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Miscellaneous - 11 BIXBY AVENUE 4/30/2018
11 BIXBY AVENUE `1 f 2101069.0-0002-0000.0 J r r t Residential Property Record Card PARCEL ID:210/069.0-0002-0000.0 MAP:069.0 BLOCK:0002 LOT:0000.0 PARCEL ADDRESS:11 BIXBY AVENUE FY:2013 PARCEL INFORMATION Use-Code: 101 Sale Price: 55,000 Book: 02140 Road Type T Inspect Date: 05/16/2011 Owner: Tax Class: T Sale Date 02/28/86 Page: 0234 Rd Condition: P Meas Date: 05/16/2011 STEPHENSON, ROBERT A Tot Fin Area: 1806 Sale Type. P Cert/Doc: Traffic: M Entrance: X DEBORAH A STEPHENSON Tot Land Area: 0.11 Sale Valid: A Water: Collect Id: RRC Address: Grantor: STEPHENSON JOHN L Sewer: Inspect Reas "C 11 BIXBY AVENUE Exempt-B/L% / Resid-B/L% 100/100 Comm-B/LP/o Indust-B/L% / Open Sp-B/L% / NORTH ANDOVER MA 01845 RESIDENCE INFORMATION LAND INFORMATION Style: CO Tot Rooms: 8 Main Fn Area: 903 Attic: NBHD CODE: 5 NBHD CLASS: 5 ZONE: R4 StoryHeight: 2.00 Bedrooms: 4 Up�n Area: 90.3 Bsmt Area: 903 Seg' T pe_.__ Code Met_ho- d Sq-Ft Acres Influ-Y/N Value Class Roof: H Full Baths: 2 Add FnArea: Fn Bsmt Area: 1 P 101 S 4713 0.110 143,563 Ext Wall: FB Half Baths: Unfin Area: Bsmt Grade_: VALUATION INFORMATION Masonry Trim: Ext Bath Fix: 0 Tot Fin Area: 1806 Current Total: 284,800 Bldg: 141,200 Land: 143,600 MktLnd: 143,600 Foundation: BK BathQual: T RCNLD: 141239 Kitch Qua1: T Eff Yr Built:- 1970 Mkt Adj: Prior Total: 267,500 Bldg: 121,600 Land: 145,900 MktLnd: 145,900 Heat Type:4 HW Ext Kitch: Year Built: 1880 Sound Value: Fuel Type. G Grade: A Cost Bldg; 141,200 Fireplace: 0 Bsmt Gar Cap:-- Condition: A Att Str Val1: Central AC: N Bsmt Gar SF: Oct Complete: Att Str Val2: Att Gar SF: %Good P/F/E/R: /100/100/75 Porch Tyne Porch Area Porch Grade Factor P 36 SKETCH PHOTO 21 �6 S . t FU FM B I 903 Sq.Ft 43 43 i 11 BIXBYAVENUE 21 Parcel ID:210/069.0-0002-0000.0 as of 10/25/13 Page 1 of 1 I LAWRENCE H. OGDEN, PE. 198 EAST MAIN STREET GEORGETOWN, MA 01833 j 978-352-8318 cell 978-502-5921 lhogden(a),comcast.net August 27, 2013 Mr. Robert Stephenson S&S Building RE: 11 Bixby Ave,North Andover,Ma.01845 Dear Mr. Moretti As you are aware I prepared a Sketch Dated 8-5-13 for the repair of a girder supporting the second floor at the above address. The purpose of this was that the existing girder was insufficient to support the second floor live load of 30 PSFand deflection critera as required by the Massachusetts State Building Code for 1&2 Family Residences. Should you have any questions please do not hesitate to call. Yours truly, ZH OF* WRB ��yG o HAROLD cOGDW ^` La ence H. Ogden, P.E. sr�u ��NAI.EU LAWRENCE H.OGDEN.P.E. POP- DOS 198 EAST MAIN STREET' GEORGETOWN,MA.01833 9'70 S07 978-352-831-8, cell 978-502-5921 -5 r-0 p P- T44a ??- WCCT TO EA�q sQ r. A '7 hAV Bis—we, SEAM 7)4,,4r 5 u p ptp r,; -p F-fonp- Tqa� ( ,-5� TO 5T 1 P F; t-) Twt- ae 15'r t F Oe'L) Al u F 00,*r- P�t 0 Of LAW HAROLD us OG A NA fL FAnTe AJ K-STER LwK 4r " 66 .is--- 0 V,4 Pa 5 of\ 6 T--,r- I -?S"A ? !5'1 LUL 6 r '3 to 0 p CP OAJ E:Aao S "Oe 15 410PLE , F—;K 15T,N C--A,,.,, -ro I Z e M 0 U QI-H 6k, A 5 PP ACTICL F SCOPE AND ADMINISTRATION R112.2.1 Determination of substantial improvement in R112.3 Qualifications.The board of appeals shall consist of areas prone to flooding.When the building official provides a members who are qualified by experience and training to pass finding required in Section R105.3.1.1,the board of appeals on matters pertaining to building construction and are not shall determine whether the value of the proposed work consti- employees of the jurisdiction. tutes a substantial improvement. A substantial improvement R112.4 Administration. The building official shall take means any repair, reconstruction, rehabilitation, addition or immediate action in accordance with the decision of the board. improvement of a building or structure, the cost of which equals or exceeds 50 percent of the market value of the build- ing or structure before the improvement or repair is started.If the building or structure has sustained substantial damage,all SECTION R113 repairs are considered substantial improvement regardless of VIOLATIONS the actual repair work performed.The term does not include: R113.1 Unlawful acts.It shall be unlawful for any person,firm 1. Improvements of a building or structure required to cor- or corporation to erect, construct, alter, extend, repair, move, rect existing health, sanitary or safety code violations remove, demolish or occupy any building, structure or equip- identified by the building official and which are the ment regulated by this code,or cause same to be done,in con- minimum necessary to assure safe living conditions;or flict with or in violation of any of the provisions of this code. 2. Any alteration of an historic building or structure,pro--�--' R113.2 Notice of violation.The building official is authorized vided that the alteration will not preclude the continued to serve a notice of violation or order on the person responsible designation as an historic building or structure.For the for the erection, construction, alteration, extension, repair, purpose of this exclusion,an historic building is: moving, removal, dem_olitipfl-or occupancy of a building or 2.1.Listed or preliminarily determined to be eligi- structure in violation of the provisions of this code,or in viola- ble for listing in the National Register of His- tion of a detail statement or a plan approved thereunder,or in 71 toric Places;or violation of a permit or certificate issued under the provisions of this code. Such order shall direct the discontinuance of the 2.2. Determined by the Secretary of the U.S.De- illegal action or condition and the abatement of the violation. partment of Interior as contributing to the his- R113.3 Prosecution of violation.If the notice of violation is torical significance of a registered historic not complied with in the time prescribed by such notice, the district or a district preliminarily determined building official is authorized to request the legal counsel of the to qualify as an historic district;or jurisdiction to institute the appropriate proceeding at law or in 2.3. Designated as historic under a state or local equity to restrain,correct or abate such violation,or to require historic preservation program that is ap- the removal or termination of the unlawful occupancy of the proved by the Department of Interior. building or structure in violation of the provisions of this code R112.2.2 Criteria for issuance of a variance for areas or of the order or direction made pursuant thereto. prone to flooding.A variance shall be issued only upon: R113.4 Violation penalties.Any person who violates a provi- b + sion of this code or fails to comply with any of the requirements Ill. A showing of good and sufficient cause that the thereof or who erects,constructs,alters or repairs a building or unique characteristics of the size, configuration or structure in violation of the approved construction documents topography of the site render the elevation standards or directive of the building official,or of a permit or certificate in Section R322 inappropriate. issued under the provisions of this code,shall be subject to pen- 2. A determination that failure to grant the variance alties as prescribed by.law. would result in exceptional hardship by rendering the lot undevelopable. 3. A determination that the granting of a variance will SECTION R114 not result in increased flood heights, additional STOP WORK ORDER threats to public safety,extraordinary public expense, R114.1 Notice to owner.Upon notice from the building offi- cause fraud on or victimization of the public,or con- cial that work on any building or structure is being prosecuted flict with existing local laws or ordinances. contrary to the provisions of this code or in an unsafe and dan- 4. A determination that the variance is the minimum nec- gerous manner,such work shall be immediately stopped.The essary to afford relief,considering the flood hazard. stop work order shall be in writing and shall be given to the owner of the property involved,or to the owner's agent or to the 5. Submission to the applicant of written notice specify- person doing the work'and shall state the conditions under ing the difference between the design flood elevation which work will be permitted to resume. and the elevation to which the building is to be built, stating that the cost of flood insurance will be com- R114.2 Unlawful continuance. Any person who shall con- mensurate with the increased risk resulting from the tinue any work in or about the structure after having been reduced floor elevation,and stating that construction served with a stop work order,except such work as that person below the design flood elevation increases risks to life is directed to perform to remove a violation or unsafe condi- and property. tion,shall be subject to penalties as prescribed by law. 8 2009 INTERNATIONAL RESIDENTIAL CODE® TOWN OF NORTH ANDOVER F NORTH Office of the Building Department 3? e�`.` .°A"°oma Community Development and Services p 1600 Osgood Street North Andover Massachusetts 01845 �9SSACNUS tty Telephone(978)688-9545 FAX(978)688-9542 October 30, 2013 Robert A. Stephenson I 11 Bixby Avenue l�tit M��,1-� L North Andover MA 01845 RE: 11 Bixby Avenue o On December 29, 2013 the building Depai owner to repair First floor fire damage. L the project. At the inspection it was obsel windows, and new vinyl siding, was instal_..- prfints per iuu CMR section R105.1. It was also observed that a front porch and rear deck were going to be installed in the future due to the evidence of footings and ledger board attachment. It also appears the addition; deck and front porch violate the North Andover Zoning code. Please be advised there is a STOP WORK order placed on the property until these violations can be addressed. The Building Department, within 30 days, needs a Certified Building plot plan that reflects the existing, new, and proposed structure and deck. A list of Qualified land surveyors has been supplied for your convince. Brian Leathe c Local Building Inspector. Brown, Gerald IkL From: Liz Fennessy[lizettafennessy@yahoo.com] Sent: Wednesday, October 30, 2013 7:30 PM To: robert stephenson Cc: Brown, Gerald Subject: Re: front porch You will need to address the Zoning Board and Building Department issues before you are able to get back to the MSV committee. Please reach out to me once those are completed and then we can restart the MSV process for you. Liz Fennessy On Oct 30, 2013, at 5:40 PM, robert Stephenson<ssbuildinglkgmail.com> wrote: Hi Liz, I understand that I knew when the meeting was. I didn't realize I was suppose to be there. I think that's where the misunderstanding was. I didn't realize I had to inform MSV for exterior alterations because a lot of properties in MSV already have these alterations. Please inform me as to how I proceed to meet the MSV bylaw and process. Thank You, Bob & Debby Stephenson On Wed, Oct 30, 2013 at 11:23 AM, Liz Fennessy <lizettafennessygyahoo.com>wrote: Hi Bob, I am not going to call you. When the building inspector tells me that you said that you didn't know about last week's meeting and don't show up, despite the public notice that was posted and emails below where I told you on the 22nd, the 17th and the 4th of October when the meeting would be, that's when we are going to keep communication to email so there's a record. Let me give you some context for this situation: The MSV Committee follows a bylaw for exterior alterations to properties in MSV, and then issues certificates to the homeowner and building department. We do not issue building permits. The building department issues building permits, and uses the MSV certificate as part of a checklist process to make sure things are in place before they issue the permit. If there is a problem with your building permit you will need to resolve it with the building department. Here's what I know about this: You have a building permit for alterations to the first floor due to fire. You have exterior alterations for your building in place that did not go before the MSV committee. Those exterior alterations are on the first AND second floor. Here's what I don't know about this: Whether your building permit was issued appropriately. If the fact that you have exterior alterations that didn't go before the MSV committee has any i consequences for you. i If that fact that you have exterior alterations on your second floor when your building permit says first floor has any consequences for you. The MSV committee is a volunteer committee. Frankly we have never dealt with anything like this before - everything else we've dealt with has been quick and easy on both our part and the homeowner's part. This issue has risen beyond what a volunteer committee can handle, at least without legal advice from Town Counsel. Because you have been told by the building department you have a problem with a permit they issued you, it should be resolved by the town. In separate emails I've had with the building inspector, I've requested guidance as to what to tell the committee and how to proceed, and he can keep you informed as well. The committee will be taking no action unless specifically instructed by the town as to how to proceed, or if a new request comes in regarding exterior alterations. Hopefully you can get these issues resolved quickly and to the town's and your satisfaction. I wish you luck. If you have additional questions that fall within the requirements of the MSV bylaw and process that I can help you with, please don't hesitate to email me. Liz Fennessy Chairperson. Machine Shop Village Neighborhood Conservation District Commission -------------------------------------------- On Wed, 10/30/13, robert stephenson<ssbuilding I ggmail.com> wrote: Subject: Re: front porch To: "Liz Fennessy" <lizettafennessygyahoo.com> Date: Wednesday, October 30, 2013, 8:12 AM I was informed by the building dept that there's a problem with the siding and windows. could you call me at your convenience at 9788071066 to discuss a resolution thank you bob stephenson On Tue, Oct 22, 2013 at 5:31 PM, Liz Fennessy<lizettafennessynyahoo.com> wrote: The meeting is at Town Hall at 7 pm on Thursday. Can you please send the requested items tomorrow? Having them for the committee to review ahead of time will increase the likelihood of a quick decision. There is greater risk of slipping another month if not enough information is supplied. 2 's On Thursday, October 17, 2013 8:48 AM, Liz Fennessy <lizettafennessygyahoo.com> wrote: Hi....our meeting is scheduled for October 24 at 7 pm. I am still waiting to hear back from the town on the exact location. In reviewing the materials, there's a couple of items that we need to see to come to a decision faster:1. Photo(s) of the front of the house showing where the alteration will be made.2. Elevation sketch of the proposed added porch(the plans you already sent are good, but we also need an elevation. You could print your photo and draw it on top of that if you want) 3. Catalog cut sheets of the materials pp ro osed. l will let you know if any of the committee members have any other requests. Thanks! Liz On Friday, October 4, 2013 7:26 AM, Liz Fennessy<lizettafennessygyahoo.com> wrote: My apologies if there was a misunderstanding. But I never would have said that because that is not how the process works. We are required to give 7 days notice before a public meeting per the law. This is the law, and it is for the benefit of all parties. If we don't do it this way, and one of your neighbors doesn't like our decision, they could hold it up by saying we didn't follow the right process. The next meeting is fourth Thursday in October. I will get back to you with the specific time and location. Liz Fennessy On Oct 4, 2013, at 7:07 AM, robert stephenson<ssbuilding I @gmail.com>wrote: 3 you talked to me and said you needed it a day before the meeting for review and I did On Thu, Oct 3, 2013 at 11:01 PM, Liz Fennessy <lizettafennessygyahoo.com> wrote: Did I talk to you, or your contractor? Because I had a conversation with someone about the meeting schedule and what it would take to do this in September. The next meeting is at the end if October. Liz Fennessy On Oct 3, 2013, at 9:57 PM, robert stephenson <ssbuildingl@gmail.com>wrote: is there a way we can go on I did not know about the 7 day deadline is it a big deal my neighbors have porches I am just moving it over to get in my front door Il will skip the hip roof until your meeting 1 On Thu, Oct 3, 2013 at 8:26 PM, Liz Fennessy <lizettafennessy@yahoo.com> wrote: We needed it 7 days before the meeting per the law. Which we discussed on the phone. Sorry for the inconvenience but we have a published schedule. On Oct 3, 2013, at 7:54 PM, robert stephenson<ssbuildinglggmail.com>wrote: 4 you asked for it before your last meeting on September 26 I dropped it off at your home on September 24 you are really holding me up from moving back in to my home after a fire on December 18 2012 I would like proceed with the work to finally move back in On Thu, Oct 3, 2013 at 9:23 AM, Liz Fennessy <lizettafennessy@yahoo.com> wrote: Your meeting is scheduled for the fourth Thursday in October. Paperwork was not in in time for the September meeting. Liz Fennessy On Oct 3, 2013, at 7:20 AM, robert stephenson<ssbuildingl@gmail.com>wrote: > are we all set to proceed on front porch 5 r' Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records.For more information please refer to:hftp://www.sec.state.ma.us/pre/preidx.htm. Please consider the environment before printing this email. 6 Deems, Maura From: Deems, Maura Sent: Wednesday, October 30, 2013 9:01 AM To: Brown, Gerald Subject: Stop Work Order for 11 Bixby Avenue Attachments: 201310300811.pdf Jerry review the draft email to Ms. Fennessy. . . . . . . . . .make any changes. . . . . . . . . .Maura Dear Ms. Fennessy, Please see the attached stop work order for 11 Bixby Avenue. I posted the order on the building on October 29, 2013. Based on the activities I observed yesterday my recommendations to Mr. Stephenson is as follows: 1) Submit an application to the Machine Shop Village Neighborhood Conservation District Commission for the front porch, 12x12 addition and rear deck. 2) The addition on the right side of the house must prove proper zoning setbacks. If the addition is not within the proper zoning setbacks, Mr. Stephenson will have to go before the zoning board of appeals for approval or removal of the addition. If you have any further questions or concer you can contact me via email or call the building office. Thank you, �� �l r ��•ud Y�c r� Gerald Brown Inspector of Buildings JJ / Town of North Andover 6 -----Original Message----- From: noreply(@townofnorthanfover.com [mailto:noreply@townofnorthanfover.com] Sent: Wednesday, October 30, 2013 8:11 AM To: Deems, Maura Subject: Message from "CommDev-Ricoh" This E-mail was sent from "CommDev-Ricoh" (AAficio MP C4502). Scan Date: 10.30.2013 08:11:26 (-0400) Queries to: noreply(@townofnorthanfover.com Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records. For more information please refer to: http://www.sec.state.ma.us/pre/preidx.htm. Please consider the environment before printing this email. 1 AL NOTICP Date F tom' Article Section o the Zoning Ordinance REAS, violations of Article Sectio/&C%f of the Building Code have been found on Article , Section of the G t 007 l these premises, IT IS HEREBY O DERED in ac c ance with the above at all ersons cease, desist From, and i • STOP W RK at once pertaini"g to c tructi n, alterations or repairs an these premises known as All persons acting contrary to this order or removi or mutilating this, notice are liable to arrest unless such action is authorized by the Department. -� UILDING OFFICIAL s. TtC' Date� � ASection #,�- l oithe zonin8 ©rdtnancs+ REAS, violatlons Qf , A1"IiCle" , Sectiotfu i / Q#the Building Code haveraeen for�Qd on Article . , Section of the C . � ZTO F WOO these premises, IT IS HEREBY'O DERED in ai.-pgalarice with the above st°a{I�p�"�ersons cease, desist From, and i ''" f`'y'i,1/ ■ e- KOp vT` V! � Tol.;P once pertaini g to c tructi n, alterations or repairs on these premises own as contrary to this order or removi or mutilating this notice are liable to arrest is authorized by the'Department. -Z {� L 15UII-DING QFFICIAL 2�,¢ e)2_ vie M f . Tic } . u loop Date� Article Section �¢ofthe Zoning 4rdinan6i REAS, violations of Article , Sectio // of the Building Code : have been found on. Article , Section of'the these premises, IT IS HERESY O DERED in acc artca witty the above at au ,ersons,.cease,.desist w . From, and ST 011 -1P W at once pertai,ni g toc truth n, alterations or repairs on these premises known as All persons acting contrary to this order or removi-4 or mutilating this notice are liable to arrest unless such action is authorized:by the Department. LIILDAG OFFICIAL 4 } J Deems, Maura 7�` PD,ZPl From: Deems, Maura Sent: Monday, October 28, 2013 10:25 AM To: Brown, Gerald Subject: Draft Email for 11 Bixby Drive Dear Ms. Fennessey, In regards to 11 Bixby Avenue here is the information that you requested. A building permit(089-14)was issued on July 26, 2013 and the scope of work on the building permit states, Fire Damage—Repair I" Floor. New siding and windows were not included in the scope of the work to be done at the above address. I spoke with Mr.Stephenson on October 28,2013 and he stated that he sent his Application For Certificate to Alter in but had not been informed of the meeting that was held to discuss his property. Mr. Stephenson would like to be on the agenda for the next meeting of the Machine Shop Village Neighborhood Conservation District Commission. I am out of the office today October 28, 2013 but will be back in the office tomorrow for office hours at fpm. Please feel free to contact me with any further questions or concerns. Sincerely, Gerald Brown Jerry, I will attach a copy of the BP card as well. Please make any changes that you feel are needed. Maura Maura Deems Building Department Assistant Town of North Andover 1600 Osgood Street Bldg. 20 Suite 2035 North Andover, MA 01845 Phone 978.688.9545 Fax 978.688.9542 Email mdeems@townofnorthandover.com Web www.TownofNorthAndover.com r p a r I it - �, � _ .�1ll�Illll_�l��l Z �, S1 1, i z II ,� r OORTH own of t E ndover O .,.. - 0 No. Z h h ver, Mass COCMIC"IWIC" �'►• ASR^TED s U BOARD OF HEALTH Food/Kitchen PERM. IT T LD Septic System THIS CERTIFIES THAT ........ !� �. .... /.� .�'�.. BUILDING INSPECTOR / ....................................................... . . has permission to erect .......................... buildings on ..11 . .'�. . . of Foundation ... . .......................................... Rough to be occupied as ....... .. ...,1. :t:r:'.. <... .F..............: ...........i:S ��.�?....:........... Chimney provided that the person accepting this permitihall in every respect conform to the terms of the application Final on file in 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 Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION TARTS Rough .......................... Service ............... ....... ......... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. i • Smoke Det. SEE REVERSE SIDE v North Andover MIMAP October 29, 2013 • a A �y ° r m � �9 a .rax S , n - - I w e I M a I •� � C/ Aid .� v f � r , As � Im a Interstates Interstate —Major Roads Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83, Roads Meters Data Sources:The data for this map was produced by Merrimack N0i Valley Planning Commission(MVPC)using data provided by the Town of {;r Easements 0t,t`° North Andover.Additional data provided by the Executive Office of 0 MVPC Boundary ? �° r°�°C0 Environmental Affairs/MassGIS.The information depicted on this map is [1 Parcels 3 L for planning purposes only.It may not be adequate for legal boundary F -^ 9 definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING M ; THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY • i + ; OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT o� _ �� ♦ ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF .j� •o���iu�A•``tg THIS INFORMATION �SSAtNUSet 1"=32ft •— ° '0 �0 t0 Q 0 0 0 D 0 0 Q ( Q O O 0 O O O O O O 20 44,2 Oj rvoN JAP Ila s f 0 0 0 0 0 0 0 0 0 0 (o 0 o 0 0 0 0 0 0 0 ' 0 0 North Andover Board of Assessors Public Access Page 1 of 1 r i NORTH North Andover Board of Assessors O • _ +F 9SS4CHUSEt Sroperty Record Card Click Seal To Return Parcel ID :210/069.0-0002-0000.0 FY:201.3 Community : North Andover SKETCH PHOTO Click on Sketch to Enlarge Click on Photo to Enlar e Search for Parcels Search for Sales \ � h= Summarya Residence f Detached Structure �� , t, Condo 11 61M AVENUE Commercial Location: 11 BIXBY AVENUE Owner Name: STEPHENSON,ROBERT A DEBORAH A STEPHENSON Owner Address: 11 BIXBY AVENUE City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 5-5 Land Area: 0.11 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 1806 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 284,800 267,500 Building Value: 141,200 121,600 Land Value: 143,600 145,900 Market Land Value: 143,600 Chapter Land Value: LATEST SALE Sale Price: 55,000 Sale Date: 02/28/1986 Arms Length Sale A-NO-FAMILY Grantor: STEPHENSON JOHN Code; Cert Doc: Book: 02140 Page: 0234 http://csc-ma.us/PROPAPP/display.do?linkld=2254958&town=NandoverPubAcc 10/25/2013 / TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY _ PROPERTY OWNERy �y -j �zz- f2/ -ser^) - Pri t 100 Year Old Structure yes no. MAP NO: PARCEL: ZONING DISTRICT: . Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other eseptic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District VWater/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Rif�?I+Z& -- /tcg9l.4cgl' id r,.n4z AM.QScf Identification Please Type or Print Clearly) OWNER: Name: R-m �tfh-"i 5r if-12 rg,✓ Phone:?7F S-671666 Address: CONTRACTOR Name: .$-t S u x Phone:. c� - !0 G 6 Address: Supervisor's Construction License: G S 0 1/ 3 Exp. Date:c�S' Home Improvement License:) „ Z6 5' _ Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT.$12.00 PE $1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: a o FEE: $ Check No.: 7e2e7 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund r Signature of Agent%Owner� � Signature.of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Location No. � Date �G . - TOWN OF NORTH ANDOVER v Certificate of Occupancy $ ,� Building/Frame Permit Fee---------------- $ ��— �' Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# 7L, 4 a 2 6 056 ilding Inspector A Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE:OF`,SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBodyArt ❑ .. Swimming Pools ❑ Well ❑ Tobacco.Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc_ ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM . .. DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ` ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Siqnature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes- .- Planning es .Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Tow;,, Engineer: Signature: Located 384 Osgood Street Iit�E DEPARTIVIF_NT =Temp Dumpster on site yes. no Located at 124 Mair, Street Fire,Departinerit-signature/date COMMENTS i Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 40,000.00 m $ - $ 480.00 Plumbing Fee $ 60.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 60.00 Total fees collected $ 700.00 11 Bixby Avenue 089-14 on 7/26/13 Repair and Replace from fire damage North Andover MIMAP October 28, 2013 AL IT k » v 3 w a i "G r z xtS y iT ^^ms�ss'�.. ,: .. • .f. . '�` Q t N ylnterslales —Interstate —Major Roads Hod—tal Datum:MA Staleplane Coordinate System,Datum NAD83, Roads Meters Data Sources:The data for this map was produced by Merrimack NORTH Valley Planning Commission(MVPC)using data provided by the Town of C,EasementsOf,�Sao r•q�O North Andover.Additional data provided by the Executive Office of C3 MVPC Boundary r ee •6 O Environmental AffairslMassGIS.The information depicted on this map is L 7 Parcels 3' L for planning purposes only.It may not be adequate for legal boundary FO o definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING It IWIVOW ; THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY ^ ; OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT �o�q w.. • ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION �SSACMUS�t 1"=53ft ^�° ��e�avrzna�ncuecc�G�a���aJaa�uae ffice of Consumer Affairs&Business Regulation OME IMPROVEMENT CONTRACTOR egistration. '467.63 Type: Expiration: 5/12/2015 Individual ROBERT STEPHENSON ROBERT STEPHENSON 11 BIXBY AVE. NO.ANDOVER,MA 01845 Undersecretary i Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supenisor License: CS-011353. ROBERT A STEPPENSON , 11 BIXBY AVE : 1ej ~: N ANDOVER Mrd 01845 4} " ilk Expiratioi Commissioner 05/22/201 i �oRry TOWN OF NORTH ANDOVER • O4,Ytec��'4y .`a 4L OFFICE OF Td-• BUILDING DEPARTMENT • e° 1600 Osgood Street Building 20 -Suite 2-36 x7q °R,n°r4a �y •North Andover,Massachusetts 01845 . SSACHt15� Gerald A.Brown Telephone(978)688-9545 IuspectorofBiiildings - Fax (978)688-9542 L HOIVIEOWNER'LICENSE EXEMPTION 113UMING PERMIT APPLICATION Please punt DATE: JOB LOCATION: Number Street Addres . Map/Lot O I� MEOVdNER Name Hom Phone WorkPhone PRESENT MAILING ADDRESS �.�,yl• Cites Tn�m Sfµt�. zip Code The current exemption for"homeowners"was extended to include owner-occupied dwellings to two units or less and to aI1ow subh homeov%Hers to engage an Ldividuabfor bire who c?oes not possess a license,provided That the owner acts as supervisor). State Building (Code Section_108.3.5.7) DEFINITION OF HOMEOWNER Person(s)who awns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family structures. A person who constructs more that one home in a two-yearperiod shall not be. considered a homeowner. The undersigned"homeowner"assumes responsibility for compliances with the State Building Code and other Applicable codes,by-laws,rules andregulations. The undersigned"homeowner"certifies that he/she understands the Town of gorth.A.ndover Building Department minimum inspection procedures and requirements and that he/she will comply with,said procedures and requirements, HOMEOWNERS SIr3NATWT •/�i APPROVAL OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption 'BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 685-9535 ' Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions._ Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A=F and G min.$100-$1000 fine NOTES and DATA— (For department use ® Notified for pickup - Date E Doc.Building Permit Revised 2010 Building Department The fol:owing is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofirg, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Li Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products i NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit i New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit I i In all cases.if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apt),-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application f Doc: Doc.Bui?ding Permit Revised 2012 R TOWN OF NORTH ANDOVER Office of the Building Department NORTH q o Leo , ti Community Development and Services rytttl 6 °O t _ - A 1600 Osgood Street, Bldg. 20,Suite 2035 North Andover, MA 01845 978-688-9545 7q �RATeD rPa` (� SSACHUS�� Gerald Brown, Building Inspector September 9, 2013 To:Anderson Adjustment,Attn:Wade Anderson Fr: Gerald Brown Re: 11 Bixby Avenue Dear Mr.Anderson, Per IRC 2009 guidelines the girder for the home located at 11 Bixby Avenue was required for structural upgrade due to damage by fire at the same address. Please see attached engineering report from Lawrence Ogden, P.E. stating same. Sincerely, Gerald Brown Building Inspector 44 � � R TOWN OF NORTH ANDOVER Office of the Building Department � pORTi♦ q 0 Community Development and Services , °p 1600 Osgood Street, Bldg.20, Suite 2035 North Andover, MA 01845 e 978-688-9545 HCHU`����� Gerald Brown, Building Inspector September 9,2013 To:Anderson Adjustment,Attn:Wade Anderson Fr: Gerald Brown Re: 11$ixby Avenue Dear Mr. Anderson, Per IRC 2009 guidelines the girder for the home located at 11 Bixby Avenue was required for structural upgrade due to damage by fire at the same address. Please see attached engineering report from Lawrence Ogden, P.E. stating same. Sincerely, Gerald Brown Building Inspector LAWRENCE H. OGDEN, PE. 198 EAST MAIN STREET GEORGETOWN, MA 01833 978-352-8318 cell 978-502-5921 lhogden(a comcast.net August 27, 2013 Mr. Robert Stephenson S&S Building RE: 11 Bixby Ave,North Andover, Ma.01845 Dear Mr. Stephenson As you are aware I prepared a Sketch Dated 8-5-13 for the repair of a girder supporting the second floor area which'sustained fire damage at the above address. The purpose of this was that the existing girder was insufficient to support the second floor live load of 30 PSF and deflection critera as required by the Massachusetts State Building Code for 1&2 Family Residences. Should you have any questions please do not hesitate to call. Yours truly, H OF (/ g Lawrence H. Ogden, P.E. Sj 0353 Ild e o it, 5m a v5�rrv) C 0 � q � v 16 - J - Date........" ......../...�5...... OF TOWN*-OF NORTH ANDOVER PERMIT FOR WIRING 88ACHU This certifies that ......T........ .......... .6 Z etl-ts &Z-&-7 . .............................................................................................. has permission to perform ............ ........?5�ee.E......�6................ wiring in the building of..,.................:�Y. ....................................... ............. ....... North Andover,Mass. . .............................i� Fae...75 ...L i c.N o#4..2. ELECTRICAL INSPECTOR` 3 Ll Check# r) Commonwealth of Massachusetts Official Use Only 32- ` -- Department of Fire Services Permit No. � - = Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS (Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All Rork to be performed in accordance with the Massachusetts Electrical Code(MEC);527 CMR�1•-20-0 J (PLEASE PRINT IAT INK OR TYPE ALL INFORMATION) Date: c 5 6 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of ' or her in ention to perform the electrical work described below. Location(Street&Number) l/� / Owner or Tenant Telephone No. �1 d Owner's Address Is this permit in conjunction with a building per it? Yes No ❑ (Check Appropriate Bog)08 — I Purpose of Building Utility Authorization No. " Existing Service Amps l Zd/ ;�qwolts Overhead Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity e Location and Nature of Proposed Electrical Work: Com letion of the followingtable may be it oh-ed by the lrrs ector o 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- o.o Emergency Lighting rnd. ❑ rnd. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones r _ No.of Switches 7 No.of Gas Burners No.of Detection and Initiating Devices 4 No.of R ages G41� No.of Air Cond. Toons No.of Alerting Devices No.of Waste Disposers Heat Pump I K-W No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers ` Heating Applianc s Kir Seeutity Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts I No.of Devices or Equiv.alent No,Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent OTHER: Attach additional derail i desired,or s required b- � dd e f r d, a r eq rr ed 1 the Inspector•of Wires. Estimated Value of Electrics Wprk: a/� (When required by municipal policy.) Work to Start: inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless ` the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify) I certl fj,under the pains rtntt pettRlties ofperjury,that the information on this application is tree and complete FIRM NAME: � L. ` P �a LIC.NO.: Licensee: Vpg 1, C `P f Signature LIC.NO.: "-7 (1f applicableteyter `AN""m tiree i en prber•line) Bus.Tel.No.; Address: ((�> L Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not lim7e 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: $ K ��� �- 1-� �l� � f � _ate � � � The Commonwealth of Massachusetts m Department of Industrial Accidents ir Office of Investigations ' 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information /^ Please Print Legibly Name(Businessl0rganization/Individual): � & CS' r C,, Address: wo plea�sd Nl -� City/State/Zip: k). A !qdo fir. � 4— Phone#: ? Are you an employer?Check the appropriate bog: Type of project(required): 1.❑ I am a employer with 4. E] I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2.Q I am a sole proprietor or partner- listed on the attached sheet. 7.`<Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' insurance." 9. Q Building addition [No workers comp.insurance comp. required.] 5. We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeolAmer doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs � insurance required.] 152, 1(4),and we have no ' c. employees.[No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#1 must also 611 out the section below shoning 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 tris box must attached an additional sheet shoo-ing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their uorkcrs'comp.policy number. 'lam an employer that is providing ivorkers'compensation insurance for my employees. Beloit,is the.policy and job site ii%formadon. 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(shovving 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 fuse 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 Idvestigations of the DIA for insurance coverage verification. I#'o hereby certo7 under the pains and pefu ' of pedurt}that the informationprovided above is true and correct. Sianatw•e: Date - Phone#: Official use only. Do not somite in this area,to be completed by city or toren official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Tovrn Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Date � Sw4°ILN�.IGYA,•.. •1 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . . . .'. . !. /�Jf , has permission for gas installation . !Irl.f�� ���✓ , . . . . in the buildings of. . . J7.P���`S a , . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . ./.;�!X.?J . . T , , , , , , , , , . , North Andover, Mass. Fee ./4 . Lic. No./�at'7. . . . . �� . . . . . . . . . . . . . . . . . . . . GASINSPECTOR Check# (pkv 8821 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK y 1 - CITY I NORTH ANDOVER MA DATE 8112113 �PERMIT# 00 I JOBSITE ADDRESS 11 BIXBY CT _j OWNER'S NAME STEVENSON GOWNERADDRESS SAME TEO FAXL � TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL EJ PRINT CLEARLY NEW:El RENOVATION:El REPLACEMENT:0 PLANS SUBMITTED: YES[J NOLI APPLIANCES Z FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 _ - BOOSTER CONVERSION BURNER ;� COOK STOVE j 4_m uy 1 �._ M DIRECT VENT HEATER � ,_ � ._. I_r �..� � i _ ,,_____�._..� DRYER a FIREPLACE FRYOLATOR FURNACE F .��-,�,,-� �,�� . ._ _.' � ,I, I E y ' GENERATOR _ _ E GRILLE INFRARED HEATER LABORATORY COCKS 1 _ aI, MAKEUP AIR UNIT OVEN POOL HEATER __._ _ ROOM/SPACE HEATER ! �._.�. ROOF TOP UNIT TEST ;- P ' UNIT HEATER UNVENTED ROOM HEATER WATER HEATER_ = -- ------ .____._ OTHER -�.. A INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 4/n�jy� LIABILITY INSURANCE POLICY Ej OTHER TYPE INDEMNITY Q BOND El �U V� j OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER [j AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance wit e ' nt provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASATTER NAME I MIKE CAPELESS LICENSE# 15851 S NA URE�— MP 0 MGF ED JP L] JGF E] LPGI CORPORATION(]# PARTNERSHIP E:J#=LLC L]# COMPANY NAME:j THE BOILER GUY/MIKE CAPELESS ADDRESS 160A PLEASASNT ST � CITY NORTH ANDOVER j STATE MA ZIP 01845 TEL FAX _ -=CELL Y�EMAIL it COMMONWEALTH OF MASSACHUSETTS PLUMBERS AND GASFITTERS LICENSED AS A MASTER PLUMBER MICHAEL N CAPELESS 105 TYLER ST METHUEN MA 01844-1905 15851 05/01/14 176378 10099 Date/W . . . .,3 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING )this certifies that . . . !. . !! . . .. . . `. . . . .. . . . . . . . . . . . . . . . . . has permission toerform . . . . . e.x. u^*-�. � �s .r plumbing in the buildin s of. . . .'!(.`. . . . . . . . . . . . . . . . . . . . . . . at . . . . . �/ . .✓! x. . . �`" . . . . . . . . . . .North Andover, Mass. 6.00 Fee (O _'. . . Lic. No. . . . ... . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check# [ Q �_/� 6'h- 7/6/r3 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY I North Andover MA DATE 4/12L k1rj I_q_,=PERMIT# JOBSITE ADDRESS 11 Bixby Ct OWNER'S NAMEJ Stevenson P OWNER ADDRESS I I TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIAL Ej PRINT CLEARLY NEW:® RENOVATION: REPLACEMENT: PLANS SUBMITTED: YESE] NO® FIXTURES"I FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM I DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM 3 DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK 1 LAVATORY 1 ROOF DRAIN SHOWER STALL 1 . SERVICE/MOP SINK TOILET 1 URINAL WASHING MACHINE CONNECTION 1 WATER HEATER ALL TYPES 1 WATER PIPING 1 * OTHER IL INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO E] �I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW ' �p 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ® AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true a accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in comp i., ce all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Mike Capeless LICENSE#1,15851__j v v S NATUR MP[3 JP® CORPORATION®# PARTNERSHIP®# LLC # COMPANY NAME I The Boiler Guy ADDRESS 160A Pleasant St CITY North ANdover STATE= ZIP 121845 j TEL 9783821017 FAX 1.� CELL I EMAIL i i r 's i' COMMONWEALTH OF MASSACHUSETTS PLUMBERS AND GASFITTERS LICENSED AS A MASTER PLUMBER iSSt;ES r•,E AR^VE UCE.NSk '0 MICHAEL N CAPELESS y s a 105 TYLER ST METHUEN MA 01844-1905 —� 115851 05/01/14 176378 r I i i Location No. v Date • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ vigBuilding/Frame Permit Fee $ a Foundation Permit Fee $ � Other Permit Fee �4 $ TOTAL D� e r4 b $ Check#�U 26632 Building Inspector TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER Print 1 00Year Old Structure yes no MAP NO: -7 ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ©'One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial f ❑ Repair, replacement ❑Assessory Bldg ❑ Others: Ci6emolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer F WORK TO BE PERFORMED: Ide ication se Type or Print Clearly) OWNER: Name: e Phone: �zl el�' 1_j a 77 Address: - CONTRACTOR Name:t Phone: F7'd . Sc 7,-a 4'6_ _ Address: e- )CI H L Supervisor's Construction License:C 5 Q// S� 5 Exp. Date: Home Improvement License:l � 7 __ __ Exp. Dat � ' yG ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. �-o D Total Project Cost: $ ' '24 FEE: $ Check No.: —7 P --R- Receipt No.:-.,Q (ado NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund Si nature of A enVQ6 ner -� - SI filature of contractor :V__ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ &mp"`eed Plans ❑ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE-OF.SEWERAGE:DiSPOSAL Public Sewer Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank, etc. ❑ Permanent Dumpster on Site ❑ 1 THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature G�0-- MMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes .- Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/si nature& Date Driveway Permit DPW Tow;. Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMF=i�T = Temp Dumpster on site yes_ no Located at 124 Main Street Fire Departinert,signature/date r COMMENTS i ,,oRTy TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT 71600 Osgood Street Building 20,.Suite 2-36 North Ambver,Massachusetts 01845 SA�Hus�. - Gerald A.Brown Telephone(970)688-9545 Inspector ofBuildings Fax (978)688-9542 HOMEOWNER-LICENSE EXEMPTION GUIDING PERMIT APPLICATION Please print DATE: j6B LOCATION: /• ` X Number StreetAddres Map/Lot TIOMEOWNER Name Hom Phone WorkPhone PRESENT MAILING ADDRESS � �lir1 Cit;Town zip Code The current exemption for"homeowners"was extended to include owner-occupied dwellings to two units-or less and to allow su;b homeot'iMers to engage an iDidividual•for hire Who does not possess a-license,provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) DEFINITION OF HOMEOWNER Person(s)who awns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family structures. A person who constructs more that one home in a two-year considered a homeowner. period shall not be The undersigned"homeowner"assumes responsibility for compliances 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 Forth Andover Building Department minimum inspection procedures and requirements and that he/she will comply with,said procedures and requirements, HOMEOWNERS SIGNAT APPROVAL.OF BUILDING OFFICIAL Revised 7.2009 Form Homeowners Exemption BOARD OF APPEALS 68B-9541 CONSERVATION 686-9530 HEALTH 688-9540 PLANNING 688-9535 � 15'.' Town of Andover to No. - : .1111, h ver, Mass, • 13 coc MCMIWIC« y1. S V BOARD OF HEALTH Food/Kitchen PERMIT T LID Septic System THIS CERTIFIES THAT ..0.1U + .P ................... BUILDING INSPECTOR ................ .. ...r........... ........ Y �. "....................... Foundation has permission to erect.......................... buildings on ....�.�.......... ��(. ......!� Rough to be occupied as ............ :�j� o.............. .........�......... .. ............................... Chimney provided that the person epting this permit shall in every respect conform to the terms of the application Final on file in 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 Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO A T Rough Service ..................VD..... .......... ................................ Final O BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE Massae husetts -Department Of Public Safety 8oarq of Building Regulations Construction su ns and Standards ice Per�isor L _ nse: CS.011353. ROBERT A11 BVCBY STEP NANDO AVE �,v �R MX- 0 18 4'5 �i lit t.t Commissioner Expiration 05/22/2014 fTice of Cousin OME 1 mer Affairs c:1aa%caeCGi &Business Regulation e iistra ion O 446763 COWTRACTOR - -_ xpiration: ,14&763 5/12/2015 Type: ROBERT STEPHENSON. Individual ROBERT STEPHENSON 11 BIXBY AVE. NO.ANDOVER,MA 01845 Undersecretary The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/EIectricians/;Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): -I(— AieflYt,a C&I U f a Address: Y�, 0 City/State/Zip: 6 AZo L,-C,1- // � Phone#: 9 7J ov-G 7/ o 6 �, Are you an employer?Check the appropriate box: Type of project(required): 1.RI am a employer with 1 4. ❑ T am a general contractor and I ' 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.? 7 E]Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their ME]Electrical repairs or additions 3. 1 am a homeowner doing all work right of exemption per MGL 11.[]Plumbing repairs or additions myself.[No workers' comp. c.152,§1(4),and we have no 12.0 Roofrepairs insurance required.]i employees.[No workers' comp.insurance required.] 13.❑Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. !Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy#or S elf-ins.Lic.M Expiration Date: Job Site Address: City/State/Zip: Attach a,copy of the workers'compensation policy$eclaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A ofMGL 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 maybe forwarded to the Off-ice of Investigations of the DTA for insurance coverage verification. I do hereby certlo under thepains andpenalties ofperjury that the information provided above is true and correct. - Signature: Date: -11 v l l a 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.CitylTown Clerk 4.Electrical Inspector 5.PIumbing Inspector [6.Dther - - - Contact Person: Phone#: Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions._ Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A-F and G min.$100-$1000 fine NOTES and DATA— (For department use I I B Notified for pickup - Date S Doe.Building Permit Revised 2010 Building Department The fohowing is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofiii Siding,g, nterlor Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster.permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New ConstructionSin le and Two Family) � g Y) { ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit i In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apt)%-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm-ated with the building application Doc: Doc.Building permit Revised 2012 �. Date..........:........ ........................ r►ORT�y TOWN OF NORTH ANDOVER PERMIT FOR WIRING $8�cHus� »This certifies that ......v......C"-... .�!.'.�.��.....! :.. y7f'.rc.. ..f.................. has permission to perform �P166,,�,� �v: r �i"9�✓ C'lx-(7 wiring in the building of.alo'"p"- -ov at .......,.. .........'� . .............North Andover,Mass. ,.. �..................k .{--................ Fee. ..`.'r...........Lic.No. 277 ......../! .................................................... / ELECTRICAL INSPECTOR Check# /��� v- Commonwealth of Massachusetts Official Use Only - a , Department of Fire Services PemntNo. if BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked [Rev.I/071 (leave blank) 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 PRI NTW INK OR TYPE ALL INFORMATION) Date: 3 - -7 - "3 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) i X 6 7 (J Owner or Tenant R 6_P n F- 9`-(-e V o K cd Telephone No. P 47 2 -96-7=1 � Owner's Address �-,C., M Q Is this permit in conjunction with a building permit? Yes ❑ No [1] (Check Appropriate Box) Purpose of Building i.� �� - N 1 (S Utility Authorization No. 3 3 3 -d� Existing Service l G Q Amps / Volts Overhead — Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity ( q :',r 2 + Reco r al- Location and Nature of Proposed Electrical'Work: u n h P-4, ex t C1 vrc U t rPr k o b'd SO P u rep Re rh o u o u 0 t^ , r U 1,cl S -F'^o n1 2, ),a-I .0 w sa-�s� L c,►���( #L Completion o theollovin table m LY be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell:Susp.(Paddle)Fans No.of Total Transformers RVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- El o mergency Lighting rnd. rnd. Ba tLery 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. Tonsl No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons ' KW No.of Self-Contained k Totals: "_"__""__"""_"'""_" "'_ Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other y' Connection No.of Dryers Heating Appliances Kyy Security Systems:Y No.of Water No.of Devices or E uivalent ,of No.of �' NoData Wiring: Heaters Sians Ballasts No.of Devices orE uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: OTHER: No.of Devices orE uivalent Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: 3 G . (When required by municipal policy.) Work to Start: 3--7-1,3 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 Y the licensee provides 1 a p vzdes 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 2- BOND ❑ OTHER ❑ (Specify:) X certify,under the pains and penalties ofperjury,that the information on this application is true and conplete. FIRM NAME: !\ P N c C v LIC.NO.: Cf 9 7 Licensee: TC�J Pa 1. (y Le is Signature LIC.NO.: _ D (Ifapplicable, nter`exe pt"in the license number line.) ,Bus.Tel.No.: : 7k'�/.S�( 3�� Address; _ 6 O Ple . SG+n l S{ N. R he)a w P lg Q(b �S Alt.Tel.No.: *Per M.G.L c. X47,s.57-61,security work requires Department of Public Safety"S"License: Lie.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)El owner F1 owner's a ent Owner/Agent Signature Telephone No. PERMIT FEE:,$ JE��cCT�S�y/.�A��y�{���'y}}}E���■'.["?��{�.�■y��C.jC��•'e�t.�I.�'{®p�•7.• P ��./• p/-�p•p.�� �1����i����TP®?��: �- _ i.lKLVV!„f'�.fI..L.G.W.+�4{��G�V�V.R.0.� ' • .. ._ r, __� 1 , � R d..R0U•T1.{.s1rF7FCT:LUJ.Qe . �'�sset�-,[ �� S�'ailefl--[ � fie-inspection xequi�rec�($50.OQ)•-[ � �'nspectoxs'camm�e�afs: - (JCnspectore Signature-xto ktials} Date x'assed--[ ) +afIed--rLc-3cnspectioxtxe�uixec�($50.00)�[ �t�pectoxS'comm.enfs: ' (lis iectoxs'pignature-•no iniEials) Date 3,MOER GROUM WSTF,CTION: pgla ed—j 1 +ailed—j ) ?�Ze-ittspectzonxeciufrec 050.00) [ J Tnspectoxs'comments: (Tuspeetoxs' ignatuxe• no initials} Date DATE Well— Re-znspec�onxequired($50AD) [ hnspecibx Comm. (Zuspector ,�igna e Sao initials} Date WSPECTxON-•OVER: 'assed--[ ) p+ailed- [ }- 'Re-insp ection xequired($50.00)•-[ 7 aspectoxe comments: - Gln specfoxs'i9ignature no initials} Date D 0 OR T A.G15.AM TO BE I+)`I1I,ED OYT AM UFT ON RITE Iff TM.ARVA TO DE INSPECTED IS NOT .ACCESSIBLE.AND A.RMUSPECTXON OF 550,0 019 TO EF,CHARGED. i The Commonwealth of Massachusetts - Department of IndustriqlAccidints Office of Investigations 600 Washington Street Boston,MA 02111 Uf www.massgov/dia Affidavit: Builders/Contractors/Electricians/Plumbers Workers' Compensation Insurance Please Print Leib Applicant Information l � v Name(Business/Organization/Individual): J G L-e�'iS �{ c e5' J. Address: e, 191easo M 1 h City/State/Zip: N l`1 0 Phone Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. [:]New construction employees(full and/or part-time).* have hired the sub-contractors 7 ❑Remodeling listed on the attached sheet.I 2.❑ I am a sole proprietor or partner- Demolition ship and have no employees These sub-contractors have g• ❑ _• working for me in any capacity. workers' comp.insurance. 9. []Building addition n and its are a corporation 'tions 5. e repairs or adds ce 10. ectrical repair [No workers comp.insurance their [(�Er officers have exercised th required.] 11.E]Plumbing repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL c. 152,§1(4),and we have no 12.❑Roof repairs myself. [No workers comp. 'employees.[No workers insurance required.]f13.0 Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: R t XL14 y A City/State/Zip: c' P4_ hd4o °' /Lfj* Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage uiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a as re q fie up to$1,500.00 and/or imprisonment, s as well civil penalties eORDER d a fie e Be advised that acopy of this statement may be forwarded d tto the p e of up to$250.00 a day against th Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and per. s of perjury that the information provided above is true and correct. Date: -3 ^ l 1 Signature: 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 Contact Person: Phone#: Information and Instruction's 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-contractors)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 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 Gou onwealthofMassachusetts Department ofladustrial Accidents Office of Investigations. 600 Washington Street Boston,MA.02111 TeX,#617-727-4900 ext 406 or 1-877�,MASS.AFE Revised 5-26-05 Fax#61.7-727-7749 www.mass.govaa, .COMMONWEALTH OF MASSACHUSETTS " •7�Al�Cm3�i c•T�,�:r1��'S-�Cl`.� _.c�:��:;��- a -i. m;� ELECTRICIANS REGISTERED MASTER ELECTRICIAN ISSUES THE ABOVE LICENSE TO: i J G LEVIS ELECTRIC CO INC JOSEPH G LEVIS 160 PLEASANT ST NORTH ANDOVER MA 01845-2706 ' 9979 A 07/31/13 880292 t THEW0R1F0LK DEDHA �fli GROUP@ December 21, 2012 FORM OF NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B Building Commissioner, or Inspector of Buildings c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Board of Health or Board of Selectmen c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Fire Department or Arson Squad c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 RE: Our File No.: P1252210 Insured: ROBERT A STEPHENSON DEBORAH A STEPHENSON Address: 11 BIXBY AVENUE, NORTH ANDOVER, MA Policy No.: F0105900 Loss Date: 12/18/2012 Loss Type: Building or Other Structure Damage A claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Ch. 143, Sec. 6 to be applicable. If any notice under Mass. Gen. Laws, Ch. 139, Sec. 36 is appropriate, please direct it to my attention and include a reference to the captioned insured, location, policy number, loss date and claim or file number. If no reply is received from your office within ten days, we will assume you have no liens of any type against this property, and the claim will be paid in our customary manner. Sincerely, Michelle M. Roust Senior Property Claims Examiner 1-800-688-1825 x1171 NORFOLK&DEDHAM MUTUAL FIRE INSURANCE CO. 222 Ames Street,P.O.Box 9109,Dedham,MA 02027-9109 DORCHESTER MUTUAL INSURANCE CO. Telephone:(800)688-1825 FITCHBURG MUTUAL INSURANCE CO. Fax:(781)329-1818