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Home My WebLink AboutMiscellaneous - 113 MIDDLESEX STREET 4/30/2018 113 MIDDLESEX STREET S / 113 / 2101031.0-0035-0000.0 I I Location No. A .7 Date TOWN OF NORTH ANDOVER 3?p:i« o ,11OpL ✓ S Certificate of Occupancy $ > Building/Frame Permit Fee $ .f cMus CH E Foundation Permit Fee $ � s� t Other Permit Fee $ Sewer Pdl%nection Fee $ Wafer pofinection Fee $ � , `��•'�`'�' �OJJ� Lir/��9/'if /I s✓ 0 e,,�, Building Inspector Gu86 `��, � Div. Public Works PERMIT O. APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. VPAGE I MAP i-40. LOT NO. 2 RECORD OF OWNERSHIP IDATE BOOK ;PAGE ZONE I SUB DIV. LOT NO. �I OCATION � �2 MC� X PURPOSE OF BUILDINGOVEA,iLr� NO. OF STORIES SIZ i��,l2,� �l9-��• i rYv� �t,t.�t: _ I -F_u� -}o s►naLe vdWNER'S ADDRESS 1 i•� i�,� 5 S; BASEMENT OR SLAB � ry��'L� ARCHITECT'S NAME ` SIZE OF FLOOR TIMBERS IST 2ND 3RD UILDER'S NAME n �..1SPAN DISTANCE TO NEAREST BUILDING \ DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES-SIDES REAR " GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION ��Aryu�LIS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE" IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES � A C/ ''ABT. BLDG. COOT /�' C)(J PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER OQ. FT. PAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COOT PER ROOM SEPTIC PERMIT NO. I• ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY 1 ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS P NS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR ` DATE FILE s c5 6 BOARD OF HEALTH SIGNATURE F OWNER O TH I ED AGEN FEE c� ,J 0 ER TEL.# Lt t`P-S�L� PLANNING BOARD PERMIT GRANTED t9 _ 4ONTR.LIC.# (53 . BOARD OF SELECTMEN sv u, INSPECTOR �tldl_DING DEPARTMENT BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY STORIESTHIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE 3 1 7 13 CONCRETE BL K. PINE BRICK OR STONE HARDW D �� PIERS PLASTER 2�PUyY�.L'>p�_�,/v W _ DRY VJALL ((�� q _ UNFIN. — — — 1 ' L C, W vv-QsD«L- S /�-�12 1V�' �. 3 BASEMENT I _ V PJ Stn QC7(�S AREA FULL FIN. B'M'T AREA1/4 `1 X � '`�— 1/1 � FIN. ATTIC AREA _ ��V" -�j p /� I�C�C til \ S* T:L-fJ` d ! 1h �2— BMFIRE PLACES CM• HE T _ _—Q- HEAD ROOM _ MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDSB I 2 3 � �_ DROP SIDING CONCRETE WOOD SHINGLES EARTH ASPHALT SIDING HA_RDI!JD � �" �� '� W�� • S *.` ASBESTOS SIDING COMMCN VERT. SIDING ASPH, TILE STUCCO ON MASONRY _ STUCCO ON FRAME BRICK ON MASONRY ATTIC STIRS. d FLOORI_ BRICK ON FRAME �� CONC. OR CINDER BILK. (� � L"", VL, STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIOR I f POOR ADEQUATE NONE t P 5 ROOF 10 PLUMBING GABLE HIP BATH 13 FIX.) = GAMBREL MANSARD TOILET RM. (2 FIX) FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING _ TAR 8 GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING 11 HEATING WOOD JOIST PIPELESS FURNACE ' FORCED HOT AIR FURN. TIMBER BMS. &COLS. STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd ELECTRIC 1st 13rd NO HEATING MORTGAGE INSPECTION PLOT PLAN NORTHERN ASSOCIATES, INC. 630 rURNPIKE STREET N.ANOOVER MA. 01645 TEL. 5041--975-7117 MORTGAGOR. WILLIAM D.b' KAREN U. YOUNG DEED REF. 2336 / 281 LOCATION.' 113 MIDDLESEX STREFr PLAN REF'. ASSESSORS 'rTY, STATE,' NORTH ANDOVER SCALE' 1- 20 ' DATE.' 10 / 29 / 91 JOB t.' 91/ 6381 GARAGE 17cc tZ I 1/2 STORY MOOD I — - ,,Iss T� i I 4 L' . . .MrDDLESEx STREET, . . .. Rfr oIrNIG DFPA.R i i, -N! CFRr1•FIED TO.' OANCNENENGLAND MORTGAGE CO. NOTE; This mortgage Inspection was prepared I FURTIAEn STATE THAT 1N MY PROFESSIONAL speoutbuildings, ciftelly for mongape purposes and is not to be relied OPINION the principle etructurNs and accessory upon as • survey. Northern Associates, Inc. accepts no 'y�� Of ngs, CONFORMfespp i0tiry for damages resulting from said reliance by �y with the setback requirements of the local zoning anyot>• ether than the said mortgagee and Its assigns In g ordinances,and that utero are no encroachments of major wnnrrctlon with its proposed mongape financing to said improvements either way across property Tinos uxccpt as ntot�aga. S H shown, o.t)1J2 C ALSO: _ r IV 6 1. P(operty is not in a Flood Hazard Area. This mortgage inspection was prepared in accordanco 4 Or=y tP `d4 p 2. p,opoity is in a Flood Hazard Aroa. With the Technical Standards for Mortgage Loan k0 f pil`t� 0 3.Information is insullicient 10 determine Flood Hatald Inspections as adopted by the Massachusetts Association Flood Hazard dotormined from latest Federal Flood o1 LAnd S"yom and 01,41 Engineers,Inc. Insuranco Rate Map Penrrll ��. l�P�r=�•vt _ , i v r L.[l O --F r�& R--w >e� q`T �'uvvt Z>-.1 - �� d 1 �� ! � i 1 f � � `J �� FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills ourtt this section***************** APPLICANT: i�_ CQ�c �-► v0 uti Cs> Phone LOCATION: Assessor's Map Number Parcel Subdivision Lot(s) Street 1 1'�,C) S-F - St. Number t k 3 ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Date Approved Conservation. Administrator Date Rejected Comments Date Approved 5 Town Planner Date Rejected Comments m�s'r �e -1-e �r- �5-C�- �v�►m Date Approved Food Inspector-Health Date Rejected Date Approved Septic Inspector-Health Date Rejected Comments Public Works - sewer/water connections - driveway permit Fire Department Received by Building Inspector Date Town of ® _ over 0 it No. 1 "�3 r� C'0 ,�,,I;�A ,Qrth Andover, Mass., aj 1993 A ADRATED r BOARD OF HEALTH Food/Kitchen PERMIT TO BU -ILD Septic System BUILDING INSPECTOR THIS CERTIFIES THAT...A�. i1. .. .O ...yl ..�. ..�....................... Foundation has permission to 006doN ........... ..... Nii Ison ...1.1 '3..."..I../ .P.A.1 .... Rough Jr11 LL..L�/J�J ....... to be occupied aseu�Vcioir I......... a..�.�� ....... .......r . Chimney provided that the person accepting this permit shal in every respect conform e 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. oq is a n * iris' Ojrep( PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this�Pper�miitt. MONTHS+�T i� Rough ��*��RMIZ, EXPI R EES I �l 6 MO 1 V T �S Final R r ? - ELECTRICAL INSPECTOR Woove �� ®� / : Rough Service 7 A 0 0 BUILDING INSPECTOR Final Permit eic�zo'. �e�cl to Occ—tq)y Il I� zii16Iilig r GAS INSPECTOR �� <<�� • Rough — Display in a Conspicuous Place on the Premises Do Not Remove Final No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner PLANNING FINAL Ga, �6 CONSERVATION FINAL Street No. Smoke Det. QMAMD MAIAT�R F1NiAi 6 0� DRIVFWAY ENTRY PERMIT__ 1 -'` MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING 1 (Print or Type) NORTH ANDOVER Mass. Date —�� building Location 1 'M ,��c.��( ST Permit s`,G- • Owners Name A to CA • New 77 Renovation Replacement il/ Plans Submitted 0 FIXTUP,=S to Z ¢ w Q N ¢ .o Cn = t- ur a „ a a v m x m Z m 0 N W »; o o a m r Uj 1- rn y y N t3 C) w z y '• .Q Q O Qtu U1 w a� -1 z a z W ¢ a a w r' w v x c� ¢ a 1- z � � z y W w a > W r W 1 z a W z o z a o u~s i a ,m > a W z < s < ,4 0 o to — a W t- ¢ x o U. n a a .i a s y ci o. t- o SUBi—$SP.1T. l - BASEMENT IST FLOOR f 2ND FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR (Print or Type) heck one: Certificate Installing Company Name LPEP\) � Corp. Address o 1 — = Partner. � ,5� irm/Co. Business Telephone: fjo?J 7tk-�.Q n Name of Licensed Plumber or Gas Fitter Insurance Coverage: Indicatethe * pe of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Q 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 coverages. Signature of owner/agent of property Owner ! J Agent 1 hereby certify that all of the details and information 1 have submitted (or entered)in above application are true and accurate to the best of my knowledge and that all plumbing Work and Installations pctforntcd under Permit iuLed for this application ww-be in complianoa with pertinent provisions of the Massachusetts State Cas Code and Chapter 14I of the General LAWS. By PE LICENSE: - Plum r Title G fitter Signature of Licensed ..aster Plumber or Gasfit r City/Town: �ti3 ga Journeyman APPROVED (OFFICE USE ONLY) License Number 1P Date.-7 I ,AORTA TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTAW ATION le- �9SSAC MUSEt h - This certifies that . . .. L ! . . . . , . .✓. 1, t ,' ; ' ' has permission for gas installation . `+. . . . .4. : . . ."9 in the buildings of . . . . .L.� . . . (��. . �,``'. . . . . . .. . `\9.49; at ! .0.`. L .N1 . .!�, . . . . , . , North Andover, Mass. Fee. . . . . . . . . Lic. No.. 1. . . . . . . . . . . . . . . . . . . . . . . . . . . GAS INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer GOLD: File h MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO 00 GASFITTING 1 (Print or Type) NORTH ANDOVER Mass. Date kuilding Location � T � Owners Name LL Y, 0 U N C' • - New Renovation Replacement Plans Submitted 0 FIXTUP=c ca A W W V� a rn a to W OW 4 a o = a z uus J Q m W a w w F O a cC y w i (j, W to W a 0: o z c a W W Q1 , Q Z cc Q R W W U Cf `dam Q, F. z F- W w a > k r W -4 1- W ,) z a w < tc t- 0 W z o o to = Q u > C W O Z 4 G Q < O O W 5 O W is z o O z U. a t7 .t 0 Cr > a a 1- O SUi�—$SA1T. BASEMENT 1ST FLOOR 2ND FLOOR 3811 FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR TTK FLOOR 8TH FLOOR (Print or Type) c (� Check one: Certificate Installing Company Name S�Cc =��G4. � f Q Corp. Address -?::)CK 991-1 Li Lj--,n [C-N (VA = Partner. C) f Ec- -s �l�Firm/Co. Business Telephone: S-69 C(0 3 ?O C-�-O Name of Licensed Plumber or Gas Fitter t SC'Cz-nl C �. Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity rj-7, 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 coverages. Signature of owner/agent of property Owner F-1 Agent El 1 hereby certify that all of the deuUs and information 1 have submitted (or entered)in above application are true and accutate to the b4 st of my knowledge and that all plumbing Work and lnstaUalions performed under Permit issued fo: this application will be in compliance wipertinent prorisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws, r B PE LICENSE: Y Plurr e �- Title G fitter Signature of Licensed aster Plumber or Gasfitter City/Town: Journeyman APPROVED (OFFICE USE ONLY) License Number Date..-. .. . :. .:� . .�. ... HORTM TOWN OF NORTH ANDOVER 3?py 4��ao ,e 1tiOL PERMIT FOR GAS INSTALLATION f 9 ,SSACNUSEt This certifies that . . . .t. !. . v . . . . ... ..... . . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . : . . . !. . .:. .. . . . . . . . . . . . in the buildings of . . . . :. . . . . f `. . . . . . . . . . . . . . . . . at . . . . . . . .� . . . !.. . . . . . . . 'I. . . . .. North Andover, Mass. Fee. . . .. . . . . Lic. Nb�J.l !. . S . . . . . . . . . . . . . . . . . . . . . . . . . . 3 1 a � `I GAS INSPECTOR WHITE:Applicant CANARY:Building Dept, PINK:Treasurer GOLD: File Town of.North Andover t NORTH Office of the Building Department Z WO Community Development and Services Division x • ♦o� «�.3'�.�.r i William J. Scott, Division Director a b,,,.,•�'.cg 27 Charles Street �SS�C1"4U D. Robert Nicetta North Andover, Massachusetts 01845 Telephone(978)688-9545 Building Commissioner Fax(978)688-9542 Mr. & Mrs. William Young July 12, 2000 113 Middlesex St. North Andover, MA, 01845 Dear Mr. & Mrs. Young: Attached you will find a copy of the letter sent out in response to your complaint of June 27''. Thank you for bringing this to the departments attention. If I may be of further assistance please do not hesitate to contact me. I may be reached between the hours of 8:30— 10:00 AM and 1:00—2:00 PM at 688- 9545. Respectfully, Michael McGuire Local Building Inspector BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 e • Location-// No. Date '��i�-eV NORTN TOWN OF NORTH ANDOVER 0 • • Oy a y Certificate of Occupancy $ Building/Frame Permit Fee $ s�cMus Foundation Permit Fee $ Other Permit Fee $ TOTAL Check # ,, 65 19 / Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING 90 BUILDING PERMIT NUMBER. O DATE ISSUED: SIGNATURE. Building Commissioner/InEQector of Buildings Date SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: //3 v,-,4�0, y 0 (2 Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sf) Frontage ft 1.6 BUILDING SETBACKS B Front Yard Side Yard Rear Yard Required Provide R red Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone , Outside Flood Zone 0 Municipal 0 On Site Disposal System 0 SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENTrn 2.1 Owner of Record Name(Print) Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: z Signature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Lkensed Construction Supervisor: Not Applicable ❑ ---k U4,10 ("C:omA f 7 Licensed Construction Supervisor: �d 3 3 3( License Number Address 717/o Expiration Date aam® )S, Telephone 3.�Registered Home Improvement Contractor Not Applicable ❑ Company Name ,Q� ,3/ �1, 4 el/I )0 ( � �T/c /�� Registration Number I mess L 0 9jo ;xv le i P 2 2 6,� Expiration Date lure Tele2hone SECTION 4-WORKERS COMPENSATION(NLG.L. C 152 § 25c(6) 1 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.......❑ No.......❑ SECTION 5 Description of Proposed Work(check all applicable) New Construction [ Yrsting twing ❑ Repair(s) ❑ Alterations(s) A❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify, Brief Description of Propose Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be (3FFICIAL USEjf3NI:�' Completed by permit applicant 1. Building (a) Building Permit Fee Multi lier 2 Electrical (b) Estimated Total Cost of CV,7 vQ �^ 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 r _ as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building pennit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name Signature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TMIBERS 1 ST2 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POS'T'S DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Castricone Roofing & Siding L REPAIRS FREE ESTIMATES Telephone (978) 682-4266 MARIO CASTRICONE 31 Court Street,North Andover,Mass. 01845 I/we, the owner(s)of the premises mentioned below, hereby contract with and authorize you as contractor,to furnish all necessary materials, labor and workmanship,to install,construct and place the improvements according to the following specifications,terms and conditions,on premises below described: Owner's Name* ..X.�:trd K.�.......... ... .............................................. ........................ Job Address. ,( ..... .L-� ... ......................................City/✓ ...... ...... ..........State.... ........ .............................. SPECIFICATIONS r... . .... .. ..e-..., '...f�'. � ��a..... � '- z : % ......................... .. .... ........ .. l . ....... ............ ............: .:......: z ....:: . : �. � .::: ......... : :........ . . ............... .,J . , . ` '. .... L ...:.. .:. ..... !, -.............................................. ..............................................:.................................... ... .......... ........ ................................... ................................. ... : :..........................: ..:.... .............. ..........................:........... �Pl .. �......... ry..� . ... .......... ......................... ..,... ..... . .............................................. ...6 .................................................................................................................................... .............r. ................................. ................................................... .. .................................................................................................................... VA............................ .. ...:....... .. . .. .. Materials and labor to cost$ .7 .:................. Payable.........................................on ................ ...............and balance in............ monthly installments of$.........................................each, payable on ........................................day of each and every month thereafter until paid in full (..............%charge per year is to be added to above cost of labor and materials and is included in monthly payments.) Contractor will do all of said work in a good workmanlike manner. Upon completion of above work,all undersigned agree to execute and deliver to contractor,their joint note in accordance with his(their)above obligation and s completion as requested by the contractor. Upon refusal to do so,contractor may at its option declare the entire contract price or so much as then remains unpaic immediately due and payable. It is agreed that if permitted by law contractor shall be paid by the owner(s), all reasonable costs, attorney fees and expenses,it addition to the amount due and unpaid,that shall be incurred in enforcing the terms and conditions of this contract and/or any lien in connection therewith. It is1further agreed that this contract may be assigned by contractor;and also that the obligations hereof shall bind and apply to their heirs,successors or estate: of the parties. The undersigned warrant(s)that he is(they are)the owner(s)of the above mentioned premises and that legal title thereto stands of record in his(their)name(s) PROVISO:This contract shall be void and of no effort if credit approved of owner(s)is refused. There are no representations, guaranties or warranties, except such as may be herein.incorporated, if any, nor any agreements collateral hereto, nor is thi; contract dependent upon or subject to any conditions not herein stated.Any subsequent agreement in reference hereto shall be binding only if in writing and signet by all parties. Cover attic storage cleaning not included. Receipt of a copy of this contract is hereby acknowledged,and it is further acknowledged by the undersigned that the foregoing provisions have been read ant the contents thereof understood and that no representation or agreement not herein contained shall be binding upon the parties and that all of the agreements ant understandings of said parties are contained herein. Owner or Owners are not responsible for Property Damage or Liability while job is in operation. q- IN WITNESS WHEREOF,the parties have hereunto signed their names this ............. �J d41ad— Accepted: ay of... rr/` = Signed....V...... . .....". ..... ......... Owne (OWNER HAS 3 DAYS IN WHICH TO CANCEL CONTRACT) Signed...................................................................... ............. Owner Per.. ........................... Signed...................................................................................... Representative � fie Comaetorru'ealth of Massa`Fauetts a' 4t�epartme t of lndt striafAxidew yi off=°f Investiyationj 600'Wasn Street Boston,A 02111 Workers'Compgnsation Insurance Affidavit Please PRINT Ledbi, a.1"Pi ICA LN3 ORTI.�TIO1V i vanne'— Location: Telephone#:- City: O I am a homeowner perforating all.work myself. C I am sole proprietor and have no one working in my capacity I ata an employer providing, workers'compensation for my employees working on this job Company Name: Address: � 46 6 City: Telephone#: Insurance Company: Policy#: Cl 1 am(circle one) sole proprietor,general contractor or homeowner and have hired the contractors listed below who have the following workers' compensation policies; Company Name: Address: City. Telephone#: Insurance Company:_ Policy# Company Name: Address: chy: Telephone#: durance Company: Policy#: �— Antacb addlitzon.al sheet if necessary Failure to secure coverage as required tinder Section 25A of MGL 15B can lead to the imposition of criminal penalties of a fine up to S1,500-00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S 100,00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify!under the pains and pen ties of perjury that the information above is true and t Dae: �correc Signature: --��-�--� Print Name:Nwr 16 Cy A S �� .✓ Phone# 6 Official Use ONLY-Do not write in this area Z)Building Department fy PermittLicense#: a Licensing Board I i City or 7 wru: o Selectmen's Office If n Health Deoariment o Other C Check It immediate response is required NORTFI 0"- o 0 V No. o a o - O� �o� L w t� dower, Mass., ORATED P?�\t�C S H E BOARD OF HEALTH PERMIT T Food/Kitchen Septic System BUILDING INSPECTOR THISCERTIFIES THAT........... ... ....... ....................... ..................................................................................................... Foundation has permission to erect........................................ bui ngs on .... I3................. ................ ..... ..... ......... Rough to be occupied as Chimney provided that the person accept! this p mit shall in:e:fry respect conform to the terms of the application on filein Final this office, and to the provisions of the Codes and By- elating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTI T ELECTRICAL INSPECTOR Rough 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. a Air' Quall y Experts, h..;. LR.-mo:val(603) 894-6465 Asbest (800) 621-1189 23 Hall Farm Road Residential-Commercirial (603) 894-7044 FAX Atkinson, NH 03811 AirQualityExperts@AQENH.com September 1, 2010 North Andover Health Department 146 Main Street North Andover, MA 01845 Dear Sir: Enclosed please find a copy of notification sent to the state for an Asbestos Abatement Project. .301 -- The job will take place on September t 5;2010. Project: Karen Young 113 Middlesex Street Any questions concerning this matter should be directed to my attention. Sincerely, Christopher Thompson — President ��. Irk- U S L n'�' i Commonwealth of Massachusetts __ _ ■ 100112498 Asbestos Notification Form ANF-001 Decal Number SEP ZQ 0 Important: A. Asbestos Abatement Description When fining outTOWN 0�NORTH ANOOVER forms on the computer,use 1. a. Is this facility fee exempt-city,town, district, municipal h pied only the tab key residence of four units or less? ✓❑Yes ❑No to move your cursor-do not b. Provide blanket decal number if applicable: Blanket Decal Number use the return key' 2. Facility Location: KAREN YOUNG 1113 MIDDLESEX STREET a.Name of Facilitv b.Street Address North Andover MA 101845 F- c.City/Town d.State e.Zip Code f.Telephone Number INSTRUCTIONS 3. Worksite Location: 1.All sections of this BASEMENT I I form must be a.Building Name/Building Location b.Building# c.Wing d.Floor e.Room completed in order to comply with 4. Is the facility occupied? ❑✓ Yes ❑No DEP notification requirements of 310 CMR 7.15 5. Asbestos Contractor: and the Division of occupational JAIR QUALITY EXPERTS INC 23 HALL FARM ROAD Safety(DOS) a.Name b.Address notification ATKINSON —� 03811 6038946465 requirements of 453 CMR 6.12 c.City/Town d.Zip Code e.Telephone Number AC000167 f.DOS License Number g. Contract Type: R]Written El Verbal h.Facility Contact Person i.Contact Person's Title 6 GEORGE P. FINN III I AS001157 a.Name of On-Site Supervisor/Foreman b.Supervisor/Foreman DOS Certification Number N/A 7' a.Name of Project Monitor b.Project Monitor DOS Certification Number N/A 8' a.Name of Asbestos Analytical Lab b.Asbestos Analytical Lab DOS Certification Number =0 9 9/152010 9/15/2010 a.Project Start Date mm/dd/ b.E nd Date mm/dd/ �0 7AM-4PM �N c.Work hours Mon-Fri. d.Work hours Sat-Sun. �o 10. a. What type of project is this? =o ❑ Demolition ❑✓ Renovation ❑ Repair ❑ Other, please specify: b.Describe 11. a. Check abatement procedures: o ❑ Glove bag ❑ Encapsulation o ❑ Enclosure ❑ Disposal only �u- ❑Cleanup ❑ Other, specify: _Z ✓❑ Full containment b.Describe =Q 12. Is the job being conducted: ❑-v Indoors? ❑Outdoors? ■ anf001ap.doc•10/02 Asbestos Notification Form•Page 1 of 3■ Commonwealth of Massachusetts _____■ 100112498 Asbestos Notification Form ANF-001 Decal Number A. Asbestos Abatement Description (cont.) 13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed, or encs sulated: 25 1 140 a.Total pipes or ducts(linear ft) 6. 1 otal other su aces square c.Boiler,breaching,duct,tank 40 surface coatings Lin.ft. Sq.ft. d.Insulating cement Lin.ft. Sq.ft. e.Corrugated or layered paper 25 pipe insulation Lin.ft. Sq.ft. f.Trowel/Sprayer coatings Lin.ft. Sq.ft. g.Spray-on fireproofing Lin.i--ft. Sq� h.Transite board,wall board Line i.Cloths,woven fabrics I j.Other,please specify: Lin S� Lin.ft. S .ft. k.Thermal,solid core pipe insulation Lin.ft. Sq.ft. I.Specify 14. Describe the decontamination system(s)to be used: 3 CHAMBER DECON 15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(g): WET 2 PLY POLY 16. For Emergency Asbestos Operations,the DEP and DOS officials who evaluated the emergency: a.Name of DEP Official b.Title c.Date mm/dd/ of Authorization d.DEP Waiver# e.Name of DOS Official F DOS Official Title g.Date(mm/dd/yyyy)of Authorization h.DOS Waiver# �N �0 17. Do prevailing wage rates as per M.G.L. c. 149, §26, 27 or 27A—F apply to this project? ❑Yes ( No B. Facility Description �N =o 1. Current or prior use of facility: RESIDENCE �o 2. Is the facility owner-occupied residential with 4 units or less? ✓n Yes ❑No KAREN YOUNG 1113 MIDDLESEX STREET 3' a.Facility Owner Name b.Address �o NORTH ANDOVER, MA 01845 1 1508-265-3993 o c.Ci /Town d.Zip Code e.Telephone Number area code and extension �LL 4. a.Name Owner'sOnager b.On-Site Manager Address Z (-� �Q c.City/Town d.Zip Code e.Telephone Number(area code and extension) ■ anf001ap.doc•10/02 Asbestos Notification Form•Page 2 of 3■ Commonwealth of Massachusetts 100112498 � Asbestos Notification Form ANF-001 Decal Number B. Facility Description (cont.) 5' a.Name of General Contractor b.Address c.Ci /Town d.Zip Code e.Telephone Number area code and extension) _ 71 f.Contractor's Worker's Comp.Insurer g.Policv Number _ h.Exp.Date mm/dd/ 6. What is the size of this facility? C �-�� a.Square Feet b.Number of floors C. Asbestos Transportation and Disposal 1. Transporter of asbestos-containing material from site to temporary storage site(if necessary): AIR QUALITY EXPERTS,INC. Note:Transfer a•Name of Transporter b.Address Stations must I I I comply with the c.City/Town d.Zip Code e.Telephone Number Solid Waste Division 2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site: Regulations 310 CMR 19.000 ISERVICE TRANSPORT GROUP, INC. P.O. BOX 2132 a.Name of Transporter b.Address BRISTOL, PA —7 119007 1 18779999559 c.Ci /Town d.Zip Code e.Telephone Number 3. a.Refuse Transfer Station and Owner ( b.Address c.Ci /Town d.Zip Code e.Telephone Number 4. IMINERVA ENTERPRISES INC a.Final Disposal Site Location Name b.Final Disposal Site Location Owner's Name 9000 MINERVA ROAD I IWAYNESBURG c.Final Dis osal Site Address d.Ci /Town OH � 44688 �M e.State f.Zip Code g.Telephone Number �o D. Certification ®N The undersigned hereby states, under the ICHRISTOPHER THOMPS Christopher thompson� -10 penalties of perjury,that he/she has read the a.Name b.Authorized Signature Oo Commonwealth of Massachusetts regulations PRESIDENT 9/1/2010 for the Removal,Containment or Encapsulation of Asbestos,453 CMc.Position/Title d.Datemm/dd/vvvvL�R 6.00 and 6038946465 AIR QUALITY EXPERTS 310 CMR 7.15,and that the information contained in this notification is true and correct e.Telephone Number f.Representing o to the best of his/her knowledge and belief. 23 HALL FARM ROAD o q.Address �u- IATKINSON, NH � 038_11_ Z h.City/Town i.Zip Code � �Q anf001ap.doc•10/02 Asbestos Notification Form•Page 3 of 3