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Miscellaneous - 1050 FOREST STREET 4/30/2018 (2)
1050 FOREST STREET 210/105._0000.0 7704 Date... . .. ... . HORTh o? TOWN OF NORTH ANDOVER 4 PERMIT FOR GAS INSTALLATION �9SSACHUSESS This certifies that Q( L . . . . . . . . . . . . . . . . . . .. has permission for gas installation ,. .(� . .1.�a., in the buildings of at . .l.caS 0. . .F0 North Andover, Mass. Feef,30.ao. . Lic. No..}.0.7.'�. .. . . :.f. . GAS INSPECTOR Check# [� MASSACHUSErIS UNIFORM APPLICATON FOR PF.,RMPr TO DO GAS F rrnNG J (Type or print) Date Cp ' NORTH ANDOVER,MASSACHUSETTS 111 Building Locations 1 VSo fa a_&4 s4z e e 'f' Permit# Amount$ Owner's Name �.��V 7 2— New 0 Renovation ❑ Replacement ❑ Plans Submitted ❑ x w 9 � F a Wj W OF OU � F x a z W co� Ew. W U z a � a WO W W � O O W O W xF A U .a U W > A a F O SUB -BASEMENT B A S E M ENT U/1 �C 1ST. FLOOR L 2ND . F L O O R 3RD . F L O O R 4 T H . F L O O R 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . F L O O R (Print or type) ` Check one: Certificate Installing Co any Name d C/ iv d> �G3 Corp. C �7 C Address z V/-V,4"4r C/ ❑ Partner. L Business Te ep one ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter `?%G/� INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No❑ If you have checked Les,please indicate the type coverage by checking the appropriate box. Liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I 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 I have submitted(or entered)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 Gas Code and Chapter 142 of the General Laws. Signature of Licensed Plumber Or Gas Fitter By. ❑ Title Plumber ?0 , City/'Town Gas Fitter License um er Master Joume man APPROVED(OFFICE USE ONLY) y COi1A�111ONW_EALTti OF MASSACHUSETTS s PLUMBERAND GASFLIN TALER LICE N ps 0 A$9rPPc9AfSt � I MICHAEL J NOVICK 4 BLAIR TERRACE MA 01960-51062 P.EABODY . , OEM i I I I ���V7 �. r I STNUT STREET UNIT 9 NORTH ANDOVER HESTNUT STREET NORTH ANDOVER HESTNUT STREET NORTH ANDOVER HESTNUT STREET NORTH ANDOVER HESTNUT STREET NORTH ANDOVER HESTNUT STREET NORTH ANDOVER HESTNUT STREET NORTH ANDOVER .HESTNUT STREET NORTH ANDOVER HESTNUT STREET NORTH ANDOVER HESTNUT STREET NORTH ANDOVER HESTNUT STREET NORTH ANDOVER HESTNUT STREET NORTH ANDOVER HESTNUT STREET NORTH ANDOVER HESTNUT STREET NORTH ANDOVER HESTNUT STREET NORTH ANDOVER HESTNUT STREET NORTH ANDOVER HESTNUT STREET NORTH ANDOVER HESTNUT STREET NORTH ANDOVER HESTNUT STREET NORTH ANDOVER NDOVER STREET NORTH ANDOVER HESTNUT STREET NORTH ANDOVER Y HESTNUT STREET NORTH ANDOVER HESTNUT STREET NORTH ANDOVER HESTNUT STREET NORTH ANDOVER ESTNUT STREET NORTH ANDOVER ESTNUT STREET NORTH ANDOVER ESTNUT STREET NORTH ANDOVER ESTNUT STREET NORTH ANDOVER 0 MAIN STREET NORTH ANDOVER 0 MAIN STREET NORTH ANDOVER HESTNUT STREET NORTH ANDOVER HESTNUT STREET NORTH ANDOVER N SOUND PARKWAY NW BOCA RATON HESTNUT STREET NORTH ANDOVER HESTNUT STREET NORTH ANDOVER HESTNUT STREET NORTH ANDOVER ESTNUT STREET NORTH ANDOVER ' 0 33 Date��...�.�i.�/....... f NORTH, r "=f 3ro`� .o-•"!.."°cam "' TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ,SgAtMUSEt This certifies that �� �Q ......................................... . .............................. has permission to perform ............. .. v/S f r� �wiring in the building v .. .. ............................................. n j , at..,l.Od�S..�'�........1.....f.................................................� ,North dove� s. Fee. ../.G... ..... Lic.No�� 1� f .. `� :fTf*/ G ... .... ���yyy •� � ELECT CAi�INSPECTOR Check # y5 - 'i :3 r Commonwealth ofMassachusetts t Official Use Only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked _ [Rev. 1/07] (leave blank APPLICATION ®R PERMIT TO PERFORM ELECTRICAL All work to be performed in accordance with the Massachusetts Electrical Code(MEC) 527 CMR 00 WORK (PLEASE PRf1Vl.ININK OR TYPE ALL.flV ATIOl� gD�ge. City or Town of: NORTH ANDO�� C By this application the undersigned gives notice of his or her intention to perform the elpeqtor ental work Wires: below. Location(Street&Number) Owner or Tenant Owner's Address _$' Telephone No. r Is this permit in conjunction with a budding permit? Yes Purpose of BuildingNO ❑ (Check Appropriate Box) ��S �'� G Utility Authorization No. Existing Service Amps / _Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps _-__-L-__Volts Overhead❑ Und rd Number of Feeders and.Ampacity g ❑ No.of Meters Location and Nature of Proposed Electrical Work: !7 Fav el Com lesion of the followin table may be waived by the Ins`---tor of Wires. No.of Recessed Luminaires No.of Ceil:SusNo.of p (Paddle)Fans Transformers Total No.of Luminaire Outlets No.of Hot Tubs ISA Generators KE VA of Luminaires Swimming Pool Above ❑ In- .o mergency lghting d. nd• Batte Units —, No.of Receptacle Outlets No.of Oil Burgers ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and No.of Ranges Initiatin Devices . No.of Air Cond. Total No.of Waste Disposers Heat Pump Number Tons ns . No.of Self,-Contained No.of Dishwashers Detection/Alertin Devices Space/Area Heating KW Local❑ Municipal No,of Dryers Connection 0 Other r3' Heating Appliances KW Security Systems: No.of Water No.ofo. No.of Devices or E trivalent Heaters ' Bal as Data Wiring: ec Si s Ballasts. No.of Devices or E trivalent No.Hydromassage Bathtubs No.of MotorsTelecommunications Wiring: Total HP OTHER: No,of Devices or E trivalent Estimated Value of Elegy trical Work: Attach additional detail if desired, oras required by the Inspector of Wires Work to Start (When required by municipal policy.) / 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 Z2"'BOND ❑ OTHER ❑ ,(Specify:) . I certify, under the aims and enalties o FIRM NAME: (Cl P fperor that he informat on on this application is true and complete. /� ain�C G � Licensee: F C LIC.NO.:- (If O.: 32 I a applicable, enter "exempt"in the license number line.) Signature (f PP LIC.NO. 9OT� Address: Bus.Tel.No.: 6 *Per M.G.L c. 147,s.57-61,securitywork requires erartment of riblet Safety 1 S License: Lic.No. Alt.Tel.No.. ;3 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑owner coverage normally Owner/Agent Signatureaent Telephone No. PERMIT COMMONWEALTH OF MASSACHUSETTS , jOF �LECTRiCiANS AS A"REGyJOURNEYMAN ELECTRiCIA ISSUES THISJJ TENSE TO HRYSTTOPHE=R" A P�Z'pRK _- m 4:4 LAWNDALE AV'E " §AUGUS . MA 01906-2743 M • E t 36227 -E 07/31/10. 3098.9 J Fold,Then Detach Along All.Perforations s I i I ff I I f The Commonwealth of Massachuse&s Department of Industrial Accidents Office ofInvestigations 600 Washington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Bu lders/Contractors/Electricians/Plumbers Applicant Information Please Print I.e `bl Name(Business/Organization/Individual): Address: City/State/Zip: Phone#: F2. re you an employer?Check the appropriate box: ❑ I am a em to er with 4, Type of project(required):P Y ❑ I am'a general contractor and Iemployees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction ❑ I am a sole proprietor or partner- listed on the attached sheet. I �• ❑Remodeling ship and have no employees These subcontractors have working for me in any capacity. workers' comp.insurance. 8' E]Demolition [No workers'comp. insurance 5. El We are a corporation and its 9' E]Building addition required.] officers have exercised their 10-[1 Electrical repairs or additions 3.❑ I am a homeowner doingall work right of exemption per MGL 11 P Plumbing repairs airs myself o w g eP or additions Y [N workers'comp. c. 152, §1(4),and we have no insurance required..) t 12. Roof repairs q ed. em . , ❑ cP ] employees. [No s=�orkeis COMP.insurance required.] 13.❑ Other `�^Y aYglicant hat chec:�s box yl rant also cut the section below shewing heir Workers' _ ;.Any who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and 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: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may Investigations be forwarded g ons of the DIA for insurance coverage verification. Y rwarded to the Office of _ I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Sip-nature: Date.: Phone#: E only. Do not write in this area, to be completed by city or town official. n• PermitUcense# hority(circle one): Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector son• Phone#• Date.... ........................ kORTH TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING S CHUS This certifies that ........ ................................................... has permission to perform .... .. ....................... wiring in the building of.../It ....... ......................................... ................. ... ...?/..................... .North Andover,Mass. Z?........ ...... at... .. Feel.-�........... Lic.No(�J�,J P........................................... EcrRicAL INs Check # (''.es � e a � ee a a� ���o`e o :� s,�• i�,s a e;,e�, ao �i°uu an raFwa 'Mda MOW Al . ao N. e uN s Commonwealth of Massachusetts Official Use Only ' Permit No. / /09s Department of Fire Services 6-1 Mo kvi Occupancy and Fee Checked 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(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 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) /Q �Q 4L`'S Owner or Tenant 1C*)%JG ( - Telephone No. Owner's Address %- Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building ,L/d�/j/f[�� 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: C1Cn od Completion o the ollowin table maybe waived by the Inspector of Wires. No.of Recessed Luminairesy No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA • No.of Luminaires Z Swimming Pool Above ❑ In- E] o.o mergency Lighting rnd. rnd. Batte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices t Tons g 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 , 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: d Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: &"Q (When required by municipal policy.) Work to Start:�?�s(! 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 cove 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 oferJu that the information on this ap lication is true and complete. FIRM NAME. I4C- C.2r LTLL�:GT��t C I. LIC.NO.: G- ?,"F 7 Licensee: �,�k Q 1-b LTi L T r Signature LIC.NO.: (If applicable, enter" empt"in the ligense number line.) Bus.Tel.No.:/a 11� S -3506 Address: C' -ldt�°Cf/' '-� v(rC i(.{`�'f Alt.Tel.No.: *Per M.G. 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's agent. Owner/Agent Signature Telephone No. PERMIT FEE:$ `�. ,f �` ©� �.. �� � � � r. h .� .� The Commonwealth of Massachusetts t ! Department of Industrial Accidents .. Office of Investigations °•°�'' 600 Washington Street it la1'� U Boston, MA 02111 l�1 www.ntass.gov/dia . Workers' Compensation Ins trance Affidavit: Builders/Contractors/Electricians/Plumbers Alanlicant Information Please Print Legibly Name (Business/Organiaation/Individual):_ i�fj�, L �rC 1 Address:_ 4 7 /4-16&4 5 City/State/Zip:��/,(�SH-f�l Phone Are you an employer?Check the appropriate box: Type o roject(required): I.0 iemployer with 4. ❑ 1 am a general contractor and 1 6. New construction 2l poyees(full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet.t 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for mein any capacity. workers' comp.insurance. 9. ❑ Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its 10. Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 1 L❑ Plumbing repairs or additions myself.[No workers'comp, c. 1.52,§1(4),'and we have no 12.[] Roof repairs insurance required.]t employees. [No workers' 13.[3 Other comp. required.] p q ] *Any applicant that checks boil#I 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 of the sub-contractors and their workers'comp.policy information. I am an employer that is.provuling workerscompensation insurance for my employees: Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. * I do hereb ify der the p in p res of perjury that the information provided above is true and correct. Si ature. Date: Phone#: 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 i Contact Person: Phone#: 1 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 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 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,not1he 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 bum leaves etc.)said person is NOT required to complete this affidavit. „ The Office of Investigations 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: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. #6I7-727-4900 ext 446 or 1-8.77-MASSAFE Fax#617-727-7744 Revised 5-26-t15 www.mass.gov/dia Date...P.'.. �aORTM °`t"`°:•'"° TOWN OF NORTH ANDOVER ` p PERMIT FOR WIRING �,SSACNUSEt - This certifies that ...`.:.:.:....................................... ...,......................... has permission to perform ...r- '���� ............................................. • w wiring in the building of.......... `? - ...................:................. ``5 p � ...,North Andover,Mass. at........... . ......................................................Q0AFee..��............. Lic.No........... ....... ......... CTRICALINSPECM Check # 9L $ d '16 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No.NMI U L--' Occupancy and Fee Checked 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(MEC),527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: l7/_= � c� 1 �/7�pS FELtZ 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) � - Owner or Tenant 4=,0 1,1^/70 U—rT'7 Telephone No. [U-5- Owner's Address ./0,iO & FST .�Z .09 "1/ IM F—A za os' Is this permit in conjunction with a building permit? Yes ❑ No a (Check Appropriate Box) Purpose of Building 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 ollowin 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- 11o.o Emergency Lighting rnd. nd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.of Detection and Toti Initiatin Devices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices Heat Pum Number•.Tons .KW No.of Self-Contained No.of Waste Disposers Totals -��� "" '•' """""' Detection./Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal E] Other V Connection No.of Dryers Heating Appliances KW SecuriySystems:* 'a co No.of Devices or E uivalent No.of WaterNo.of No.of Heaters KW Signs Ballasts Data Wiring: of Devices or Equivalent �- No.Hydromassage Bathtubs No.of Motors Total HP TelecommunicationsWiring: ` No.of Devices or Equivalent 'i1[J OTHER:gi! ari hv- w d /�qlhLLb d Attach additional detail if desired,or as required by the Inspector of Wires.,' Estimated Value of Electrical Work: -0 300- (When required by municipal policy.) Work to Start: 2�2�'��fs 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 T' BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. �y FIRM NAME: P.r C. gFCV1?T 7-y LIC.NO.:29c C Licensee: RM fi/ lr C�X/�/C/i Signature LIC.NO.:f J p (If applicable, enter "exem t"in the license number line.) Bus.Tel.No.:1 wf-SS- Address: _ V / © Alt.Tel.No.: GYjc!�5C L*ter M.G.L c. 147,s.57-61,security work requires D artment of Public Safety"S"License: Lic.No. UO J qJ X 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's agent. Owner/Agent Signature Telephone No. PERMIT FEE:$ ;1! The Commonwealth of Massachusetts k� ! Department of industrial Accidents Al Office of Investigationst 600 Washington Street 1aii? . a/ Boston, MA 02111 ~i www.n2ws gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/organization/individual): OTC '1 — col ;r Y Address: CF-Z4 G/ -Sct3- / 83. City/State/Zip:��Lr/y /� fJ��1�G Phone#: 1' �- �j7ff- qq 5��'S� Are you an employer?Check the appropriate box: Type of project(required): L 0 I am a employer with 4, E] I am a general contractor and I 6. 0 New construction mployees(full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet.t El Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working for me.in any capacity. workers' comp.insurance. g. Building addition [No workers' comp,insurance 5. 0 We are a corporation and its 100 Electrical repairs or additions required.] officers have exercised t . heir 3.0 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No-workers'comp. c. 1.52, §1(4),and we have no 12.[] Roof repairs insurance required.]t employees. [No workers' 13.0 Others'-LUI?T TY comp. insurance required.] *Any applicant that checks bort#l 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. ZContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I ant an employer that is.providing workers'compensation insurance for my employees, Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lie.#: Expiration Date: �• Job Site Address: City/State/Zip- Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Si azure Date. 2 r 013 Phone#:0L r - �1�1-8 Z 5 O� C,�G/ G/7- 511�- 3/83 I . Of,ricial 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#• h 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 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,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 nurnber 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 r 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 bum leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations 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: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ,I• 600 Washington Street Boston, MA 02111 Tel.# 617-7274900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia Location 27 No. Date NORTH TOWN OF NORTH ANDOVER - A Certificate of Occupancy $ u. Building/Frame Permit Fee $ CNUS Foundation Permit Fee $ Other Permit Fee $ ' Sewer Connection Fee $ Water Connection Fee $ TOTAL $ .j Building Inspector ,r .70 `� O Div. Public Works r=�""'f'r-4✓i..fs'C.++'---w—••--a^--`•-Cerru+.�--'�..-r-.._...;- ,;;;" ".�, "�4^c"_-/'i,r`*!» r�. t LocationSn ►'c�� ' No. d3 3 Date —S-?S NpRTIy TOWN OF NORTH ANDOVER pfae ,stip p Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ � s�cHuSE } Other Permit Fee $ k �? Sewer Connection Fee $• Water Connection Fee $ 1 TOTAL ! Buildpfillnspecto r w 8461 L A Div.Pub' Works (76 1 ':- STLocation �>t `?�S�C' No. Date { �o�*h TOWN OF NORTH ANDOVER$ . n Certificate of Occupancy $ -X 41 Building/Frame Permit Fee $ Z2 Foundation Permit Feer $ ({�✓,�nJ s4CHUyE v.. Other Permit Fee $ Sewer Connection Fee Water Connection Fee $ TOTAL $ � #gg S c f4 tTSSBuilding Inspector ~' 7892 Div. Public Works � a 3. PEa�iIT xo.- APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 MAP 4J0. /O` LOT NO. 2 RECORD OF OWNERSHIP ;DATE BOOK ;PAGE — a ZONE a CS I SUB DIV. LOT NO. LOCATION PURPOSE OF BUILDING OWNER'S NAME / _`,N/,�,G I/, J/ A ._ /. NO. OF STORIES SIZE It OWNER'S ADDRESS D � �f n„-• D�.\� BASEMENT OR SLAB ARCHITECT'S NAME /1O 1f.CA► 1�1 SIZE OF FLOOR TIMBERS ,01ST ;Ly`Q 2ND G���1 y/�! 7T 03RD BUILDER'S NAME I.AM � � SPAN V DISTANCE TO NEAREST BUILDING Pl1 DIMENSIONS OF SILLS --- DISTANCE FROM STREET pD /Q (/ POSTS [LISTANCE FROM LOT LINES -SIDES QO REAR GIRDERS Al g - pt � AREA OF LOT FRONTAGEe�wJ V HEIGHT OF FOUNDATION � / /` THICKNESS IS BUILDING NEW yeu SIZE OF FOOTING 0 X Zdl / IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE G IS BUILDING CONNECTED TO TOWN WATER X-*�(X/ BOARD OF APPEALS ACTION. IF ANY w� •J IS BUILDING CONNECTED TO TOWN SEWER N 0 ,v IS BUILDING CONNECTED TO NATURAL GAS LINE AlQ y INSTRUCTIONS 3 PROPERTY INFORMATION PERMIT FOR FOUNDATION ONLY LAND COST SEE BOTH SIDES REGULATED BY PARA. 114.8-S. B.C. EST. BLDG. COST EST. BLDG. v COST PER 8 FT. PAGE 1 FILL OUT SECTIONS i - 3 _ Q PAGE 2 FILL OUT SECTIONS 1 - 12DA'� I Z ( 'FEE PAID W/ EST. BLDG. COST PER ROOM Odij -SEPTIC PERMIT NO. / 9� ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING . O 4 APPROVED BY (Jy ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS r. PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR f DATE FILED o"-% '•v Z N BUILDING INSPECTOR SIG TURE OF OWNER OR AUTHORIZED AGENT • F E E Z zz 00 OWNER TEL.# 66 'K-53317- .5b K-5 ` /sa CFOPERMIT FOR FRAMUBUILDING y PERMIT GRANTED CONTR.TEL.# /y 19 ATE: FEE PAID:.,,,.....,.,.. CONTR.LIC.t H.I.C.# C Iz 12Z�, T ti i BUILDING RECORD w 1 OCCUPANCY 12 SINGLE,FAMILY $roulES THIS SECTION MUST SHOW EXACT DIMENSIONS, F LOT AND DISTANCE FROM MULTI.'"FAMILY- OFFICES APARTMENTS -- LOT LINES AND EXACT DIMENSIONS OF BUILD NGS. WITH PORCHES. GA- x RAGES, ETC. SUPERIMPOSED. THIS REPLACES PL T PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE 3 1 2 13 CONCRETE BL K. PINE I' BRICK OR STONE HARDW-D PIERS PLASTER _ DRY WALL ? / UNFIN. ` 3 BASEMENT' •�AREA FULL ✓ FIN. B M T AREA i /1 '/, FIN. ATTIC AREA NIO B MT FIRE PLACES HEAD ROOM MODERN'KITCHEN _ 4 WALLS I 9 FLOORS `\ ' -i CLAPBOARDS B 1 2 3 \ - IDROP SIDING CONCRETE 'WOOD SHINGLES EARTH _ ASPHALT SIDING HARDW✓'D _ ASBESTOS SIDING _ COMMCN '•--__ VERT. SIDING ASPH.TILE • '�' J� i :f!' STUCCO ON MASONRY STUCCO ON FRAME.• ~ _ . 1 { ,Vr!'+, i ~L 1 t1 !•`� BRICK ON MASONRY ATTIC STIRS. 8 BRICK ON FRAME CONC. OR CINDER BILK. STONE STONE ON MASONRY WIRING STONE ON FRAME , - - ---- - - }' SUPERIOR l POOR ADEQUATE NONE 5 ROOF 10 PLUMBING r GABLE HIP BATH (3 FIX.) GAMBREL MANSARD TOILET RM. (2 FIX.) FLAT I SHED WATER CLOSET ASPHALT SHINGLES f LAVATORY WOOD SHINGES. KITCh1EN SINK SLATE -NO PLUMBING TAR & GRAVEL STALL SHOWER f1� ..j ROLL ROOFINGH MODERN FIXTURES / TILE FLOOR TILE DADO 6 FRAMING II 11 HEATING - WOOD-JOIST PIPELESS FURNACE ' FORCED HOT AIR FURN. {TIMBER BMS.)&COLS. U- STEAM J STEEL ffMS.'&'C0L-5ti HOT W T'R OR VAPOR t- ��, { er •� " / WOOD RAFTERS— _ AIR CONDITIONING RADIANT H'T'G (LLQ UNIT HEATERS \ / 7 NO. OF ROOMS GAS OIL -,...,+wa�w•a.,.,s�, —.8 \r Fwd�sfiD i1�-+ l B-M-T E 1 2nd -i ELECTRIC 1st €/ 13rd I 11NO HEATING y�y�� }� ,, ..,.....� ,.. ..moo hiw 3=,Tim Town oove �► =No. 033 Y ,. :�. {yyy �, flrt yy dover, Mass., o �- LAKE T ?.. �. COCMICM_w,CK V BOARD OF HEALTH Food/Kitchen 4F: Septic System ' PERMIT T BUILDING INSPECTOR THIS CERTIFIES THAT �.%n q���%At-- M6E. �luPN� 7.......... Foundation has permission to erect.4.X.1X7....CNIe.. buildings on.. ..............•....... Rough ' ................ Chimney to be Occupied as.��..E..��E1Y'c�� ` .' ��1<1.4�..... ....Z.. l(�,..� . 1�....................... e provided that the person accepting this pe it shall in every respe t conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection A er tin an( Construction of ' Buildings in the Town of North Andover. PER>IIfITO�t FOUNDATION ONLY PLUMBING INSPECTOR REGULATED BY PARA. 114.8-8. B.C. VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Z� 4 FEE PAID I Final PERMIT EXP ELECTRICAL INSPECTOR UNLESS CONS uT _ Rough Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building PERMIT OR FR&MMW Rough Display in a Conspicuous Place on the Premises — Do Not Remove DATE: LalFEE PAID:_____ No Lathing or Dry Wall To Be Done FIRE DEPARTMENT __Until Inspected and Approved by the Building Inspector. Burner PLANNING FINAL CONSERVATION FINAL Street No. Smoke Det. SEWER/WATER FINAL DRIVEWAY ENTRY PERMIT 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: 4�zoivvr� Phone LOCATION: Assessor's Map Number Parcel t� Subdivision Lot(s) 7 Street D2 s St. Number 105D ************************O ficial Use only************************ RECOMMEND TI NS P)F TO AGENTS:1121, 9 Date Approved Conservation Administrator ,, ^ Date R( j ected l Comments 30 JY ; ��• V"�', kr ��►a°,�1Lt. O�Q40 Date Approved Town Planner Date Rejected Comments Date Approved Food Tnspect r-Health Date Rejected Date Approved Septic Inspectoor-Health Date Rejected Comments17-y g�- 4V X ZJ YS S Public Works - sewer/water connections - driveway perm / Fire Department1 4:2 Received by Building Inspector Date ei ,-- PLA •;. / 100 � • I I '- - - - -- - - -- - - - --� � ` OMMONWEALTH OF RADIUS / 0D� WEL t i HELL \w �F MASSACNUSfns +�y ++ 1 PROPOSED AREA6 AC.f / _ - - - - -- - ,i C.P•A• / s / r FN p• DRAIN / INV 96.0 �� 1 'o,Q i 31 ' 100, BUFFER ZONE • Y 1 ` 1 W y -- --- / . LIMIT OF I , •� F �', 30 \ ' \ 0� SUBSOIL 3 ti o \ PSOIL AND \ / a' h CLIA, OF _ SEE NOTE 2) ,..' V1. NG TO LIMIT OF' • X10, AROUND TRENC,HES s'-'s �. ..� : 31 RCS O RESERVE AREA \� 42' ' op. \ T \ AL-LON '. _ \ ERC 3 1500 c IN, \ \ / -BO ` . . SEPTIC TANK it4' . • , O \� ' - �� � / • " _10Q•..: NOTES wm+� to FT / 1Atd06 RES( .SE 'AREA ».. 1 00 NG WET oR WATEI�ORRRE \ SYSTEM 1 TP 5 \ of THE s E �ro TppS01L 5u p!PERV10 RU►� _ v, E EXCAVARON_ 4" 'moi:\ O _.♦ - - - _ - i » .•^'_ �.i 5.,1 k.'`• "t.' J i ,r N T I - r.. - - .'. ,.: • .�j(,� \ s:" N. :..` .�. •-:.*.- a .. .. 1'f w .. l ,,: t-J,t• .•,I" �. •gyp wV•_-� y r� Y .• _ .. .y... d ...� ..•1 Y .� . ?ti+ - �. .pig �:. ',f, ,� $..s °I"'h j• .h ,r .,;�, .h � ..t: ..r, ,� s 3. c+ry, ,:,3. �°„ ,� ,,� •„ � �� ,?;7�t�.C,;- r' -:? �'''•�. {' ra.. `?y'., r, +i.. .y ..�•'r'f �:A .y, 'a, m •,!,t �� "x�.,.. �� ':f' .t: 'D' ,�ycr i• 4)qy� `` i ->.. 9 'z n., t. w°cM 'I' ,;'. •.!F�s.. �. y �+'•:S>,+i $. "�}'i-�.ryt. :6. . ..{. t ww�'�'-.. ijr� .a �y 'h I. �I'. i�. .,,,,tea :�� •ice' '19.i•. y,:)•-. �'J^`,t, 1: �A�., .,+�' ..fir;,:, _ .Hz'S �TS;• r :�'U'.� r :5./ ;X 7^.••rt e .Ri•.y� .w. ; .1t .q. ��. ♦� ��.Y`. �I:v �i' M1'rYfY fiw./Q!���5, b _cs':/l ,1 �A nt� e+�` �.^T � -4 v^'.,Q,4:' y. •� r�. ,pjy:�.�, .;jw ;1:.. q5i;.fir; ��"'}.� ,� �'P•,r v ' � �ysr. a'�C yW4N � � 1r�,>t` 7s' - ac ,W;J f ' • X39� � N N � \ \ m 0 us LOT 3 , FEMA ZONE-A \ / FEMA ZONE-X o / ti �� M1 LOT 4 I3.16 ACRES \ • W N b I_�f\ IRON Z I PIN / 10" POURED FOUND IPI CONCRETE / FOUNDATION FOUND h , h `t, N\ X30 SE=&A �R�S JPO+•w �- T w IRON k (PVeU s 9O FOUND - �IRON LOT 5 C NPIN V �36'OO' W - FOUND gRfge� �oTH STREET s 61-90.47- w 67.31' *LOT 4 LIES WITHIN A RESIDENCE 1 (R-1) ZONING DISTRICT* NOTES: CERTIFIED PLOT PLAN THE PROPERTY LINES SHOWN WERE OBTAINED AN OF M, OF LOT 4 FROM A PLAN ENTITLED "' PLAN OF LAND ,� LOCATED IN NO. ANDOVER, MA," DATE 8/31/94 y DANA , FOREST ST., N. ANDOVER BY CHRISTIANSEN & SERGI, PLAN #12455 N.E.R.D. BTAtiuyLEY OWNED BY: AN UNIMPROVED PORTION OF LOT 4 LIES WITHIN No.38044 COLONIAL VILLAGE DEV. CORP. ZONE A. (100—YEAR FLOOD) AS SHOWN ON THE SURVEY BY: FLOOD INSURANCE RATE MAP FOR THE TOWN OF DANA J. S TAN D LE Y, P.L.S. N. ANDOVER MA., COM. PANEL # 250098 0012 C DATED (REV) JUNE 2, 1993. SCALE: 1"=80" DATE: 2/6/95 C4 —C)�3—, sO f�T V I Town of over No 033Ir M ort dover, Mass., _XA'RQAQ---f 21 199 ^f` I a LAKE ' � COC HiC NE wick A' � 1f j - DRA T E D PP C�s BOARD OF HEALTH ow PERMIT T D Food/Kitchen s.y Septic System `, T BUILDING INSPECTOR ,- THIS CERTIFIES THAT-COL-0 .....V......�...1........6....E.........V..........�.....�..�..I..L..y.P.... .............................................. _ (Adation has permission to erect.4A�.1c�D.... N1e,. buildings on ...1:oSQ4....�o 'r....�...................... '�J Rough to be occupied as��Ol?&a........... �... .... ?�'..`1� .�.. . . . Chimney provided that the person accepting this pe�init shall in every rasps t conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection Alterati n d Construction of Buildings In the Town of North Andover. PERMIT FOR�OI� IDATION ONLY PLUMBING INSPECTOR REGULATED BY PARA. 1142-& K VIOLATION of the Zoning or Building Regulatio, s Voids this Permit. Rough ��� , 74) i? l C FEE PAID 1� Final PEP F �I' _ - Na C� S-b- qo ELECTRICAL INSPE( COR UNt ',S L A, i ..��� t //J �'� 1 -__• 'sough "9MIT F FRAIUBUILDI! Iry /.'..... . . .. :`� �... cervi- // B IILDIN, IN: 'EC IR final Dk ") /_ .FEL: P"n :_., — — — — Occul U.1 "c)n) . ht_gt417(_(J to (:1I d �Lh. �lil, G. LS IN3PE( 'IUR F ough Display in a Conspicuous Place on the Premises — Do N it R move final No Lathir g or Dry Wall ' o Be Done Until Inspected and Approved by ti e Building Inspector. FIR: DEPART [ENT Burner PLANNING FINAL CONSERVATION FINAL S.reet No. Smoke Det. SEWER/WATER FINAL DRIVEWAY ENTRY PERMIT Location Ll No �" .- Date Z TOWN OF NORTH ANDOVER W &ORTN pfD ;e,�0 3 � p Certificate of Occupancy $ Building/Frame Permit Fee $ 'ss sE` Faundati Fee $ Other Pe it Feqck�VA $ zS Sewer Connection Fee $ _ Water Connection Fee $ t TOTAL $ � Building Inspector 7934 Div. Public Works 0 t 120 Main Street, 01845 KAREN H.P. NELSON1a Town Of . Dirrrtnr :,.. NORTH ANDOVER (508) 682-6483 BUILDING ` '•••• ' CONSERVATION •ds„” 't DIVISION OF HEALTH PLANNINGPLANNING & COMMUNITY DEVELOPMENT w CHIMNEY APPLICATION AND PERMIT C PERMIT DATE LOCATION 14o o 6 r 5 OWNER' S NAME O /,I h I r / De. y I 0 1r, �� BUILDER' S NAME MASON ' S NAME .}� MASON ' S ADDRESST_ ��P / MASON ' S TELEPHONE MATERIAL OF CHIMNEY �(�/f %✓�� INTERIOR CHIiiNEy EXTERIOR CHIMNEY NUMBER AND SIZE OF FLUES THICKNESS OF HEARTH Will chimney or fireplace conform to requirements of the code and have rules and regulations been received: jDATE 1 SIGNATURE OF MASONS Ill CONTR. LIC. # EST . CONSTRUCTION COST/CONTRACT PRICE PERMIT GRANTED FEE ROBERT lA, BUILDING INSPECTOR L Z4�� INSPECTED pFhrr.�uS 7 OEPARTMENT OF PUBLIC SAFETY SOLID BRICK REOUIR_ED .� CONSTRUCTION SUPERVISOR LICENSE Nuiber: Expires: Birthdate =N' ST BE DISPLAYED ON THE PREMISES CS 053104 01/05/1998 01/05/1951 t Restricted To: 00 JAMES C OIPANFILO wu .� BaiL� 15 BENNETT STREET GOMIASSIGNER WOBURN, MA 01801 To '" o fAndover No. 033 , �ort yy dover, Mass., 21 .19 T 0 't LAKE �A COCMICNEwICK�\�� DATED BOARD OF HEALTH E , ; Food/Kitchen henPERja1 Septic System�1674 ^ BUILDING INSPECTOR �oL.OTI�AL v�L1.A6ic... �Y ' t .S► THIS CERTIFIES THAT !M..:................... ... oundation 2 3 �� has permission to erect.:*:0i'�....�At�1�..buildings on ...1.Q ,....�Fo T....�. .. ......................!�..1-�".. oug. r to be occupied as g�Nf�4.� rn�. . ���n. 4!� �... d�,..��4f1A�1�....................................... imney5a f A. 4{ ...... provided that the person accepting this pe it shall in every respe t conform to the terms of the application on file in Final this oiffc,o"and to the provisions of the Codes and B -Laws relatingto the Ins a ti n r Ion of Bulldingar tithe Town of North Andover. y p � ����'•"^ 0 SLY PLUMB ►F 3 4t1 I, REGULATED BY PARD, 114U B.G srEcroRs h; ,z �F�f } VIOLATION of the Zoning or Building Regulations Voids this Permit. " (/7,712C t cap ;. FEE PAID r_�_.____ PERMIT EXP -S-IN p M S-D` �o ELECTRICAL INSPECTO UNLESS CONS U �1. ough � �9� PERMIT FOR FRAMUBADIN % y Service n• . {; "I` tu"" (. ,}��/�..,�....... ..... BUILDING INSPECTOR Final DATE": -Iq� FEE PAID: Occupancy Permit Required to Occupy Building GAS INSPECTOR ' 1 Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final n r f 7 t . . No Lathing or Dry Wall To Be Done ' ted and A roved b the Building Ins ector. FIRE DEP TM Until Inspected pp Y 9 p ' n/ Burner Lj �' "l� C� I � CONSERVATION FIN L Street No. .• '' - ,, Q�.F4 ± ;: PLANNING FINAL �l ? Smoke Det. SEWER/WATER FINAL DRIVEWAY ENTRY PERMIT : c S t ;' } ..,a CER4a1IfFICATE OF USE & OCCUPANCY P ,,Town of North Andover , p ity 40ding PermitNumbeDate r. ' 41 4 ' "t �,n a'9 �'} � �, � .� '" d , r= � • f l�a���dr°i4 .. - - � x f,5 � ,� • 1 b z t�,3 _,, 4 , ,� F�,''i' I ' THIS CERTIFIES THAT suiLDINaG� otCATED ON � �oSo"� T ^F, l 4I �. ,, t o i OCCUPIED SAS M AIAL ''yW��t Vi IN ACCORDANCE s;; �;) ip ll�. W Ilan !d2'6/R ' ; ,��F ' � is t � �,h � � ��r Q���� �• ;,. Ilk 3� � '� I �� �'1 '�t �WITH.,THE PROVISIONS OF THE MASSACHUSETTS STATE'BUILDING CODE AND. { y. � f SUCH°OTHER)REGULATIONS AS MAY APPLY. I SS f i x _� x, s '{ CERTIFICATE ISSUED TOt `!tt4�. YILIdGR. VEKi�.4PMk �' > i z ` � �, � � f �4 �' � �.l�F' L 'F�'•'� � it 5 1 1 � � ��� • " Y ADORES 0 N , t 0 Ai��� Arm ti r I F � a n(� w t 0 W000 MUCTUUF:S willaatetto Industries, xzQ. !N„ Biddefot$,ME Engineered Hood P=duCts 3 0 PROJECT .TOB NG.: ME WATS:800-M-6716 U DESIGNER: DATE: 3/7/95 SHP.SI': Out-O&Statr.SW-341-9612 E Fm 207-282.2423 puum PRODaCT MADING (WITH TOTAL LOAD DI MWR AND HAXIKUH SHEAR AND NOMST) Ln W3. 505 FLF DL i 145 PLY LL 360' PLF m m m � a d0{Z�4 a - This truss is designed is acxorda nce With th< (9 luest rcv4b s oETPI anVor PCL and will Ire soled obar a pcofeuional engineer.in rhe sure or sures requited(upon eequm)after approval or this plotted �+ N elcntioa to usur.compliance with design conc-.pt N il.7' �(�•� -d actual iobsiteconditians- o N PZACTION - 6186 IDBS HOM811T = 37891 FT-LBS REACTION = 6186 LES 00 a DEFLECTI OHS LL - 0.65" = L/ 450 TL = D.9211 = LJ 311 o *•* USE 5.125 R 2a INCH Sobendl.a GL.B(24F-94 DF/DF)LD JnS�ECTFt1t�ANTNO 8Z ( lad% LOAD DURATION FACTOR USED FOR ALLOWABLE MAR AHD MOMENT). � U3 TI-0 A'!s r tdXr r-)dL�6rr cf IPI Q ALLOi�ABi�E SHEAR � 326$0 HY }{ 1Q'6 � 4483 � E- ALLOWA 5LE MOMENT - 52 3 4 0 t$ OF N KIN 3= 35 G L8Nt31'Ft = 1.55 ia. EELD!ERMCATION -� > m CONTINUOUS LATSRI L BVPPoJM R89011) AT TOE RDGS �• 0 APPROVED caC3 AFPROVEDASNOTED �4 Ln rn - Approval of this drawing secs that dimensions om and quantities indicated conform to actual job f site requirements. s, Sig esd Due C N � Company U - O _ _. FROM :DednT FAX NO. :9783ee6781 Apr. 22 2010 10:03PM P1 APR-22-2010 03:?OP FROM.RXERS POOL,rA 10 & 975-454-5517 TO:19(838@6791 0.2 A /Z I BUILDING PERMIT a'."•�•;:,;+$' TOWN OF NORTH ANDOVER APPLIC i EXAMINATION permit NO: = Data Rec01ve0 Date ORTANT:A licaat must oo Witte all items on this PUC %R77h 'A vie •x:'tiM:ss.•r�'�`'.t p�Y,. ;i; e,i ar."r '�•;�����:$: •i'i�•. I.f'SIS! .� ittwI/L" �JSytt L�yt/� �yA�� TYPE OF IMPROVEMENT PROPOSED USE I Residardial Non-Residential Now Building n farhil Addition - I Two or more family Industrial Alteration No.of units: Commercial Repair.replacement Aesessory 1194 Others; Demolition I Other °`°� •c. _ � ; � `•�� - � '':%�c�o�ipiaM <.,l�l'alfer�'ds..;. :water,_'s�,�'O;�iilct';�: ', DESCRIPTION OF WORK TO BE PREFORMED: 'CecIon at 4 4al IdendQcadonmu T?lw or(Print Clesriy) OWNER: Name: An[ 6ya rte, Phon o r6 —66 !$ Address: 6 96 AeS z= ?''• s�!/�_. d[.T�y►'' S.^ Z#fl'l�:! :3!ttd�-�tr43.': . I I qtr ,; f��• Y�ie/XIVw�`"_fwyll►�•'?+_fir,rrag ,✓.' ff��! ARCMITECUENGINEER Phone: Address: Reg. No. FFE SCNffDULE:OULDWS PERVIr.41200 PFR S14M.00 OF 7NE%Or.Ac MMA MP cost"ago ON S126.00PER S.F. Total Project Cost: S A510t,10 FEE: S Check No.: Receipt No.: NOTE: Persona vmtracting with uarg1,* Bred contf►aetors do not have access to rrar e,�fund Sigaatixe;df�arratr$i;lar-" FROM :DeanT FAX NO. :9783886781 Apr. 22 2010 10:04PM P3 APR-22-2010 03:31P FROM:ROGERS PWL,PATIO 8 979.454.5517 T0:19783686781 F.4 ..r _....�'~. ... - waodmwm wE TAKEN 1f1E Piyjin F�j,� WcAlID IN NO. APOM, VA." BY pmwsm a S". PL #12458 N.UM � \ f LOT 4 ,( ' a1i App \ � V Ilk � l =. Za+MG p1STR1CT • 1 4 iJES M I"IN A RES DENCE 1 (R- EC PLAT PLAN • Lo RT1Ft CE , ,,�IS wav MA E lu OF LOT 4 p,NooVE FOREST. ST., N- UN as SOMA '" pwNEp BY: nus ���+� u+ �A� o ► GE DEV. CORP a w0=N+a w"gY-LAW a COLONIAL AL dlOPxll�'AY 1M6 ib+E fJF oDMsl�a sui. 19Y.': wl ss t s u pAN A J. STANQL.EY, P.L.SOMFOYM is • uwc m .0 WAW p�6 hot Al®t®Wo it ON I i "�80' Dgn. 2/6/95 "�si►h+teohs a `F �7 S( E: Op1o{1lgtfY PAIis� FROM :DeanT FAX NO. :97838 781 Apr. 22 2010 10:03PM P2 PPR--22-2010 03,31P FROM:ROGERS PoOl-,NT10 & 9TS-454-5517 T0:19783W67B1 F•4 PRO' nu S wri v E TAX 4 !-.1,4 IHE DATE A4 \ �pCA1FD a ►� vim, Ma SIM A4 k ima, oL 8't C1�lS�N+� �,3rJ LOT 4� r, sae ACRES . Lot 3 �. - ir \ 's to* Paum i !� r Ql w i� a ,{fir., L? �� � (7 ► LOT s, 1- � SST -.,VFW v ao ,. V \9 • LOT f I-t Va-n 114 A RESIDENCE �oNfNG GtS�ICT CERTi FLED PLOT PLAN 4 � C F l.4 T 'Be" KMAf w VE � N00 o� ST„ N . A �„u„l, FOREST. •owNEo eY: ,c n�o� 5 I 1=0 Alo Me is u4 CMAP At=- wn�+ ate► DEV. CORP �� c CF uM" aF COLONIAL SURVEY BY: �T ISE ng . ► N 5 m,r mmx r hT mss" tw DANA J- StANDLEY, P.L.S. mom am Tot+1 AR IS MTt0u► .—Aff DAIM 2/g�95 RPR-22-2010 03:30P FROM:ROGERS POOL.PHTIO 3 978-454-5517 T0=1970%6781 2.3 / aou e- AiWE! JOINfi 46 AT 4 4' l 6 W 14, 4'-7 1/4 _4 lie R4'+« , } r 4' R9, 6' \4 � Lj < \\ 6' a I -4X-44— PANELS 6, PANELS TO BE REMOVED WHEN USING STEP OPTION 4 Z' 4' t 3' I; 9' RADIUS STEEL STEP e CURVED SPTR3090)=XXX PLASTIC SttP I • PANEL LAYOUT DIG SPECIFICATION w 1 AS• x 343' t�AS I M "" Owe► 1e1lOYVee3 AR%-jK W l W41 err "are001";tw w.n,°�io� agIMleww aK1aNlA�aepiNlidArAtIAY®M¢a®rRf�/ vaNwE �s4�+ '� + ero" 4N>~1v foiacAaiwemre vofidcAi1B1�1Ma weaeu+MwewwweawdwNlrwr PF d! ft 1 or 9 28s Date.—.$. . . . .. . . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION �9SSACMUSE� This certifies that . . .ye e:4-!''. . . . . . . . . . . . . . . . . . has permission for gas installation 1. in the buildings of . .f!. Pis.u.jt 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . at ! f o. . . .Fp.1) t . . . . .` . . . . . North Andover, Mass. Fee. a.J Lic. No.3. . ' . . . . . . AS INSPECTOR Check# f 3 4732 MASS APPROVAL # MASSACHUSETTS UNIFORM APPLICATION FOR'PERMIT TiYM GASFITTING (Print w Type) (�, a Mass. Date - Permit 3t 73 L , (fie�0 ___ Building Location I O o •of IFOM 0%m's Name p 6n5 I: _ 4-e PAC 0 r`� Type of Occupancy � C1 I°'W I New p Renovation (( Replacement p Plans Submitted: Yap No([ Ul W b Y = S •f In W 0 rt !- tn W Q O {1 J Q 1'. t Y 2 2 0 t L' z O u < a ¢ O D 0 = r- 91 W 6 C < N cc. W4 Z V = Q C W C W /- W !� = b Ct d F' C.� = [r � -b Om z 0 = W O M S Z W Q til Z < < O O W O \I 1 o < W SUB—BSMT. r BASEMENT IST FLOOR +I I X 2ND FLOOR I I I 3RD FLOOR I I 4TH FLOOR STH FLOOR I 6TH FLOOR I 7TH FLOOR I eTH FLOOR Installing Company Nana YANKEE GAS Check one: Certificate Address 140 SOUTH MAIN STREET ;S Corporation 103C MIDDLETON, MA 01949 [. Partnership Business Telephone 9 7 8—7 7 4-2 7 6 0 L Firm/Co. Name of licensed Plumber or Gas Fitter WILLIAM R. HARRIS INSURANCE COVERAGE: have a current liability Insurance policy or its substantial equivalent which r,*ets the requirements of MGL Ch. 142. Yes [R Fdo ❑ If you have checked�L• please Indicate the type coverage by checking the i.Wopriate box A liability Insurance policy 13 Other type of indemnity❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does nct Izvt 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: OwrWj— Agent❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information i have submitted(or entered)in above a.-)- cn are tipe and accurate to thVbV al my knowledge and that all plumbing work and installations performed under the permfue3'c for thu n q with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of thetivriey T oflicense:Plumber gmt, ar mer Title Gasritter Master License Nu be.- 3785 ptyRown Journeyman AOFovEff-(6FFZENL j vkORTH r O��S�eo ,•q�A • O to ��SSAC PUBLIC HEALTH DEPARTMENT Community Development Division Date: October 29,2007 Address: 1050 Forest Street Re: Application for 3 season/porch addition Dear: Mr. and Mrs. Krouitz, Your application for the 3 season addition has been reviewed by the Health Department. The application was denied on, October 29,2007, for the following reason as shown in red: 1. X Missing information 2. X Passing Title 5 inspection of septic system required per local N. Andover regulations 3. ❑ Location of structure not acceptable 4. ❑ Undersized septic system To address the problem(t H#1 is checked, please supply: a. Floor plan of existing and proposed addition—all rooms b. Certified plot plan showing house, septic system and proposed project in scale(you may pick up an as-built septic plan at the Health Office) H#2 is checked: a. Have the septic system inspected by a certified Title 5 inspector to determine whether it is operating properly: (inspector list attached) OR b. Tie-in to municipal sewer I If#3 is checked: j a. Relocate the project If#4 is checked: Options 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofoorthandover.com s t a. Provide additional information proving that the existing septic system meets current capacity requirements. Please consult a professional engineer or registered sanitarian to determine the flow capacity of the septic system. b. Hire a professional engineer to design a new septic system that meets State Regulations c. Request approval of a deed restriction agreeing to always be a--bedroom home. i. Submit a request in writing to the Board of Health identifying why the need to upgrade the septic system is a severe hardship.. ii. Attend a BOH meeting to address the board iii. If approved, record the deed restriction at the registry of deeds Please feel free to call the Health Office at 978-688-9540 with any questions you may have. Sincerely, SLaw7yerAA blic Heal irector 00 Cc: building Department File h 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Date.......... .............1..j...... OT TOWN OF NORTH ANDOVER PERMIT FOR WIRING CMus� This certifies that ........ . ..... :` .. ................ has permission to perform ..........t..•.. r wiring in the building of 0 ........................� . ,North Andover,Mass. - I Fee ... Lic.No: ,- �. ELECTRICAL INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer GOLD: File The Commonwealth of Massachusetts out— l's. Oolr�`/ ?,Cott ' Department of Public Safety � O:tuNMY 4 fe.or.eaee_,5�� M BOARD OF FIRE PREVENTION REGULATIONS S27 CMR 1200 3/90 (taa., blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be periormed In accordance with the Massachusens Electrical Code.S27 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date r � J— City or Town of ,V < A/`3 n �4 fa 42, To the Inspector J Hires' The undersigned applies for a permit to perform thee 4lectrical Work described below. Location (Street 6 Number) Amer or Tenant M 2 SIL Q A L Owner's Address Is this permit in conjunction wi1th_-a building permit' Yes k No ❑ (Check Appropriate Box) Purpose of Building ( ?<t[ r Utility Author tion NO.� Existing Service Amps / Volts Overhead ❑ Undgrd No. o / New Service®Amps Z—t)Volts Overbead a Undgrd❑ No. of Meters_ / Nuaber of Feeders and Ampacity. Location and Nature of Proposed Electrical Work tN �� No. of Lighting Outlets �} No. of Not Tubs No. of Transformers ora ��� No. of Lighting Fixtures Swimming XVA Pool Above In- LI) g rnd. ❑ rnd. ❑ Generators 1CVA No. of Receptacle Outlets No. of Oil Burners No. of Emergency Llghting BatteryUnits No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of-Zones V No. of Ranges No. of Air Cond. Total No. of Detection and I tons Initiating Devices Disposals No. of Neat Total Total No. of Dis po sTons T1W No. of S=c:ndiag Devices No. of Dishwashers Space/Area Heating XW No. of Self Contained Detection/Sounding Devices No. of Dryers , Heating Devices 157 Local❑Municipal ❑Other . Connection S ss No. of Water Heaters X17 No, o. o Low Voltage i Ballasts Wiring No. Hydro Massage Tubs No. of Motors Total HP CATV OTHER: INSURANCE ODVERACEt Pursuant to the requirenams of Massachusetts General Laws I have a current sbilit Insurance Policy including Completed Operations Coverage is substantial equivalent. YES NO[] I have submitted valid proof of same to this office. YLS NO ❑ If you have check. YES, please indicate the type of .overate by checking the appro?r -,* box. INSURANCE BOND C] OTHER C] (Please Specify) (Expfration to Estimated Value of Eleetr cal Mork S Rork to Start Inspection Date Requested'_ RoughFinal Signed u.:4er the penalties of perjur;t FIRM NAME N. Ja L 7—A I C l? J, LIC. too. t' Licensee I 45MP-111 S tar , LIC. NO. - •._ Address 35"ReW PION D ) Ylw- .A ! f"n Z470� Bus. Tal. No. Alt. Tel. No. OWNER'S INSURANCE WAIVER' I as aware that the Lie es does not have the insurance coverage or ras s atantial equivalent as required by Massachusetts-G weral wsTa ,man -that sr-sigaaLme-on-this perwit application waives this requirement. Owner Agent (Please check one Telephone No. PERMIT FEE S - (Signature of Amer or enc • �ar' Date. . HORTh °f 3r °` TOWN OF NORTH ANDOVER O I. 0qppww• - PERMIT FOR GAS INSTALLATION �,SSACHUSEt This certifies that has permission for gas i/nstalllattiion Al / : , `f GG . . in the buildings of . at .�// J . ��-�1r et . .._ . . . Andover, Mass. Fee;-` C Lic. No . . . . - . . . . . . . . . . . . . AS INSPECTOR Check# 4556 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING _ (Print or r 1lf Type) 1r . Perm -�� # Building Location l sa Eme-S+S� / Owner's Natne%. r' / fZ S L -e, Type of Occupancy PRIG T7 New ❑ Renovation Rep lacement ❑ Plans Submitted: Yesp No h N ¢ W b Y 2 ¢ Q CN fi N Q O 0 S !� o LI < ¢ _ z o < m F y m O b = s t 3' IOOI-�1 Wh z i = s Q a c W ~ = rA Y < W < C Uj r 1A m 2 0 11- W Q M S O O to O y H 3 c O 0 e > a 0. 1- o SUB—BSMT. BASEMENT IST FLOOR 2N0 FLOOR 3RD FLOOR I 4TH FLOOR STH FLOOR 6TH FLOOR ?TK FLOOR BTHFLOOR Installing Company Name YANKEE GAS Check one: Certificate Address 140 SOUTH MAIN STREET C& Corporation 103C MIDDLETON, MA 01949 p. Partnership Business Telephone 978-774-2760 C Finn/Co. Name of Licensed Plumber or.Gas Fitter WILLIAM R. HARRTS INSURANCE COVERAGE: I have a current liabillty Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 13 No ❑ If you have checked yes. please Indicate the type coverage by checking the aw opfiate box A liability insurance policy L3 Other type of indemnity O Bond 0 OWNER'S INSURANCE WAIVER: I am aware that the licensee does net 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: Ownet J Agent p Signature of Owner or Owners Agent I hereby certify that all of the details and information I have submitted(or entered)in above app;caticn are true accurate to the f my knowledge and that all plumbing worst and installations performed under the permit' for this doP WnYDe i liv)>P all sa pertinent provisions of the Maschusetts State.Gas Code and Chapter 142 of t, ral taws a By Tof license: Plumber gnatu mt>er or mer Title Gasfitter Master License Number 3785 City/Town iJoumeyman APPRdVED( I NL j ,P C PERMIT rro. �// APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE MAP 4,40. y LOT NO. ) '7 2 RECORD OF OWNERSHIP DATE BOOK :PAGE ZONE IR_i I SJB DIV. LOOT NO. I 1 LOCATION (051) FAST` ST-. N rfjXV A ASA. PURPOSE OF BUILDING j)�5+�G�1cE (S)AJGL,� ., •. - .._ "'•,_. '', OWN[R'S NAME �K 9 Ji17V.AlIF- AAcC �J�. !1'VT NO. OF STORIES � -/9`I'ZE �l�C�d S.)' . .-.. V'��^' OWNER'S ADDRESS 10�•t .L.�i�C/V v` BASEMENT OR SLAB ARCHITECT'S NAME 9IZE OF FLOOR TIMBERS IST 2 )< 2ND Z)er () 3RD SUILDER'S NAME JJiu- Tr _ (fozjuwt4Lylc� SPAN _ + �I 13' 5U4'+ DISTANCE TO NEAREST R'.11LDING f s� I DIMENSIONS OF BILLS �X, 2-x-f DISTANCE FROM STREET o-7o I POSTS �X�-+AC+ DISTANCE FROM LOT LINES - SIDES p REAR 4.00 + - GIRDERS 6X'I z 31/Z X 14 M,L AREA OF LOT 3. 1& hZtf-S V FRONTAGE I-75 �' HEIGHT OF FOUNDATION THICKNESS io IS BUILDING NEW L YZ-t-EtaLOpp SIZE OF FOGTING 'o+' x 2D+' IB BUILDING ADDITION 1-020@i• MATERIAL OF CHIMNEY EW1cIC IS BUILDING ALTERATI IS BUILDING ON SOLID OR FILLED LAND SOLl1� WILL BUILDING CONFOR IREMENT9 OF CODE Y&S 19 BUILDING CONNECTED TO TOWN WATER NO BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER Ao IS BUILDING CONNECTED TO NATURAL GAS LINE Nt� INSTRUCTIONS 3 PROPERTY INFO TION. LAND COST 901 0 0 SEE BOTH BIDES tfT. BLDG. COST - /y�� /�/O PAGE 1 FILL OUT BECTIONS I - 3 EST. BLDG. COST PIER FT. ,s PAGE 2 FILL OUT SECTIONS I - 12 c7LJ '4 ` EST. BLDG. COST PER ROOM 00� �. SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 "PROVED BY 5 ATTACHED GARAGES MUUT CONFORM TO STATE FIRE REGULATIONS PLANS MUST B[FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED � BUtLDINO INSPtCT01 SIGN TUR[ O OW ER 6 RIZED AGENT F E E `OWNER TEL/ PERMIT GRANTED r ?I U CONTR.TEL/ 113�l L..o 15997 CONTR.LIC./ s , 1 H.I.C./ + r ,. h I, IBUILDING' RECORD 1 OCCUPANCY 12 ANGLE FAMILY srovl S THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY' offlCEs LOT LINES AND EXACT DIMENSIONS OIF BUILDINGS. WITH PORCHES. GA- APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION I 8 INTERIOR FINISH CONCRETEYJ�I{ CONCRETE BL K. PINE BRICK OR STONE HARDW O PIERS PLASTER V DRY WAIL UNPIN. 3 BASEMEHt I AREA 'FULL FIN. B'M'T' AREA _ 't '/ FIN. ATTIC:AREA _ NO B M'1 F14E PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS ( 9 FLOORS 5 CUPBOARDS V, e I 7 3 DROP SIDING CONCRETE WOOD SHINGLES EARTH ASPHALT SIDING HAROVI D ASBESTOS SIDING COMfACN _ VERT. SIDING _ ASPH. TILE _ STUCCO ON MASONRY _ STUCCO ON FRAME MRY ATTIC SIRS. 6 FLOOR I_ BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING ' STONE ON FRAMf SUPERIORADEQUATE I NONE 5 ROOF 10 PLUMBING GABLE V BATH 13 FIX.1 _ GAMBREL MANSARD TOILET RM. 17 FIX.) 7 LA1 SHED WATER CLOSET _ ASPHAl1 SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK l SLATE NO PLUMBING _ TAR 6 GRAVEL STALL SHOWER _ ROIL ROOFING MODERN FIXTURES TILE FLOCK TILE GADO 8 FRAMING 11 HEATING WOOD JOIST 1/ PIPELESS FURNA(:f FORCED HOT AIR FURN. TIMBER BMS. 6 COLS. STEAM STEEL BMS. 6 COLS. HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING RADIANT H'T'G . . UNIT HEATERS 7 NO. OF ROOMS GA$ OIL B'M'1 R1 2-d 3 —11 NO HEATING y Town of North Andover BUILDING DEPARTMENT , Homeowner License Exemption (Please print) DATE 10/15/97 JOb LOCATION 1 USD FoizEs-r SS T" Sourz-} Number Street Address Section of town "HOMEOWNER" ,/4/-kl< JL/,A)AhE M`&ON)A6LE (08)686-725- (60)924--1770 Name Home Phone Work Phone PRESENT MAILING ADDRESS /0!57D Fae-&S7- S�.eT A/. +;Ajb6V6,P_ _ A4A— 01845 City Town State Zip code The current exemption for t°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 HOMEOWNER: 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 dwell- ing , attached or detached structures accessory .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 Bulding 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 North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with s ':d procedures and .requirements . HOMEOWNER' S SIGNATURE APPROVAL OF BUILDING OFFICIAL vote: Three family dwellings 35, 000 cubic feet , or larger, will be �_quired to comply with State Building Code Section 127 .0, Construction ,i trol . i The Commonwealth of Massachusetts Department of Industrial Accidents =- Office of/osesUgaUens - 600 Washington Street 3. Boston,Mass. 02111 Workers' Compensation Insurance Affidavit name 114*0_K l)- A'6 o/V I A G L E location: /060 &R E.S T S7-Y2Z6T city /JQP_T14 /7ybOVE1 phone# (S 8) 686-725¢ (2/1 am a homeowner performing all work myself. M I am a sole proprietor and have no one working-i any capacity n I am an employer providing workers' compensation for my employees working on this job. rom,a raise address r r• t�hone:# �ncnrancg rrr pokey.# E] I am a-sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers'compensation polices: company name address �t15' phone:#... policy i address phone:# to attc Failure to secure coverage as required under Section 25A of 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 hereby certify under the pains and penalti f erj - hat the information provided above is true and correct. f Signature Date 10115197 Print name AWR K I Im c6 1 l—E Phone# lSaB) &8 6-7 2S4" official use only do not write in this area to be completed by city or town official city or town: permit/license# OBuildiug Department ❑Licensing Board ❑check if immediate response is required ❑Selectmen's Office []Health Department contact person: phone#; 0Other (revised 3/95 PJA) Information°and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law", 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 theoccupant 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-sueh employment be deemed to be.an employer. MGL chapter 152 section 25 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, 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 requiremenis_of this chapter have been presented to the contracting authority. y Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and i supplying company names, address and phone numbers as all affidavits 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, 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. City or Towns 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. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. N� � The Department's address,te;l phcne- and i affiee of Wesfigallolds 600 Washington Street Boston,Ma. 02111 fax 9: (617) 727-7749 phone 4: (617) 727-4900 ext. 406, 409 or 375 a N7�p01� N o\N N \f \ N \ rp O\ r I� AL SIA ZONE-'4 yry f Ak LOT 4 LOT 3 I 3.16 ACRES 2 STORY 3o WOOD FRAME IRO 'oPIN VNe FOUND I PROPOSED IRON PORCH WEL PIN e'er FOUND �I LEACHING FO _FIELD EPTIC J?�. RF \bs•e* H mos- TAN �� �•k. Jg W IRON ^'• PIN (P(/ g FOUND IRON LOT 5 e(/ 3.80 _ PIN C VAR,Aet�p N 8`038'00• W FOUND STREET S 81ro0•4r W 67.31' * LOT 4 LIES WITHIN A RESIDENCE 1 (R-1) ZONING DISTRICT NOTE: PLOT PLAN THE PROPERTY LINES SHOWN WERE TAKEN OF LOT 4 FROM A PLAN ENTITLED " PLAN OF LAND ► LOCATED IN NO. ANDOVER, MA, �+�� � �� " DATE 8/31/94- � ,�� FOREST ST., N. ANDOVER BY CHRISTIANSEN & SERGI, PL #12455 N.E.R.D. 90asavu g OWNED BY: g®• 3su9 MARK & JEANNIE MCGONIAGLE SURVEY BY: —RHUSSELL J. BOUSQUET, P.L.S. SCALE: 1"=80' DATE: 10/10/97 ,'.17 pr FORM U - LOT RELEASE FORM + a INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from f' '. •6. .."di' 41a Boards and Departments having jurisdiction have been obtained. This does not relieve <*e, the applicant and/or landowner from compliance with any applicable or requirements �r . APPLICANT FILLS OUT THIS SECTION t. x �k 1 ii ( '• 11 V APPLICANT '�j PHONE V&to k "r �OCATION: Assessor's Map Number PARCEL 5 yY �rf' SUBDIVISION LOT(S) t " 31i7REET ST. NUMBER ' r M1txIN rt pay i� } Y OFFICIAL USE ONLf RECOM NDATIONS OF TOWN AGENTS: ' MA wov� CONSERVATION ADMINISTRATOR DATE APPROVED 10 - �i r DATE REJECTED r = , . k COMMENTS-_ -D fit) ( I�S IBJ�l�t IJ 4 U TOWN PLANNER DATE APPROVED DATE REJECTED '+ ►" + :COMMENTS � �. ` ZY . ' FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED 729x DATE REJECTED h i g) ' COMMENTS Vit,. B rft�,Yk s{r ahs an peMql;Ya Y N , PUBLIC WORKS-SEWER/WATER CONNECTIONS s{ 'k DRIVEWAY PERMIT w FIRE DEPARTMENT r 41 tJJ ' RECEIVED BY BUILDING INSPECTOR DATE41�F_4 _' F� f F r1ORT To' wn of _ Andover l z dover, Mass., 19 / �0 9�COCN)CHEWICK`'�'%` , qO � r.TSPw �qs RATED PP �� `G BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System G C cZ BUILDING INSPECTOR THIS CERTIFIES THAT................................................ %�......s. 'o. .1V.l.4..:........C..................................................... Foundation has permission to treff....... A........ buildings on ....../::c>. r ........�vim.C9...6................�. A. .... Rough to be occupied as .......r./t:i/ .......... �� L- Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION START ELECTRICAL INSPECTOR Rough ........................................ ...... . ... i:. ....................................... Service . . . BUIL ING INSPECTOR / Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final _ No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. NORT own of over * , l dover, Mass., 19 9 AOA LA E D S E BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT................................................1 .... ..................................................... Foundation has permission to iwi f:...... /Z...-..... buildings on ....../:.�:j ........r.6!................................ '6;..... Rough to be occupied as........................................................... N.-7-......... :.�� . =-�i�...................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION START ELECTRICAL INSPECTOR Rough ........................................ ..r.. ..... . .... . ... ... . Service.... . . . ........ BUIL ING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det.