HomeMy WebLinkAboutMiscellaneous - 112 AUTRAN AVENUE 4/30/2018 (2) - J -112 AU7RAN AVENUE
210/045.p_0015-0000.0
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Locatiogy—
No Date Zo cvk�—
TOWN OF NORTH ANDOVER
e
Certificate of Occupancy $
Building/Frame Permit Fee
Foundation Permit Fee $
Other Permit Fee $
' : :TLI), TOTAL $
Check# 39(4-57
25893 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
z Print
PROPERTY OWNER gl-r,� Ile/
Print 100 Year Old Structure yes (no
MAP NO: PARCEL5 06� ZONING DISTRICT: Historic District yes Machine Shop Village yes
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑ Septic 0 Well ❑ Floodplain ❑Wetlands ❑ Watershed District
❑Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Q Q
Identification Please Type or Print Clearly)
OWNER: Name: C' �c� ,,�ErC-Lt�- Phone:9?,0—
Address:
CONTRACTOR Name: /r ��—� .1%G1 S Phone:i:;�l? -
Address: ZZ
. Date:Ex'
Supervisor's Construction License:
p ` p
Home Improvement License: Exp. Date: tO
ARCHITECT/ENGINEER Phone:
I
Address: Reg. No.
FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ �1 2 FEE: $
Check No.: ��,� Receipt No.: �b ! 3
III
NOTE: Persons contracting with unregistered contractors do not have access to he guaranty and
Signature of Agerit�Owner Signature of contra I
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Sta ed Plans ❑
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
o 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)
o Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal 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
Doc: Doc.Building Permit Revised 2012
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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 ❑
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THE FOLLOWING SECTIONS FOR OFFICE USE ONLY �
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
I
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
I � �
Conservation Decision: Comments
! Water & Sewer Connection/Signature& Date Driveway Permit
]DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Departrnedt signature/date
.COMMENTS
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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
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El Notified for pickup - Date
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Doc.Building Permit Revised 2010
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NORTH
own of E ., ndover
o - to
No. _T
kgih ver, Mass, b I• I �,.�
C OC NIC N�WtCN ���
A0
4ATE9) PJr' (�
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BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
THIS CERTIFIES THAT .....................�s.kwote........!��?u . ............ BUILDING INSPECTOR
.
�` Foundation
has permission to erect .......................... buildings on ..�.lJh. ...�.�... ......... .. . . ............................�
Rough
to be occupied as ........ '"""Y'""....... ..... .!`1�..�1... ......... .............................................. Chimney
provided that the person accepting this permit shall in every res c onform 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
Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit.
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCT ARTS 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.
Smoke Det.
SEE REVERSE SIDE
Proposal for Carpentry Services
Michael Naples *MA CSL#94290
I l Clayton Street *MA HICR#153013
Lynn,MA. 01904 *EPA Lead Safe Certification
1-617-257-1443 NAT-43847-1
_ - aceary ue augu ,
Phyllis&Hugh Jones
112-114 Autran Avenue,
North Andover,MA.
I hereby submit cost and specifications for labor and materials for work to be performed
at 112-114 Autran Avenue,and to consist of:
• Roof
Strip existing roofing and install architectural style shingles.
Install ice and water underlayment where necessary.
Install new ridge vent.
Add more vents at soffit to increase attic ventilation.
• Attic
Install bathroom vent kits to exhaust air through roof.
Remove and replace damaged insulation.
-- ---,--Install ventilation-channels:
Treat discoloration on plywood with a spray on solution.
• All construction debris will be removed from site.
• Contractor will acquire necessary permits.
• A spot for a dumpster will be required in the driveway.
• Scheduling for start of work will be done once proposal is signed.
The total cost in accordance v nth the above st ecif cation-S is: $8,500.00
$4,000.00 to be paid upon signing of proposal and the balance to be due upon completion
of work. (please make checks payable to Michael Naples)
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The Commonwealth of Massachusetts
t 1 Department of Industrial Accidents
t Office of Investigations
t / 600 Washington Street
Boston, MA 02111
•i www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information _ Please Print Legibly
Name (Business/Organization/Individual):
Address: //
City/State/Zip: G Phone #:__,gZl'2
Are you an employer?Check the appropriate box:
1.❑ I am a employer with 4. F-1 Type of project(required):I am a general contractor and 1 T E]New construction
employees full and/or part-time).* have hired the sub-contractors 6.
{ p )
2.&1 am a listed on the # 7. Remodeling
sole proprietor or partner- attached sheet.
ship and.have no employees These sub-contractors have 8. ❑Demolition.
working for me in any capacity, workers' comp. insurance. q, ❑ Building addition
[No workers'comp. insurance 5.-El We are a corporation and its 10.7Electrical repairs or additions
required.) officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 l.❑ Plumbing repairs or additions
myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.]t .employees. [No workers' 13.❑Other
comp. insurance required.)
'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 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 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. Lic.#: Expiration Date:
Job Site Address: I(Y •L Ate 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and enalties of perjury that the information provided above is true and correct
Signature: Date:
Phone
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#•
1.4, ,44.:r4"
i Unrestricted-Buildings of any use group which
contain less than 35,000 cubic feet (991m)of
Massachusetts -Department of Public Safety Ienclosed Space.
Board of Building Regulations and Standards
Construction Supen icor
License: CS-094290
MICHAEL A NAPES :. ,
11 CLAYTON STREET r= Failure to possess a current edition of the Massachusetts
LYNN MA 0190-fv State Building Code is cause for revocation of this license:
For DPS licensing information visit: www.Mass.Gov/DPS
rxpiratiot>
Commissioner 06/20/2014
Office of Consumer Affairs and usiness Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 153013
Type: DBA
Expiration: 10/23/2014 Tr/f 232751
M.A. NAPLES CARPENTRY
MICHAEL NAPLES
11 CLAYTON ST
LYNN, MA 01904
Update Address and return card.Mark reason for change.
- Address Renewal n Employment F] Lost Card
DPS-CAI is 50M-0004-6101216
Date..
R
"oRT:AMo TOWN OF NORTH ANDOVER
p PERMIT FOR PLUMBING
t i i
,S$ACMUSE�
This certifies that `?. . . . .c..�. .� .�.,.t' : . ,�?!!.� . . . . .
has permission to perform . . . .'.... . . . . . . . . . . . . . . . . . .
plumbing in the buildings of . . . . . . . . . . . . . . . . . . . .
at. (I.. .-. . . . . . . . . . . . . . North Andover, Mass.
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Fee. .l>!.- .Lic. No./�. .a. - . .�. a. -C�. i. ... . . .
PLUMBING INSPECTOR
Check # `
4954
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER,MASSACHUSETTS
DateBuilding Location OwnersNameLatAN� n Permit# qr
Amount !J
Type of Occupancy
New Renovation Replacement Plans Submitted Yes No
FIXTURES
z
w x a �V
Q w
w H w H QCr
p a F -
'�
il
o CN ►� d d
151:IIOQ2
3M FLOM
4IH FLOCK
5IH FLOCK
6M FIO(R
7IH FLOCK
SIH FLOCK
(Print or type) Check one: Certificate
Installing RompanyName 11 Corp.
Address V, Q' Fi Partner.
Business Telephone Firm/Co.
Name of.Licensed Plumber.
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policyN& Other type of indemnity ❑ Bond
Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature 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 Plumbing Code4d— ter 1 of the General Laws.
By: igna o icense um er
Type of Plumbing License
Title
City/Town 1 nse Aumbpr Master Journeyman
APPROVED(OFFICE USE ONLY
y
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Location
No. '7Z Date
MORTN TOWN OF NORTH ANDOVER
3j ` ._ _ • ooc
f 9
4 ; : Certificate of Occupancy $
�',S''•°•E<� Building/Frame Permit Fee $
scmus
Foundation Permit Fee $
Other Permit Fee $
4
TOTAL $
Check # c ��X
18436
Building Ins6edor
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REP RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER: �? DATE ISSUED:
r �
SIGNATURE:
Building Ca Ione for of Buildings Date Z
SECTION 1-SITE INFORMATION O
1.1 Property Address: 1.2 Assessors Map and Parcel Number:
J 1 77LAAL/) Y57+ 1 U C) l
Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area Fronts 8
1.6 BUILDING SETBACKS ft
Front Yard Side Yard Rear Yard
Regaired L Provide Required Provided Required Provided
v
1.7 Water Supply M.G.L.C.40. 34)- 1.3. Flood Zone Information: 1.8 Sewerage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zona ❑ Municipal ❑ Oa Site Disposal System ❑ J
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 'iStfiCt: NO m
2.1 Owner of Record
P-H Ca L Li S on.f P S S PW
Name(Print) Address for Service
r V -7 —95 ' U�;—OQ
Signature Telephone
t
2.2 Owner of Record:
�Lth/ NffOC�t-moi BGcOZIy T�/ SBrl 0
Name Print Address for Service: z
Sibaftire Telephone 90
SECTION 3-CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: Not Applicable ❑
Licensed Construction Supervisor: 0
License Number
Address >i
Expiration Date ic
Signature Telephone r
3.2 Registered Home Improvement Contractor Not Applicable ❑
Home Depot t 2 G q ?)
Company-Name 345 Greenwood Street ! 0 M
Worcester,MA 01607 Registration Number r
Address �(J� r
�� Expiration Date z
Si na a
Telephone G1
t
SECTION 4-WORKERS COMPENSATION(MG.L C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes......X No.......0
SECTION 5 Descri tion of Proposed Work check aH appIlcable
New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Addition ❑
Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify
Brief Description of Proposed Work:
9
SECTION 6-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY
Com leted b permitapplicant
1. Building /
�' (a) Building Permit Fee
Multiplier
2 Electrical (b) Estimated Total Cost of
Construction
3 Plumbing Building Permit fee(a)x (b)
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5 Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I> as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf,in all matters relative to work authorized by this building permit application.
Signature of Owner
Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
C ,as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief
Print Name
Si ature of Owner/Agent Date
i
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR T VIBERS 1' 2• 3
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CBDANEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
NORTH
Town of
4Andover
No.
dover, Mass.,
O COC HIC HE WICK
t
�oRA T E D BOARD OF HEALTH
Food/Kitchen
PER T D
Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT. Foundation
............ ....................................................... .. ............................... .........
00
has permission to erect........................................ buildings on...����/...............................................1112...................... Rough
to be occupied as............. 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
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTIONT Rough
'5500( - Service
.........
.. ............................................................
BUILDING INSPECTOR Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
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.
SEE REVERSE SIDE Smoke Det.
North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
Number is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c11, S150A.
Home Depot
US Greenwood Street
The debris will be disposed of in: Worcester,MA 01607
(Location of Facility)
Signature of Permit Applicant
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
,x� ,
Aug 02 05 04: 53p Michael Bedard 1-401 -246-2868 p. 7
FROM•: KIMBLY FAX NO. : 6033629679 Ju1. 25 2005 09:21PM P4
RO?aQ0R/f?YEAl1.,N`rCONTRACT
Bmach Name: Date: �7{e13+5 Scold,FWltidW and Instailtd by'.
THD At-Horne 5avicm Inc.
dWO The RMN Depca At-Kine Se iws
r345A Gteeitaooai$tom d4^ILt%Nr,
MA0160-1
Branch Wamitcrt�+.....� Job th! 7 Tell Pees(&M)b.S7-5182: Fs.-SM"56 7159
F-waa nx 7s-Z§ W WU U d C o7t3U as Cast,1.e0 16421
G7 u:r 545522; MA hone 4mewwrst C.W—Iot Ra.++ld 12/ts,l UstaiU6.Ad&,= • / A(T�"/{f / (���j 'At/.!-- 3 ,0)
city State Zip
Law att9.�.a't r i!; M.tYrc wart,Rte I$FAW
Mame AddYcq:-
(If different from lesm[ligrion.4ddewsf City Stave
! I/We(Yott(•'Ptuchattr"),the oaVrtGti of she ptopatty Itxatad as shtt above inatalishan addttss,
eanttaer wtt r orae par V.S.A..lac.("''p�nc ')to ft�tish dettverand urmW For the i iationaPati awxriE
described on the attachM Spec Sheet Y: 1��� iz-wperated 1111fda ey rekM4M atsd wade a pill
FI�; �
tW--R$ rill b moral rely 061ract 14 Wilts m-bula Di or the job,Ibmt D*W
lb blipdoos due to a attacrtarai problems vvM liwR bottle air ltecame work Po4wM 10 cotapk
was am indtided is deemsraet,
DHPOSIT PkkMP.NT OPTIONS
1 (34ed m rued v.diebba.A.Wu crzdfit gpau )
�7 AAlOUNT S � K'I10cic, Ctadta[L'6 Paeul Ss.ias bleary CMdea
�*I.BSS118POBlT S I 2. GeaaCom+ eaw;mym=a*jut.suds0WSia, j
F
SALANCEDur �.+ V;aa DLenva Aaenic.tEapas �
ON COA'iP1LIrriam $ O The tSoaroDepa 3bkoe n YLo alma DOW C*
lelmam 1416 or cootr*a Awmat d w upab eantatka A�alhhte CeodlR t ML i ffi?L C ClLlry j
["ceetrad. Aasf: BW.Dda.
Na.e u 11 appunaa _,�.,,,
Indlealt Patmeat M*IhW For 'By RvIoor tt"Awt lo+., qsa to am H see now w.t,.
qA
BALANCE DUE ON COMPLL-n0 v: reteaxc.d cxsiu a forak dt tadic4ta!
�� t:au�2,aldvs•a tt; Aare
Hsi.ar B:IK, Authot'laatiaa Codes
Ik Piaaj 4 cnt
# if
Putcttsser gees(stat'unmodiaseiy gem stattrN story dtsrnpltaion tri the worst,Purdre.c will execute a Campfetion C
and pay any baltnca due. Pttscltaser ciao aVm to bo}oin4y ltd wvcr4ly o1ollgare9 acrd l labk hereunder.
f eaa at; d This aF=ma:ot and its attachments,irx1utiib(g aq fie me ng egteemew,contain the complese a�
ween t es and ren not he amenar modifiedtatJPss in xntang to a Separate eg into dju:d by boos putc
NOTICE TO PURCHASMi4
Do eel trate tWs eaatr&at We yen road it.You are catidod to s eompWoly aaalota copy at tpa coatryci c the lima you VI
is as#cobalt year rki co &2a not riga asy Compkllan Cerd&nk or Westover mating tb+t you are sgLw w11h ibe eatir
taciote tlth Projea9 b cam#tets La W pro to hater rq�eaote>LKan from repre�tfq�or sceepttag a Compltttaa CerMllca
mF tie uvraaC prt.r m the sK[sil compIctles at apt work to he per mlowd mad er thr cani-roet
Yon mty iter this tract*cdem at aay not prior to sddWti l of the tWrd bu4nors day ataerAcd.te or esti rotacm sec;
G.yacaagpa tar as eatptauaiisa of this rhVJgL Then w2l3a s urvW r egkW to 25%*r the centrad amaaaa(t Q
eaocstted*t4rshaatrr AF LR the ibkd hiMnos day. I
HY MY/OLJ2 SIGNATURE BELOW,to V&AQREE TO HH BOUND BY THE TERMS OF THits CONYXI. f.i/Wt AC'KNOIX,
RCC6iPT OF A COPY OF TdlS CONTRACT AND TWO COMPLETED COPIES OF THE NOTICE OF CANcEL:.AnoN.
BY MYkOUR SIGNATURE BELOW,UWE UNDERSTAND TEAT THE ArMEM�1T M SUBJWT TO REVLrW OF MY/OUR
CREDIT HISTORY AND IIWE AUTWRIZE HOME DEPOT AUTi14L=D CONTRACTOR.TO VERIFY AND REVIEW MWOUR
CREDIT REC'OR0 WITH AN INDEIENDINT CREDIT RIPORIT40 AISENCY AVD ARLWE THEM FROM ALL LSAoILITY
IWCVRRBO FROM IALIOV ISSI OK ERRORS, iia NOT INGN TSPS CONTRACT IF THERE ARE ACVV BLANff
SPACES.
SUBINIT TED BY: Date:
k '
ACCFPITO SV: Date: '
Date:
Hotata�
a:' � i°t'K fie' ta'ttDRf aND WAttR4Yt57»S'Att2.=TY'?OMMRlV=Zfia)E AYEAPSPART Or TFUCCLYrRAT
'fie-since Ale Yrtae.Q.tauaf tmY-Sda Ceewh.a
s-s t-os Csc
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AT-HOME installed
SERVICES Siding and Windows
Board of ammma"itAtliod mm am"#a. _
NOW CONTitAiCTOR License or registration valid for indivldul use only
before the expiration date. if found return to:
Board of Building Regulations and Standards
_ anent CardOne Ashburton Place Rtn 1301
Boston,Ma.02108
THE Plotrte
3200 COBS
ALTANTA,t3A 3QQ1BO r
Not vatld wltliout signstur
Location oZ !`�A hA N �U�2
No. ' Date �� �g -o3
gORTiy TOWN OF NORTH ANDOVER
:•,4O
Certificate of Occupancy $
#�7b''••"''<�'s
Building/Frame/Frame Permit Fee $ ��
ssACNust 9
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ t/O
Check #
16 7 7 'building Inspector
TO"I 'l OF NORTH-ANDOVER
- BIM D]NG_D PAR MENT
APPLICATION TO GrDNSTRU MW RRI OVA :ORrl> IOLIS$A ONE OR TWO FA>GA'DWffi.E:ENG
BIIII DINGPERMTP NUMBER
- DATE ISST7ED: o
70
SIGNATURE: L
Buildinof B ' Date- - _-
SECTION 1-SITE INFORMATION Z
1.1 Propaty Addn= - T.1 Assessors0
Map mld Pmcd Number:
2 AJIAye-
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L6 BUII DING SETBACKS ft
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SECTION 2-PROPERTY OWNERSHIP/AUTHORIZ1tD AGENT
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2.1 Owner of Record t 1
I..OYr G,�n{, O al tOr� [, y•1•tOr1•�
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Name(Prim) Address for Service
Signature Telephone
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N t Address for Service: Z
a. 64 661 f11
Si T hose
SECTION 3-CONSTRUCTION SERVICES QO
iconsed Construction Supervisor:-
Not Applicable a
IleensedCQnsfruction.Snpatvrsor• ..
T .
Address: Expusbon Daft.
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Srgnawre Telephone
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0 3.2 Registered Horne Improvemeqt Com Wtor. _ a Not APPS
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Company Name -�
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SwIaturc Tel - V
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2Fie Co=nonwealth of%1=sachuse=
W Depan=nt ofInductria1Ax dents
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off=o f esti
.rL,• .�.• �?LTlg ation5
600 Washzngtor,Strext
Boston A�A 02111
Workers'Compensation Insurance Afndavit
APPLICANT INFORMATION Please PRINT LtdhLy..
Name: Larr-a�ne.
Location: J 1 L, �J T V—&VI) /4L -
City' xY-A0,JeY- Telephone#:
❑ I am a homeowner performing all work myself.
❑ I am sole proprietor and have no one working in my capacity
2"I-am an employer providing workers'compensation for my employees working on this job
Company Name: R M ti' tlM S2r✓i C2S r �-r�
Address: .32-p C.oS� GL A 2.�► A Par /#20
City: A+'l c., Telephone#: &00 (,S'7'
S'1 —S187—
Insurance
SlgZInsurance Company: C ew►vr`t r a o 4- Policy#: LA--C. 216 9 b6 41
❑I am(circle one) sole proprietor,general contractor or homeowner and have hired the contractors listed below who have the following.
L_
workers' compensation policies:
Company Name:
Address:
City: Telephone#:
Insurance Company: Policy M
Company Name:
Address:
City: Telephone#:
Insurance Company Policy#:
Attach additional sheet if necessary
Failure to secure coverage as required under Section 25A of MGL 15B can lead to the imposition of criminal penalties of a fine up to $1,500.00
and/or one years' • risonment 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 cop of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
1 do hereby cc un er t e pains and penalties of perjury that the information above is true and correct.
Signature: Date: \�•��'D3
Print Name: ���� V t��cli _ Phone#
Official Use ONLY-Do not write in this area
o Building Department
City or Town: Permlt/License*:
C)Licensing Board
❑Selectmen's Office
o Health Department
0 Check if Immediate response is required 0 Other
INF oR1VA' oN &INST.12ucnoNS
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 anindvidual, 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 bean employer.
MGL chapter 152 section 2S'also-states that every state or local licensing agencyFshall 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
requirements of this chapter have been:presented to.the contracting authority.
Applicants
Please fill..in the workers' compensation affidavit completely,by checking the.bok that applies to your situation
and supplying company names, address and phone numbers as all affidavits may submitted to the
Department of-Industrial Accidents for.confamation 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'-snre•that-the°afFidavit=is=complete.andprinted: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 _5112in 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 your cooperation and should you have any
questions, please do not hesitate to give us a call. F _.
The Department's address, telephone anti,fax number:
The Commonwealth o`f Massachusetts
."'Departmienf'of ndustriaCAccidents
Office of Investigations:
600 Washington Street . ,
- — Boston,Na 02111
Fax# (617) 727-7749
Telephone# (617) 727-4900 ext. 406, 409, or 375
HOME IMPROVEMENT INSTALLATION CONTRACT
GDSOW,Furnished&Installed by
Plane,. tr ate: _ The Ham Depot Installed Sales
�_job#: ? 7 3 b�.3 345A Greenwood Sere,Worcester,MA 01607
Number: Tot!Free(800)657-5182; (508)756.6686. Fax:508-756-2859
Federal[DO 75.2699460 ME Lic N C 02439 RI Coat,Lies 16427 CT Lido 563522
MA��I��n ContractorReg.st26R93
�/ _ vA___—— U —
Instaliadon Address: CII, State Zip
g;;i rrtj �
s• ' 6;
Driver's Lie.k& a Work Phone: Iltatree Phone.
Home Address: State Zip
(if different from Installation Address) City
eofert;nfortnation UWe("Purchaser"),the owners of the property located at the above installation address,offer to
contract with The Home Depo o epot")to furnish,deliver and arrange for the installation of all materials as described
on the attached Spec Sheet p_ ,incorporated herein by reference and made a part hereof.
Home Dgpot reserves the right to cancel this contract if,upon re-Inspection of the job,Home Depot determines that It
cannot perform its obligations due to a structural problem with the home or because work required to complete the job
was not included in the contract. EPOSIT PAYMENT OPTIONS
( ubjeet t nd verification and/or credit approval.)
Check, len Check or US Portal Service Mosey Order
(� ( pays to The Home Depot).
CONTRACT AMOUNT S —
2. redit C - or otter payment options-Cirew One Wow
*LESS DEPOSIT S a Mastercard Discover American Express
BALANCE DUE Home Improvement Lo Home Depot Credit Card
ON COMPLETION $ Available Credit:$LCXrSL- --(HIL&HDCC ONLY)
*2s%of Contract At upon it of thisAare Exp•Gale:
caro , ie•th(r I/3`a) Contract Amou is required �n` L�Al
f M Nems as it appears on card: M(7
Indicate ymet Method For -By mylour signature below,I/We agree to allow The Home Depot to charge the
n
BALANCED E QCO Method
ForETI a ve re a credit card�dcpositted.
���
olders gnature
If this is a finance transaction,the agreement for financing• contained in a separate docu I. hich is ircotpo herein by
R rencc,and made as art h eof Amt-Hommt S rr�
edit/Lo A do f.#
rch r agrees that,i"mm di�tq y�upon sot sfattorY cuthe wo ,Pufe �r ill ex u ornpleiifieaand pay ary
ba)antt due(unless the job is fifranced,in wfiich case,umission f eeut. C pletion Certificate, a Depot will be paid in
full by the lender), Purhase�110
lsa rces to be jointly and se obligated d liable her rider.
fpr Maw Residents Only: ontractor,at owners ex rise,sh t procure I permits required by law as follows: Owners who
secure[heir own permit t,exclud om th aranty f rid provisions of MSL Chapter t42A. Unless otherwise noted
within this document,t is contract sh not im y the y lien r other security interest has been placed on the residence.
lEntiri Agreement: is agreement d its achments,including any financing agreeme ntain the cam ete agreement
between the parties an can not be a en a or modified unless in writing in a separ greetnent signed by th parties.
NOTICE TO PURC R
Do not sign this contract before you read It. You are entitled to a ly filled-in copy of the contra t the time you sign. Keep
it to protect your rights. Do not sign any Completion Certinc r agreement stating that you are stied with the entire project
before this project is complete. Low prohibits home rep ntractors from requesting or acceptin Completion Certificate signed
by the owner prior to the actual completion of the to be performed under the contract.
You may cancel this transaction at any a prior to midnight or the third business day after a date of this contract. See Notice of
Cancellation for an explanation of this right. There will be a service charge equal to 25 of the contract amount if the job is
cancelled by Purchaser AFTER the third business day,
BY MY1OUR SIGNATURE BELOW,VWE AGREE TO BE BOUND BY THE TERMS OF THIS CONTRACT. ACKNOWLEDGE
RECEIiTf OF A COPY OF THIS CONTRACT AND TWO COMPLETED COPIES OF THE NOTICE OF CANCEL TION.
BY MY1OUR SIGNATURE BELOW, UWE UNDERSTAND THAT THE AGREEMENT IS 5UBIECf TO VIEW OF MY/OUR
CREDIT HISTORY AND UWE AUTHORIZE HOME DEPOT AND RMA HOME SERVICES,INC.,A HOME EPOT AUTHORIZED
CONTRACTOR, TO VERIFY D VIEW M /OUR CREDIT RECORD WITH AN INDEPENDENT CREDIT REPORTING
AGENCY AND RELEASE THE FR LL !CITY INCURRED FROM fNA VE TENT OMISSIONS R ERRORS.
SUIIIv 17MD BY: Date:
Sales Consukle
ACCEPTED BY: _ Date:
Homeowner
Date: ---
Homeowner
NOTICE:ADDITIONAL TERMS,CONDITIONS AND WARRANTIES ARE SPAYED ON THS RRYME SIDE AVD ARE PART OFTKLS COWRACr
white—Brunch File Yanow,—Cuatoi w Fit4c—Saks Combant
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NORTFI
E
Town of ..: . over
No. 193
o� CoC,;C'P dover, Mass.,
A0RATEO P �C5
S H E
BOARD OF HEALTH
PERMIT T Food/Kitchen
Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT....... ...... .:r.'.. ` �.....�..�.............v� ��O 'V
.......��........................./Q............................................. Foundation
• �r u�
has permission to erect.............�..................... buildings on ......��.............../..�..L1.......................,,�......................... Rough
�'Q /AC F_ M C A) 'r W11t) v 0 �S 1N 201/d*/Ve
C - Chimney
to be occupied as �.........
........ . ....................................................................................................................................................
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 rel ing to the Inspection, Alteration and Construction of
Buildings in the Town of North Andover. V6- Z) 71� � 0 PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
PERMIT EXPIRES IN 6 MONTHS Final
UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR
Rough
C..........................................
Service
BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
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.
SEE REVERSE SIDE Smoke Det.