR CONTRACTOR AP,PLIESFOR BUILDING PERMIT L as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in alf matters relative to work authorized by this building permit application Signature of Owner Date SECTION 7b OWNT;)EyAUTHORIZED AGENT DECLARATIOtY I, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief . C"k Prim Name LA) rn it) 1W)7_ S of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIIV1 M 1 2NLJ3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIIv1ENSIONS OF GIRDERS - HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING % MATERIAL OF CBRvWEY IS BUU DING ON SOLID OR FILLED LAND:' IS BUILDING CONNECTED TO NATURAL GAS LINE- m m m m V VJ 0 m C � d CO210 Q CD n Z y cD o -a CL r- c2 CD CL = y ac O c c CD CD o CL CD CD O CD w w 23. C CD ca CD d O y �0 C v CO) O 'CD Z CD o 1. oCD 0 CD cn n O cn n O cnz by o: `I 0 O CD O J=3 O CLc m m CL CC7 C O N C 0 N H m C• N O CT L= �. CD »m o ='dd= d CD Q � go CD N O ? CD = m o 0 O N �o� ? N - n � � �m W CL CD N aCD �• m co, 90N =_ CL p� N = m c, WO N f Ne T ffin N O CD I a CD W a �4 •w co co C2 mCD CD •dr N i CD :I •"2A O O CD O ' _ � o CD .s C) . CD CD CD 1 - W y m C CD d 03 2 V CA C3 o=: C3 y 9 0 0P=h **fir TO I o c CD C/J D ;'l ►z-3 m ny i1 f' 0 O a z co atz � OQ n � H w G ` I o c CD ►z-3 w O a z co atz � OQ n � H w G ` G G 0 r O O I o c CD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print Name: f w\ U / �4.X�6 Ae -v-,V—ek Location: CityPhone 1 y - Hr.Otot�t,f � 1 Q -1y ' 6tto F-1 am a homeowner performing all work myself. F -1I am a sole proprietor and have no one working in any capacity �am an employer providing workers' compensation for my employees working on this job. Company name: �MA-- se e -CA Lc3 1rc Address _zzLo ca� e, �,_✓U.., ' 0'ZOv Company name: Address City: Phone #• Insurance Co. _ Policv # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as 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. I do herby cerhhS�under ttkpains and penalties of perjury that the information provided above is true and correct. Z Print name\a.>�Voc�R. Phone # 54 i,Sts'6tek Official use only do not write in this area to be completed by city or town official' 0 Building Dept ❑Check if immediate response is required Building Dept 0 Licensing Board 0 Selectman's Office Contact person: Phone #: 0 Health Department 0 Other FORM WORKMAN'S COMPENSATION 6 e �w NOD �f Q. O , HOME IMPROVEMENT INSTALLATION CONTRACT �. Branch Name: t, � r•L– ` ,tL%4v I.,' Date: 7 Branch Number:, f _ _--� Job #: Installation Address: I: Home Address: `'ed -'u" t (if different from installation Address) .i_ 1 Sold, Furnished dt Installed by Thr_ Home Depot Installed Sales 345A Greenwood Street, Wvlcester, MA 01607 Toll Free (800) 657-5182; (508) 756-6686: Fax: 508-756-2859 Federal ID# 75.2698460 RI Cont. Licit t"27 CT Lich 565522 MA Home Improvemen(Ccintramw Reg. 0126893 i Ld q4 may! mss. n i City State ip License: Work Phishv. Home Phone: 4= 1 4 ( (Cf (if eir7 ;''moi I ("t17*- J. City .. State Zip •r k84f4.£, Informase tion I1We ("Purchaser"), Ke owners of the property located at the above installation addr0s, of"fer to s.• � contract with The Home Depot ("Home Depot") to furnish, deliver and arrange for the installation of all materials as described on the attached Spec Sheet # , incorporated herein by reference and made a part hereof. l Home Depot reserves the right to cancel this contract if, upon re -inspection of the job, Home Depot determines that it cannot perform its obligations due to a structural problem with the home or because work required trY complete the job was not included in the contract. CONTRACT AMOUNT $_ *LESS DEPOSIT BALANCE DUE , ON COMPLETION $—I i -�_- •23% or Contract Amount due upon execution or this contract (unless project is financed through Chevy Chase, in which case no deposit is required). Indicate Payment Method For BALANCE DUE ON COMPLETION //IL c itc- DEPOSIT PAYMENT OPTIOS (Subject to fund verification and/or credit npprovai.l Check, Cashiers Check or US Postal Service Moncy drdt:r (made payable to The Home Depot). 2. Credit Card* and/or other payment options - Circle Cilie Below E.s Mastercard Discover American Exptess Home Improvement Loan Home Depot Credit lard i Available Credit: $ i HIL h HDCC ONLY) Aec4:'09d)l., LI22lr'.. k -Exp. Date: _(-,f"'fJ[•' y.�.�_ Name as it appears on card=- ,.,�iUL.'.t..''��_ *By mylour signature below, I/We agree to allow The liet Depot to charge the above rofFxfice0 credit card for rhe deposit indicated Ji 1 A. ;' Cardholders Signature ' Daie If this is a finance transaction, the agreement for financing is contained in a separate document, which is inccirporated herein by Reference, and made a pan hereof. At -Home Services Credit/Loan Application Ref. #__ Purchaser agrees that, immediately upon satisfactory completion of the work, Purchaser will execute a Completion Ce ficand pay any balance due (unless the job is financed, in which case, upon submission of the executed Completion Certificate, Home Depotatc. wdl be paid in full by the tender). Purchaser also agrees to be jointly and severally obligated and liable hereunder. For Mass, Rea{dents Only: Contractor, at owners expense, shall procure all permits required by law as follows: Owners who secure their own permits will be excluded from the guaranty fund provisions of MSL Chapter 142A. IJnle#s otherwise noted within this document, this contract shall not imply that any lien. or other security interest has been placed on a residence. Entire A&Ctalient : This agreement and its attachments, including any financing agreement, contain the complete agreement between the parties and can not he amended or modified unless in writing in a separate agreement Signed by both parties. NOTICE TO PURCHASER Do not sign this contract before you read it. You are entitled to a completely filled-in copy of the contract at the time you sign. Keep It to protect your rights. Do not sign toy Completion Certificate or agreement stating that you are satisfied with the entire project before this project Is complete. Law prohibits home repair contractors from requesting or accepting a Completio Certificate signed by the owner prior to the actual completion of the work to be performed under the contract. You may cancel this transaction at any time prior to midnight of the third busitsess day after the date of this coy Cancellation for an explanation of this right. 'There will be a service charge equal to 23% of the contract cancelled by Purchaser AFTER the third business day. BY MY/OUR SIGNATURE BELOW, VWE AGREE TO BE BOUND BY THE TERMS OF THIS CONTRACT RECEIPT OF A COPYOF THIS CONTRACT AND TWO COMPLETED COPIES OF THE NOTICE OF CAN( BY MWOUR SIGNATURE BELOW, VWE UNDERSTAND THAT THE AGREEMENT IS SUBJECT TO RE CREDIT HISTORY AND VWE AUTHORIZE HOME DEPOT AND RMA HOME SERVICES, INC., A HOME. DE CONTRACTOR, TO VERIFY AND REVIEW MY/OUR CREDIT RECORD WITH AN INDEPENDENT CI AGENCY AND RELEA" THEhMROM ALL LIABILITY INCURRED FROM INADVERTENT OMISSIONS OR SUBMITTED BY: L' Date: / ') '—" e onsu tanr� 'act. See Notice of Count If the Job is ACKNOWLEDGE CION. EW OF MY101IR )T AUTHORIZED DIT REPORTING tRORS. P,fVC ACCEPTEDBY,�,•;, f llT Homeowner l'- Date: I N Homeowner r1 p"1 NOTICE: ADDITIONAL TERMS, CONDITIONS AND WARRANTIES ARE STATED ONTICE REVERSE SIDE AND XRE A5LR7' OF�4 HONG&& White - Branch File Yellow - Customer Pink - Saks Consultant 0110.02 SA -SC �1' J 6 E. \`I A a e a v a 'A as u N REM # N Q m m r r z L' a m CL 1w )eco o m a zr N Cm `� =r fit Cr C A Sa E 0 cp C3 C � m oD Cr ::I Q m a N P C N a e a v a 'A as u N REM # N Q r N 0 � � x 0 C a vi m A H Color d � Q spa y i C ro N m 0 m � � 1 ; C I o J-TITjype 0 �Q g° 4 Q� (% 72 7 Q � w 7, � n x r g fa fa N C3 C � m oD Cr ::I Q m a N P C �� �► �+13� ►fli161�, OiRT•IFICATE OF LIABILITY INSURANCE QATSlid7W e rm +t inn APPUED R18K SER`/10E3, INC. P.O. SOX 28� 900 SAN FRANC POO, CA 94129-1900 RMA QUO MEERVICES GPS DELAWARE, INC. 3200 Ct3an LLI RIA PARKWAY, STE. 200 ATLANTA, 39339 03A THE, M MI DEPOT INSTALLED SALES V lii)S1UA1;Fi8 AFFORDING CDVI:OBAGE NAIC St INSUAEAA: iAIMAHIMA 1512E%&V%,r ^r LNftAalll a■er.. 11ME POLIMES OF INSURANCE USTED BELOW HAVE 89SN iSAJED TO THE iNSUREUNAMED ABOVE FOR THE POLICY F011100 INDICATED. NOTWI'THsTANCANa ANY F(MuImEMW, TERN OR CtltJCiMON OF ANY CONTRACT OR OTHER OOMMENT WITH RESPECT TO WHICH THI& CaPrIP)CATE MAY DE MUM 014 1 TAY PSATAM. THS E INSIRNJCAPIROED BY TME POL GIIES DeSCRI®E5 HERSIN 19 &UiUECT TO ALL THE TERMS, EXCLUSIONS AND MNoMoNB OF SUCht POUCIIa4. AQQF1IeGATS:URAiTJS 414CWN MAY HAVE BEEN REDUCED BY QA10 CLAIM. •'....--1 r—.--,—:= s-r_—ems.- -•-• ..�...._--�,.o.�._-..�_-- Yens.�Rbiap�pjj�f UleaEilCNtj1'G'L,N-ERALItAmli.Bi: r-- CU1A/i OCC"sq RI+L' ASJYgMONUEIFA{p�{tRY t�--- i'ANY AU 10 IRcxEcuiaD�luTGs i�HIM AS.'TO� wh4whi D �VTQS II GARAGR UANWly, ANY A1dm �',,�E,Y,,A,E,AgVl1iM79/1�` '�g^iJ�ABItA'Y ' OCC:SR 1 „ A;ma MADE 4 F De:rucTl@tr ; ti1lat�x�ac Ew ANDAwD T Ni6E IwSPLAAd161TY MY ONOFt.I�e g11rPA Sv1Ex>QCL ; i dE QA*,capn16rNytEw KIM,` CAGbi RpkwCG 1 i ■ 1 iii LIES IXP PIRSONAL1ADV1N,JURY gALAiy RCCA k i J oDuc" �1oPAGG ;s 6 CCIAtis o)$WG1IWMIT f !eA rd.naJ RY - -- lP0Gr ov ' 6ppiLvINJUKY � L lrer+xaK11> I i PROPFJTfvOAMn� � . I7arsedG�ntt WTO Br(LY•IiAACC.'P,EVT S -- ------'- 1 OTWERTNAN JA ACC a .� i i AuTp(�Y: I m lM.ek 025-0}000503 i U k3GpiATTOPr OF O�RiiAtON>b Y LOGATiONS/ VFtiiCLEO! E7tCt1JS!(r9t4 ACC Jii DY EVIDENCE OF COVERAGE RMA FiQME54 SERVICES OF DE PIRA HOME DEPOT 3200 CCSB OALiLERIA PARKWAY, STE. 200 ATLANTA, GA 2.0339 25 (2001JU) LAI IL;L 3/10/02 I 3110/03 Ai SHOULD ANY Of -INE AGOVE DESCA10kD POIIOU of CAliegU.lD @EFd1R64 TH! n7umRATKU 't UL? A`L' "NQ I,at 401 WML ENatAYOA TO k&WL -30— CAYB wla "hi NOME TQ TNG CEAYIFICATE NfXt4M NAM15 TS TH6 Len$ oLfT iAiLURg Tp w so VAv Impm NO OiUGATvN OR LAMP OF ANY KiNO Lwow Thi$ 1kSumsR, rrs ACIENT3 OJ 00044w Li OR 11 r 7 Board of Euiidt+M ekaswodotat and Staodordo HOME iMPROYCOgNT 00"TRACTOR RptstroVon: 126303 EWWII W: */&2004 TAW: Suppieronant word Hone Oepot At -biome UNcee PAUL VENTRE 3200 COBB GALLERIA PKWY Y ON Z2�_. -+P�jrw- ! ALTAjYTA, CxA 30339 Adaete�t -a ACORD CERTIFICATE OF LIABILITY INSURANCEDATE F0/17/2002 PRODUCER Janice Christo Insurance A �' 1114 Broadway Somerville MA 02144 - THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE INSURED ' Wright Electric Co., Inc., 84 Church Street Wilmington, Ma. 01887 — INSURERA:Itt Hartford INSURER B: Norfolk & Dedahm INSURER C: INSURER D: INSURER E: I401N A _1AL1:.s THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MM/DD/YY POLICY EXPIRATION DATE MM/DD/YY LIMITS A GENERAL LIABILITY 08UUCBU2479 08/01/2002 08/01/2003 EACH OCCURRENCE $ 1,000,000 FIRE DAMAGE (Any one fire) $ 50-,000 X COMMERCIAL GENERAL LIABILITY CLAIMS MADE � OCCUR / / / / MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 1,000,000 POLICY JECT LOC B AUTOMOBILE LIABILITY BA8002828 05/02/2002 05/02/2003 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ X ALL OWNED AUTOS / / / / BODILY INJURY SCHEDULEDAUTOS (Per person) $ 250,000 BODILY INJURY HIRED AUTOS / / / / NON-OWNEDAUTOS (Per accident) $ 500,000 PROPERTY DAMAGE (Per accident) $ 100,000 GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO / / / / OTHER THAN EA ACC $ AUTO ONLY: AGG $ A EXCESS LIABILITY X OCCUR EICLAIMS MADE 08UUCBU2479 08/01/2002 08/01/2003 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 $ DEDUCTIBLE / / / / $ RETENTION $ A WORKERS EMPLOY RSOMABLSn ION AND / / / / X TORY LIIMITS ER E.L. EACH ACCIDENT $ 100,000 OBWBCCDO657 05/18/2002 05/18/2003 E.L. DISEASE -EA EMPLOYEE$ 500,000 E.L. DISEASE - POLICY LIMIT $ 100,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER ADDITIONAL INSURED; INSURER LETTER: CANCELLATION TOWN OF N . ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE ELECTRICAL INSPECTOR EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL TOWN HALL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT N . ANDOVER MA 01845— FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE AUTHORIZED REPRESENTATIVE / / . ACORD 25-S (7197) ,% ,�" © ACORD CORPORATION 1988 qT. INS025S (9910) ELECTRONIC LASER FORMS, INC. - (800)327-0545 t' Page 1 of 2 Location / �,A //1(- � /) 5 , , /` L No. -S 17 Date Check # of) TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ 36) - Foundation vFoundation Permit Fee $ Other Permit Fee $ 3a— TOTAL $ 16111 /W, Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING 77777717 Tis„ ' . #er Utilia lC7s�}]ni BUILDING PERMIT NUMBER: t3 - DATE ISSUED: SIGNATURE: ��-"— Building Commissioner/I for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: l 0 1,klti we rt. 161 1.2 Assessors Map and Parcel Number: 42f3 00/0 Map Number Parcel Number / A /11J a ✓e � 4J, /1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record 13, 4 &Z-41 ✓l - Name (Print) Address for Service GI %if— �a�l7--o�f0 Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construcfio ttpervisor: - Address Signature Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone Mo M Z O v n M O Z M 90 O mn ic r v M r _r Z ^ Q SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......0 No ....... 0 SECTION 5 Description of Proposed Work check all applicable New Construction ❑ Existing Building Repair(s) Alterations(s) ❑ Addition 0 Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I Item Estimated Cost (Dollar) to be Com leted by permit applicant OMCIAL USE ONLY 1. Building e�L, -70d v0 (a) Building Permit Fee Multiplier 2 Electrical \ (b) Estimated Total Cost of Construction 7Q • U O 3 Plumbing Building Permit fee tel X (t,) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT Jlas Owner/Authorized Agent of subject property Hereby authorize C to act on My bel in all matters relative to work authorized by this building permit application. &`' -zoo b! Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Signature of Owner/A ent Date ` NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR T EMBERS 1 ST2 ND3 RD SPAN DIN ENSIONS OF SILLS DIN ENSIONS OF POSTS DIMENSIONS OF GIRDERS 11EIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHFv1NEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Tel: 978-688-9545 Town of North Andover Building Department 27 Charles Street North Andover MA 01845 HOMEOWNER LICENSE EXEMPTION Please print../� , DATE/ Y `-4 * �/(J� 3 JOB LOCATION k h/-/1-1(eX_ Af (Otye /V A J 0 OX P( i1"-7 Number Street Address Section of Town "HOMEOWNER Number Home Phone Work Phone PRESENT MAILING ADDRESS Me /t ��/ SG, �1' A/f /V JOde-It /4� O City Town State Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings of six units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. (State Building Code Section 109.1.1) DEFINITION OF HOMEWOWNER: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one to six family dwelling, attached or detached structures ac- cessory to such use and and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned "homeowner" certifies 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. rr HOMEOWNER'S SIGNATURE C I4(�AIL4 I I l G.LtO I�CJAI1 td -7--o AA APPROVAL OF BUILDING OFFI Note: Three family dwelling 35,000 cubic feet, or larger, will be required to comply with State Building Code Section 127.0 Construction Control. n C/) m m C/) 0 m .Voco CD o _ CO2 10 CD O 7 L—J CO) _ O _ CO2 M n C O y d n CD 0 CD CD CDH CO) 0 CD C 0 CO) C2 cr Cos aO S.a y =tm n m Cl) cm m C2 06 m Z y m �* y° =r CL 0omCO o N O .+ N il Erm _ R � p cc* `r O O y: n O —CO 0 CD r a Om :� .�-vi *4100 /� A o CD rv^J m CA r m C7� n � y z c ad ch ►•� H p� OCD cn . C N d N CCD z r CD C C* cn H m�. co cn cn 02 CD a� Crf : c o CI O d C " O M ro C) n n O -- G O � r d C� CO 'o F y E° O a 0 d O W v I r Q r H 0 9 O C CD a Date. .7 ..-. /.. G ?. . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .... .� (�l. ..... �� . ............. has permission to perform .... l ............... plumbing in the buildings of .... �? .< <. ��.!/�. t ............. at .. /c... ,(. ,�9. �. /0>/!. . l .��.......� ... , North Andover, Mass. Fee. IV.C... Lie. No..1,2.j�.?.�. ........,Y:. .. ....... PLUMBING INSPEECtZR Check # 5537 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location !L WJALLIev— _ O )O'i z - a I Owners of Date Permit # y^f 1 7 Amount Ali C_ New Renovation 0 Replacement Plans Submitted Yes No • ; (Print or type) Installing Company Address .I2fo Check one: Certificate & INS "--yq'—A6❑ Corp. 0 Partner. . B__Firm/Co. Name of Licensed Plumber: ,_ IC#f'A JCd/ 1 E[r(.vryi/1��J Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy SL_ Other type of indemnity 11 Bond Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner El Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and ins ions pe r ui ed for this application will be in compliance with all pertinent provisions of the Massachu S Pl g Code and Cha 142 of the General Laws. BySignature of LipenseaPlumber Type of Plumbing License Title City/Towni nsm a Master Journeyman ri APPROVED (OFFICE USE ONLY MzW;:k7j1MMMMMMMMMMMMMMMM MM mmmmmm (Print or type) Installing Company Address .I2fo Check one: Certificate & INS "--yq'—A6❑ Corp. 0 Partner. . B__Firm/Co. Name of Licensed Plumber: ,_ IC#f'A JCd/ 1 E[r(.vryi/1��J Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy SL_ Other type of indemnity 11 Bond Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner El Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and ins ions pe r ui ed for this application will be in compliance with all pertinent provisions of the Massachu S Pl g Code and Cha 142 of the General Laws. BySignature of LipenseaPlumber Type of Plumbing License Title City/Towni nsm a Master Journeyman ri APPROVED (OFFICE USE ONLY