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Miscellaneous - 115 SUTTON HILL ROAD 4/30/2018 (3)
/ 115 SUTTON HILL ROAD 210/060.A<0009-0000.0 I I PO Box 55098 Boston,MA 022055098 _Fi17-951-0600 _- — - Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec 3B To: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectman City Hall City Hall NORTH ANDOVER, MA 01845 NORTH ANDOVER,MA 01845 RE: Insured: JOSEPH M PIOTTE and KATHLEEN R PIOT TE Property Address: 115 SUTTON HILL RD,NORTH ANDOVER, MA Policy Number: HMA 0233857 Claim Number: BOS00064176 Date of Loss: 8/10/2015 Company: Safety Indemnity Insurance Company 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, Chapter 143 Section 6 to be applicable. If any notice under Mass. Gen. Laws, Chapter 139 Section 3B is appropriate,please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim number. Allan Leavitt Claim Examiner 9/1/2015 Safety Insurance Company Homeowners Claims Unit P. 0. Box 55098 Boston, MA 02205-5098 Phone: (617) 951-0600 EXT 3213 Fax: (617) 531-8891 Email: AllanLeavitt@Safetylnsurance.com Safety Insurance Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec 3B To: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectman City Hall City Hall NORTH ANDOVER, MA 01845 NORTH ANDOVER, MA 01845 RE: Insured: JOSEPH M PIOTTE and KATHLEEN R PIOTTE Property Address: 115 SUTTON HILL RD,NORTH ANDOVER, MA Policy Number: HMA 0233857 Claim Number: BOS00036718 Date of Loss: 3/18/2013 Company: Safety Indemnity Insurance Company 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, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim number. Allan Leavitt Claim Examiner 3/28/2013 Safety Insurance Company Homeowners Claims Unit P. 0. Box 55098 Boston, MA 02205-5098 Phone: (617) 951-0600 EXT 3213 Fax: (617)531=8891 Email: AllanLeavitt@SafetyInsurance.com TOWN OF NORTH ANDOVER 7 BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOyLrISH A ONE OR TWO FAMILY DW_Ey�LLING }SE BUILDING PERMIT NUMBER: r DATE ISSUED: „� rn SIGNATURE: �4jx.� Building Commissione for of Buildings Date Z SECTION 1-SITE INFORMATION IO 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided R red Provided 1.7 Water Supply M.G.L.C.40.1 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private 0 Zone Outside Flood Zone 0 Municipal ❑ On Site Disposal System 0 SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of Record Name(Print) _ Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: O Z M Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: O �SM �G� �w / � l'/USI License Number mn Address ,/ t� ►1 i /,o � > Expiration Date ic� Signatur lephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ &� CfA—&---A Company Name rn Registration TMr Address �9�U ^9P7J^ ,7'S31 ^ Signal Telephone Y/ SECTION 4-WORKERS COMPENSATION(M.G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result o 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 ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: q[ 2ct � `C I If SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be �}I CIAL USE'"Ony Completed by permit applicant .....,.. . . .. 1. Building (a) Building Permit Fee Multiplier ,s 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 CJZr Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, ,as Owner/.Authorized Agent of subject property Hereby authorize to act on N11 lop My behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, as Ow Qer/Authorized Agent o 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 s- ® S Si iature of Owner/Agent Date NO. OF S TORIES SIZE �+ BASEMENT OR SLAB SIZE OF FLOOR TMERS IST 2ND 3RD SPAN DIMENSIONS OF SILLS AILNSIONS OF POSTS DE\,ENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHINMY 1S BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATUTAL GAS LINE Location No. Date NaRTM TOWN OF NORTH ANDOVER N 9 Certificate of Occupancy $ '"M°';<�' Building/Frame Permit Fee $ s�CHU Foundation Permit Fee $ Other Permit Fee $ TOTAL $ — Check # iti IP 18477 / _Building Inspect-0 Y + R N 10 Aa 13, Chimneys Residential & Commercial Roofing All Types Of Siding CHIMNEYS POINTED-REB 1L -CAPPE© Expert Masonry Work Mass Toll Free *Roof Leaks Experts * Licensed & Insured 1-800-WAIT-4-USLocally Owned&Operated Since 1476 '"---'L sem: License#034200 (924-8487) ftaz 1' oZ,4oAff We Work Year Round '�i Ila�ll UA ry�7 3 � n� +I i iiti I r'+ w • • i �• �S� kx I ,�✓� � s a >t � _ X11 i 1 :r P �a5� ! • ! i t � 4 f Proposal Submitted To Phone Date_ Street Job Name S Tian j-("L L City,State&Zip Code Job Location lob Phone JLJ14%0S Lf I*f4 We Propose hereby to furnish and labor in accordance with specifications below, for the sum of: � �%lG'� t„1� Si7�-f�T t ,l�/i�rCL'` '%t� . Dollars �,1gi�aooa JaGp All material is guaranteed to be as specified. All work to be completed in a workmanlike Authorized manner according to standard practices.Any alteration or deviation from specifications be- Signature: low involving extra costs will be executed only upon written orders,and will become an RONA- extra charge over and above the estimate.All agreements contingent upon strikes,accidents NOTE:This proposal may be or delays beyond our control. Owner to carry fire,tornado and other necessary insurance. Our workers are fully covered by Workmen's Compensation Insurance: withdrawn by us if not accepted within<,x t='' days. We hereby submit specifications and estimates for: ldinstall 3 feet of special "Save Seal" ice and water barrier protection along all bottom edges of roof and top to bottom in each valley. 4 roof is stripped, we will apply conventional ice and water shield � ( 3 ) ft. high in the same locations previously described and tar paper will cover the remaining bare wood. Any rotted or damaged boards will be replaced at per linear ft. + or ( 6*•t,4� ) per sheet of plywood. W"I"nstail heavy gauge aluminum drip edges along every edge surface of each roofline.gl" i UCover entire roof (s) with I , premium grade shingles (Color of choice). ct-J���> 3- Itz Replace all pipe boots where possible. LdSeai all flashings with clear Geo-Cel sealant. No black tar unless previously applied. w Nemove aii work reiarea oepns. CS Contractor warrants roof against all leaks due to defects in his workmanship for 12 years under normal circumstances. Local current references and proof of workman's compensation insurance gladly given. &'Remarks + C�Et�"!P'-(- GAI-E C06lW R,06—C UC-"?T 7`" 7;C."'W9jC.; t/cP7-1 2 =fee-1 f tt.�'!. - c wr 2 C r2�'M►' ;�wO 3 f'�:a�= T�c� f w�'��'( �!-� 'c`�'1 LJ t�L d� �'.� i� F�c.� �l�rJC=a?G.'-1��i�✓ ()1i! `J 6,1 Acceptance of Proposal -The above prices, specifications ; v� and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment Signature: will be made as outlined abo e. Date of Acceptance: L v�^ Signature: ✓ \V — The Commonwealth of Massachusetts De artinent o Industrial Accidents Office of investigations 600 I'Vashington Sheet, 7'Ir Floor Boston,Mass. 02111 Workers' Compensation Insurance Affidavit: Building/Plumbing/Electrical Contractors A licant information. Please PRINT le ibf' name: address:1-1 city � l(1�i stater zip:( T phone# / r- work site location(full address): v 0 `�n ❑ I am a homeowner performing all work myself. Project Type: ❑New Constniction❑Remodel ❑ I am a sole proprietor and have no one working in any capacity. ❑Building Addition ZrI am an employer providing workers' compensation for my employees working on this job. ALL J�Cn d�c= / 00 company name /� address: V- . / l city: / "11 v vj A4,4A=s S /l,1� phone#- insurance co. / 1� � �� ofpolicy# /'1" C- o ! Yd / d 120,3 ❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers'compensation polices: company name: address- city: phone# insurance co. policv# company name: address: city: phone M insurance co. Policy# Attach.addthonal sheet if necessar I' Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do here4cer ' n the 'ns andp tallies of perjury that the information provided above is triteand correcSignature Date O "Print nam `s pJ �1 G r Phone# ��— 9-1-S f�� 1 § .. ..r.., t, ? ';:r.,7.__.,,...:'. ..,d.':r%.w§. -' ....n..dt..F:.• 5.,:.. .. -:» .. < '... i 1 .,t . T - t official use only do not write in this area to be completed by city or town official " L; I} city or town: permit/license# ❑Building Department []Licensing Board ❑check if immediate response is required ❑Selectmen's Office ❑Health Department contact person: phone#; ❑Other fv (revised Sept.2003) Y vLLE1 I Irlvr+I E. %01 L-lr%WILog I I II'lWWIIver. DArE1MMJODiYYYYj �✓'� 07/08/2005 ntoDUCER THIS 091tTiFICATE 18 ISSUED A6 A MATTER OF INFORMATION ntemet Insurance a ONLY AND CONFERS NO'RI©HTS.UPON THE CtRTIO CATZ HOLDER,THIS CERTIFICATE DOES:NOT AMEND,EXTEND OR S22 Chickering Road ALTER THE COVERAGE AFFORDEO'BY TIC POLICIES BELOW. slOrdAndoveT, MA 01845 INSURERS AFFORDING COVERAGE . .NAIL# NSURED INSURERA: NORFOLK 6 DECHAM WSURANSE COMPANY JOHN LANZAFAME INSURER 0: AIM DBA ALL.UNDER ONE.ROOF INSURER C: 30 TEMPLE DR INSURER o: . METHUEN,MA 01844 INaUReaE 00%%VAG TME POLICIES-OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED..NOTWITHSTANDING. ANY RSQUIREMENT,TELA OR CONDITIONOF ANY CONTRACT OR OTHER DOCUMENT wITN RESPECT To WH IC"THIS CERTIFICATE MAY BE WILLED OR MAY PERTAIN,The INSURANCE AFFORDED BY THE POLICIES DESCRIED HEREIN 15 SUBJECT TO ALL THE TERMS.EXCLUSION$AND CONDITIONS OF SUCH. POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TR TYPE OF 1#IBURAM POLICY NUMWR tteprs A GENERAL LM�aILnY' 201550636 6/312005, 012006 EACH OCCURRENCE s t.000,000.00 COMMERCIAL GENERAL LIASJUTY. pMUO TIT f 1.000,000.00 CLAIMS MADE Q OCCUR MED EXP n ane'sraon) 'S.000.00 PERSONAL•ADV INJURY f t 00p D00.00 GENERAL AaaitzdAry I1.00Q,000.00 GEN'L AGGREGATE IJI+RIT APPLIES PER: PRODUCTS•COMP/OP At1G 1.2000.000'00 POLICY f7 PROJECT M LOC AUTOMOINLE LIABILITY COMBINED SINGLE LIMIT I ANY AUTO 900 dein) ALL OWNED AVTOS BgDiLY IN.iURy = SCHEDULED AUTO$ HIRED AUTOS �DILY+NJtNRY f.. NOWOWNED AUTOS H sctldBn!. p OPERTY DAMAGE f t�seddanry GARAGE LL41MUN ` AUTO ONLY•EA ACCIDENT 16 ANY AUTO T7� EA ACC-LS _ A{)TO� A6G Is EXCOSLAAMELLALVOLITY WH,CCCURMNCE 'L _ OCCUR Q CWMBMADE A(kGREGATE 1 DEDUCTIBLE 1 RETENTION i1 g _ "R ILA t °N�uRD AWC7009464012003 7 7/912004 17/9/2005 Y ANY,OROF+RIfirORlPARTNERlEXECUTIVE E.L.GACHACCIDENT 8100,000.00 O"mERIMEMBEREXCLUD60R. E.LINIIEAIE-EAEMPLOYM 1.t00.000.00 e'ysC 4edQtde under 600:000.00 rit'PROVISIONS below E.L DISEASE•POLICY'LIMIT 5 OTNER CARPENTER CERTIFICATE HOLDER CANCELLATION JOHN LANZA<=AME &MOULD ANY CF THE ABOVE 0WRISEO PQLICIFA BE CANCELLED BEFORE THE EXPIRATION DIA ALL UNDER ONE ROOF DATE THMOF.T71l19WUI�IORRIi MWILLENDEAVORTOVA�L 30 DAYS WRITTEN 30 TEMPLE DR NOnCE 1n TTS CERTImmf HOLDER NAMED TO THE LEFT,BUT FAILURE 70.00 80$HALL METH UEN,MA 01844 WPM NO 0811GAM OR LIAMM CW ANY MIND TME tnMiR ITS AGENTS OR REPRE5vft m. AUTHm=D REPREBENTAITVE , 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 at: 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. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 10A. The debris will be disposed of in: �1 V 02036(4 �C Sal't-"� �zll�'/u# (Location of Facility) In Signaturea 't Applicant Fire Department Sign off: Dumpster Permit p Date NORTH o To _: t R over _ _ �. wn 0 No. - �, o _ LA - = dover, Mass., COCHtCMEw1CK y1. S RATED PPG �C� 4 BOARD OF HEALTH Food/Kitchen PERMIT T Septic System BUILDING INSPECTOR THIS CERTIFIES THAT..... LW...... ........................................... .................................... . ....�.......... Foundation • left has permission to erect................ ....................... buildings on ....�...5... .............. ... ..................... Rough to be occupied as Chimney . . .......................................................................................................................................... provided that the arson ac ing this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provi ons 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 S T 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. Alternative Veterinary Services, LLC Invoice 9 Hodges Street North Andover, MA 01845 Date Invoice# 978-683-5775 8/1/2005 57 Bill To North Andover Health Department 27 Charles Street North Andover, MA 01845 RECEIVED JUL. 2 5 2005 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Description Amount Animal Inspector Monthly Fee 300.00 ti y Total $300.00 f � MASSACHUSETTS UNIffORM A.PPLICATON FOR PERMIT TO DO GAS FITTING T ype or print) Date /(o •P)- -000 NORTH ANDOVER, MASSACHUSETTS a� Building Locations /j+ Su7c"`' l� ?�' Permit# Amount /o�plle Owner's Name j NewJE Renovation Replacement Plans Submitted m n U z F C C m =t z z F Cn w 't v7 Cn n L W %� Z .r C ` ai w it vl s7 Z ^' w > C Cn - B A S E M ENT b$ IsT. F L 0 0 R 2N U . FLOG R 3RD . FLUOR 4T 11 . F L O G R slit . FLOUR 6T It F L U O R 3 23 Date. . ���.:. � .... Check one: Certificate Installing Company ❑ Corp. i NORTH TOWN OF NORTH ANDOVER — El Partner.h ,e . . F? y •e pp PERMIT FOR GAS INSTALLATION I ❑ Firm/Co. SACHUSE ' Check one: 1 1 Yes No❑ ��,J ite box. ' T is certifies that .lQ. -� Q� Bond ❑ h permission for gas installation �, I . . . . . . . . ice coverage required by Chapter 142 of the in the buildings of). . . . f quirement. I at . .1,6 -.. �.. %: �-L � , North Andover, Mass. `I 1 ❑ Agent ❑ Fee . . . . . Lic. No:✓/,�V . • • �-•'`-`"'-V. .. . . . . . . . . . . in above application are true and accurate to the GAS INSPECTOR I 9p S ,� ;r Permit Issued for this application will be in WHITE:Applicant CANARY:_Building Dept. PINK:Treasurer ��hapter 142 of the General Laws. Signature of Licensed Plumber Or Gas Fitter By: Title ❑ Plumber CityiTuwn ❑ Gas Fitter License ivumo r Master loumeyman APPRO'v'ED( >Fr•ICF USE ONLY) 1 Date.. 354 3 TOWN OF NORTH ANDOVER OF4.�.40 n1ti0 32 " o PERMIT FOR GAS INSTALLATION r,:- a s • a i, • SSACHUSEt This certifies that . . . . . ?. .::: . . . . . . . . . . . . . has permission for gas installation . ... . . ... .. ... . .. ..°%. . in the buildings of . . �.�. . . . . . . . . . . . . . . . . . . . . . . . . at ` -. -� ~ t''. :.r North Andover, Mass. Fee! :... . . Lic. No: GAS INSPECTOR WHITE:Applicant CANARY: Building Dept. UPINK:Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING Ar {Print orr,Type) Mass. Date 42- 219 Permit Building Location_,. /l5 J 7,7&) wn-z. Owner's Name P6 77,-< Type of Occupancy �FSIDE�cJi7 fJL New [ 1 Renovation ❑ Replacement ❑ Plans Submitted: Yes No p N = Y W N N Z 0 CC N W W cc O O U F- tl W Z O u 4 CC 0 O }' w Ix:a W Oa. 0 N N d W W = Z � 0 cc 0 W W W (a J Z Q = a W cc W r.. W 1-.. X CC (� tf1 tl }• Z J H Z F. W W O > LL {-� U J t.. w Z Q W Q �' y. 0 0 Z 0 Z OW. O N = Q w W z. Q Cr Q ¢ .= O tl Z a 3 C d .Qj C01 ¢ y D a Fes- O SUB—BSMT. BASEMENT I ST FLOOR 2ND FLOOR 3RDFLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company Name BAY STATE GAS COMPANY Check one: Certificate # Address 55 MARSTON STREET XO Corporation 1862 r LAWRENCE, MA 01840 ❑ Partnership B,,-mess Telephone 508-687-1105 t ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Francis X. Corkery INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No O If you have checked res, please Indicate the type coverage by checking the appropriate box. A liability insurance policy Other type of indemnity O Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner❑ Agent El of Owner or Owners Agent hereby certify that all of the details and information 1 have submitted(or entered)in above pplication are true and accuWe to the best of my knowledge and that all plumbing work and installations performed under the permit iss f r this application will n mpliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s. (/ T e of license: Plumber Signature of Licensed Plumber or Gas Title Gasliitter Master License Number 8697 City/Town Journeyman APP.POVED OFFICE SE ONLY) i, BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES PROGRESS INSPECTION FEE N0. APPLICATION FOR PERMIT TO 1DO GASFITTING , 1. MG• NAME & TYPE OF BUILDING_ LOCATION OF BUILDING i r PLUMBER OR GASFITTER LIC. NO. PERMIT GRANTED DATE _.19 GA3INSPECTOR 4 Date. 3 3 TOWN OF NORTH ANDOVER pL o PERMIT FOR PLUMBING ,SSAcMUSE� This certifies that . . .1. . ' . . . . . . . . . . . has permission to perform . .---• -r . r '4-- plumbing in the.buildings of . . . . . . . . . . . . . . . . . . . . . . at �.f. -. .. . . . . . . .. . . . . . ./. .,_)North Andover, Mass. Fee.Xs. " . . .Lic. No` lam. . N._ . . .l-:�j-��.-��-�. . . . . . . . . LP UMBIN6INISPECTOR WHITE: Applicant CANARY: Building Dept. PINK:Treasurer E MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Date Building Location l� S(f e�.✓/ ./1vJ Owners Name Permit Amounts Type of Occupancy ,�a•'C l��' ` New ® Renovation Replacement Plans Submitted Yes 0 No FIXTURES a a x a d H x a A w a F FW a Q x a F pro E" Z �BgVIC R4SRM f ISI HIM M FILM 3MFIaR M FI M 5M Hfm 6If1 R9R -A 7IHHBM 01 RaR (Print or type) Check one: Certificate Installing Company Name Corp. Address �� 60X72 Partner. Lgr,�q �✓r� PNS-� D�8'`7`Z— Business Telephone G .—q,Fo y Firm/Co. Name of Licensed Plumber. J✓n ��l�o�? '� Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: ❑ Liability insurance policy Other type of indemnity ❑ Bond -i 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 lumb' g Code and Chapter 142 of the General Laws. By: Signa ol Licen'Swtum er Type of Plumbing License Title 2493-7 City/Town icense NUMDer Master El Journeyman z APPROVED(OFFICE USE ONLY Location No. Date /l1-/ys7 Otit� o rORT1� TOWN OF NORTH ANDOVER , 1'1.0 O? • • OA, . ' p Certificate of Occupancy $ • ;41 Building/Frame Permit Fee $ --^---- sACMUs 4�' Foundation Permit Fee $ Other Permit Fee $ •� v Sewer Connection Fee $ Water:Connection Fee $ TOTAL $ L�S�•G'. .C�_ I -99 Building Inspector 6626 Div. Public Works Pwurr W. V, APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1 MAP KJO. LOT NO. 2 RECORD OF OWNERSHIP JDATE BOOK 'PAGE ZONE SUB DIV. LOT NO. I n LOCATION /45 -5o7-mo/w,- / PURPOSE OF BUILDING U7-/4_/7(/ J hIfp OWNER'S NAME( �l /// A Ir/1/ NO. OF STORIES SIZE V OWNER'S ADDRESS /�� SU.7...�I i 1 f1 IL` BASEMENT OR SLAB ARCHITECT'S NAME ! SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME SPAN DISTANCE TO NEAREST BUILDING Q^.'/OO DIMENSIONS OF SILLS DISTANCE FROM STREET R POSTS DISTANCE FROM LOT LINES-SIDES �V® / REAR GIRDERS AREA OF LOT 601600 °_p, /f00 FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW vyV SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS 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 L D COST SEE BOTH SIDES EST. BLDG. COST 7690I PAGE 1 FILL OUT SECTIONS I - 3 EST. BLDG. COST PER SQ. FT. PAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED BOARD OF HEALTH SIGNA URE OF OWNER OR AUTHOR-1 0- AGENT FEE PERMIT GRANTED !/OWNER TEL.# PLANNING BOARD CONTR.TEL.# 19 CONTR.LIC.# BOARD OF SELECTMEN ` �� � "8UILJ)INNSPECTOR BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY _ STORIES THIS 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 2 13 CONCRETE EL'K. PINE BRICK OR STONE HARDW D PIERS PLASTER _ DRY WALL UNFIN. 3 BASEMENT 11 AREA FULL FIN. B'M'TAREA _ '/. 1/2 l/. FIN. ATTIC AREA _ N_O 8 M FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS 8 1 2 3 DROP SIDING CONCRETE WOOD SHINGLES EARTH ASPHALT SIDING HARD\!,/'D ASBESTOS SIDING _ COMMCN VERT. SIDING ASPH.TILE _ STUCCO ON MASONRY _ STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. & FLOOR _ BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIOR (� POOR _ ADEQUATE NONE I 5 ROOF 10 PLUMBING GABLEHIP BATH )3 FIX.) GAMBREL MANSARD TOILET RM. (2 FIX.) _ FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING _ TAR & 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 It} 3rd NO HEATING t Y O y Q I t- r ` ORT��' } of � ofrAndover © No. 467 A AN ort dover, Mass., / 19 ft - 1C HiC HE w�CK �� A a� '7.9SoRAT4.,=BUILD BOARD OF HEALTH PERMIT TO Food/Kitchen a Septic System BUILDING INSPECTOR THIS CERTIFIES THAT....*Phf.dt6*Aft.40.40.0#.. ...low ........................................................... Foundation s has permission to erect..."..f*V............... buildings on .... ........ Rough pi �It..rl.AL.l...T. ......iS........ .......�........'Ix . t0 b8 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 PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR Rough .....�............ .... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display n aConspicuous Place on the Premises — Do Not Remove Rough P Y i . p Final No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner PLANNING FINAL CONSERVATION FINAL Street No. Smoke Det. SEWER/WATER FI NAL DRIVEWAY ENTRY PERMIT AOLA-ocation Af No. Date MORTN TOWN OF NORTH ANDOVER F � _ O� 9 Certificate of Occupancy $ sACMUSEt� Building/Frame Permit Fee $ n Foundation Permit Fee $ Other Permit Fee $ TOTAL $ r Check # 1 3 v r / '-Building iUr Spector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING hITORs N , BUILDING PERMIT NUMBER. DATE IS SIGNATURE: AaAW ic Building Commissioner/1for of Buildings Date 17-11- 0O SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: /M A A110 Ue PL A4 Map Number Parcel Number 1.3 ZoningInformation: 1.4 Property Dimensions: Zoning Diaiic_t Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided —Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. blood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone 0 Municipal ❑ On Site Disposal System 0 J SECTION 2-PROPERTY OWNERSHIPIAUTHORMD AGENT 2.1 Owner of Record ,Name(Print) Address for Service: i to Telephone 1-2.2 Own'r of Record: Name Print Address for Service: z M Signature Telephone go SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Sic ?//P� �/sC/,� G /"� Licensed Con�struction Supervisor: ��7�� ' 600 onCr'I ->� �O � �pyP/Z License Number AAdM S7- 16- 'Zoo f Expiration Date Signa re Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ S"r SZ/w 6- Company Company Name /�`� t'o 1�1 &Lr Cr'[-N C hAxot l-k Registration Number r Addres ,,,Z p ��2-Zo7Z Expiration Z xpiration Date ^ r nature Telephone Y v a I SECTION 4-WORKERS COMPENSATION(M.G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......❑ No.......❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Addition ❑ .t. . a. Accessory Bldg. ❑ Demolition - ❑ Other ❑ Specify 1 Brief Description of Proposed Work: } �. Remove 7/9 Lov$'!e w/WdoW� &.7� f� SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be E;EI?FICA .USE=UNLY Completed by permit applicant 1. Building OO (a) Building Permit Fee 7ol 100, Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a) X (t,) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on My b�atters rel iveo work r thorized by this building permit applicati n. _Zl l cs o Si iature of Owner Da e SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, 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 a Signature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIIvMERS iST2ND 3 SPAN DINIENSIONS OF SILLS DIMENSIONS OF POSTS DINIENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHDANEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE ' •� (`\ ✓/re ZJofn�nanraea�.(�to�./lc�iaael/a �\ HONE INPROVENENT CONTRACTOR Registration: 101846 ' Expiration: 6/29/02 Type: Individual STEPHEN N. KEISLING Stephen Keisling 1 68 Glenncrest Or. 'r ADMINISTRATOR N. Andover NA 01845 i i i! .da.�t..+u r - �.:4�a.✓...ar.w..wn .n..•+.nlw....� -Tl&e T069jmonll/P.[la 00 aaaac/Luoelta I BOARD OF BUILDING REGULATIONS License:"CONSTRUCTION SUPERVISOR Number CSti _ 027489 ;Birtgd to Oj71611953 Expi ras,07/15 001 Tr.no: 11352 ro: 00 I 1 �i a ��'•'; j STEPHEN M'KEISLIN t 68 dLENCREST DFOi,:{' L•!'♦.wA �i NANDOVER, MA,'01W Administrator t c U .1 0 oH PRODUCT 11 a Q To Reorder Can I-&*M54= r Q p a s tt l Page No. of Pages STEPHEN M. KEISLING Building & Remodeling 68 Glencrest Drive NORTH ANDOVER, MASSACHUSETTS 01845 MA Lic. 027489 Home Impv. 101846 Phone 682-2072 PROPOSAL UBMITTEDTO PHONE DATE -10 W,7-2/.0S- I � i a� TREE JOB NAME //,s_ CITY,STATE and ZIP CODE JOB LOCATION ,�/ok � ARCHITECT DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: LtrGro�u+o Q),. U�..- ........ - ......�� t.. ......:. ... ....................... .......9.` -.......................... .................... ....... ............................................a .. .I.......... �.._ .... ,,........., ..... � ? .... r ............... .�,... .. .. ............. ... ................................................_ cv - -�e cam,,a �-. ............. ............ ..................... ..... _ .........................0 ................ .................................................................................................................................... ......._�L_!/.............................................._ ............. _ .... u ........ `.. (,r c`' ... ' ',' �`"",................ ..............................................................................................._...................................................................................................................................................................................................................................................................................................................................... ......... ................................................................:..............................._._. �t���or 7G�0. vti ..................................................................._...................................._....__.........._................................................................................................................................................................................................................................................................................................. ........ ................... ................................ ,,, `- .1 ��................................................. ............................................................................................................. ...................................................................................................................._........_................................................................................................................................................................................................................................................................................................. . ..................................................................................._:............................_..._......................................................................................................................................................................................................................................................................... .... Hit proPUBC hereby to furnish material and labor—complete in accordance with above specifications, for the sum of: dollars($ ). Payment to be made as follows: All material i r s guaranteed teed to be as specified. All work to be completed in a workmanlike manner according to standard practices.Any alteration or deviation from above specifications Authorized Involving extra costs will be executed only upon written orders,and will become an extra Signature charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control.Owner to carry fire,tornado and other necessary insurance. Note:This proposal may be Our workers are fully covered by Workman's Compensation Insurance. withdrawn by us if not accepted within days. ArrPtltaurr of proposal —The above prices,specifications ALO and conditions are satisfactory and are hereby accepted. You are authorized Signature to do the work as specified. Paympnt wij be made as outlined above. c a .,..... ... .. ...__.... ._.....,.,,...,,,«.k.w,uau.a..r+.+.,+ar,..wuca......... ...... .. .. .. ....a.n,Yaw..o.. ,H:oti..ya..d.wn,.,.,a,..,,,....•-.--_ Farm DECLARATIONS PAGE 1 CONTRACTORS ADVANTAGE SPECIAL Family Casualty Insurance Company POLICY NO. 2005XO431 ra Qenmont,New York NAME OF INSURED AND MAILING ADDRESS: AGENT NO. 2591 OFFICE NO. 2591 STEPHEN KEISLING JAMES W UGONE 68 GLENCREST DR FARM FAMILY INSURANCE N ANDOVER MA 01845-1315 10 S MAIN ST STE 208 TOPSFIELD MA 01983-1832 978-887-8304 RENEWAL TRANSACTION EFFECTIVE 03/21/00 POLICY PERIOD FROM 03/21/00 TO 03/21/01 12:01 A.M. STANDARD TIME AT THE LOCATION OF THE DESCRIBED PREMISES THE NAMED INSURED IS: INDIVIDUAL BUSINESS OF THE NAMED INSURED: CARPENTRY-NOC LOCATION OF DESCRIBED 68 GLENCREST DRIVE PROTECTION CLASS IS: 04 PREMISES NO. 01: N ANDOVER MA 01845 CONSTRUCTION IS: FRAME PREMISES 01 BLDG 01 BUILDING MATERIALS / EQUIPMENT STORAGE BUSINESS PROPERTY COVERAGE: LIMITS OF TERM ADDL/RTN INSURANCE PREMIUMS PREMIUMS BUILDING 0 0 0 BUSINESS PERSONAL PROPERTY 5,000 74 74 BUSINESS INCOME AND EXTRA ACTUAL LOSS SUSTAINED NOT EXPENSE EXCEEDING 12 MONTHS INCLUDED INCLUDED BUSINESS LIABILITY COVERAGE: BUSINESS LIABILITY - PREMIUM IS SUBJECT TO AUDIT BODILY INJURY/PROPERTY DAMAGE 500,000 PER OCCURRENCE 1,000,000 AGGREGATE 500,000 AGGREGATE FOR PRODUCTS - COMPLETED OPERATIONS HAZARD MEDICAL EXPENSE 5,000 PER PERSON FIRE LEGAL LIABILITY 50,000 PER OCCURRENCE CODE DESCRIPTION PAYROLL TERM PREM ADDL/RTN 91342AA CARPENTRY-NOC 15,600 276 276 THE LIMIT OF INSURANCE FOR THIS BUILDING SHALL BE AUTOMATICALLY INCREASED BY 5% ON AN ANNUAL BASIS DURING THE POLICY PERIOD. ACTUAL CASH VALUE (ACV) - BUILDING OPTION DOES NOT APPLY. DEDUCTIBLE: $250 DEDUCTIBLE APPLIES EXCEPT WHERE NOTED IN THE POLICY OR ENDORSEMENTS. COUNTERSIGNED BY: BF 30 05 01 98 INS.:°ED CCPV PROCESSED DATE: 02/14/00 NORTH Town of ,` dover 0 E dover, Mass., COCMIC HE WICK yt A0RATED `S BOARD OF HEALTH PE T Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT... ......... ........ ....... ........ ........... ................. . ................................... ........... .. ...... .... // � • A ••• •• • Foundation has permission to ere buildings ofl/ / /b ... ... Rough ...... to be occupied asepe�rsio . Chimney .. ................... ....................... ... .. ............. ....................... ............................... provided that the ccepting this permit shall in every respec conform to the terms of the application on file in Final this office, and to the p isions 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 UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR Rough ....................... .. . . .... Service &TIMIN6 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. Location ��� �./✓-r—� �? No. �I � / Date NaRT� TOWN OF NORTH ANDOVER J6. • • LP * ; . Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL "Check # i 6 3 .;/ �� _....� _'Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING ^YY+, 3 BUILDING PERMIT NUMBER: 56 / DATE ISSUED. / 0/— 3 X SIGNATURE: Building Commissioner/Inspect6r of Buildings Date Z SECTION 1-SITE INFORMATION O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: s1AI /L 1201 c A- Map Number Parcel Number r - 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(so Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required J Provided v 1.5. Flood Zone information: .8 Sewerage Disposal System:SupplyM.G.L.C.40. 54) Public ❑ Private 0 Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System 0 SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT rn 2.1 Owner of Record (, Z-"O ->f- 4,*7-*y /.� Name(Print) Address for Service r Signature Telephone I 2.2 Owner of Record: Name Print Address for Service: O Z M Signature Telephone M SECTION 3-CONSTRUCTION SERVICES 7� 3.1 Licensed Construction Supervisor: Not Applicable ❑ i '/ /�� _S e RWF W ,CL 1j'e1AJ 6' Licensed Construction Construction Supervisor: 002 7YcP9 6a �P.jr,9P s� \VR, No /i N��t�PG jaw License Number mn Add s - ¢7aP d P?--207 2 Expiration Date ic Signatu a Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name /D l ylo m tqS, �"da4.g-- Registration Number I"a Address r G�aQ � oy Z Expiration Date Signature Telephone Y/ -------------- f SECTION 4-WORKERS COMPENSATION(NLG.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......0 No.......0 SECTION 5 Description of Proposed Work check au applicable) New Construction ❑ Existing Building ❑ Repair(s) Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIti USE-QNLY Completed by permit applicant 1. Building =j (a) Building Permit Fee e S",:>O, Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee tel X tbl D 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 7b OO ���OWNER/AUTHORIZED AGENT DECLARATION I, J /e leeIsC/I Al tl— as Owne uthorized Agen 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 S�P PS �elflr,y Print — � Si attire f Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB ND RD SIZE OF FLOOR TIMBERS 1 2 3 SPAN DIMENSIONS OF SILLS DIN ENSIONS OF POSTS DIMENSIONS OF GIRDERS EiEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIIv1NEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE +- + + r + »- I i j i � I -+--+ -+ - � + + /"x" - /V�,./fr�+__,�/•n�l.»fT"- / + T T - T - .-- + - + _ It + �(yrMtar+l.- � + « -- �- r --� —+ ---+ + � - r + r + + - r + - + + r + -+- r-•+ - +---t- -+ t + r t t +-- - r + -�-- + + + + � -r _r—r- _r_-�T -_«—r--r_-r. - •-__- • r--- r - -r----r- + + -+- i [Ell 77 SI uti j I , I I I w The Commonwealth of Massachusetts w F a Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 °�M Sv•' Workers'Compensation Insurance Affidavit Name Please Print Name: It-el`se /;U G- Location: v-7—7 .9 ,v /4i�j L City IVO A%D Phone # 5�12 ZP4/0 0' I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers'compensation for my employees working on this job. Company name: Address City: Phone# Insurance.Co. Policv# Company name: , Address City Phone#- Insurance Co. Policy# Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of.a fine up to 31.500.00 and/or one years'imprisonrnent.as_wellas_c:nal4maltiesin-thelcnm-f-a-STOPVMORK-OPJDER and ofine.af.($IJDDM)-aAW.-gainstz)p- understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification l do hereby certify under the pains and penalties of perjury drat the MormabGon providled above is true and correct Signature pate- 2.0 o3 Print name 19 10.31 1 AJ �r Phone.# 97P w1,PZ-20 2 Z Official use only do not write in this area to be completed by city or town official' City or Town Pemlt/Licensi El Building Dept []Check if immediate response is required lJCenS%liQ Board E] Selectman's Office Contact person Phone A E] Health Department F, Other FarmDECLARATIONS PAGE 1 FamilyCONTRACTORS ADVANTAGE SPECIAL Casualty Insurance Company POLICY NO. 2005XO431 ® Gienmont,New York NAME OF INSURED AND MAILING ADDRESS: AGENT NO. 2591 OFFICE NO. 2591 STEPHEN KEISLING JAMES W UGONE 68 GLENCREST DR FARM FAMILY INSURANCE N ANDOVER MA 01845-1315 10 S MAIN ST STE 208 TOPSFIELD MA 01983-1832 978-887-8304 RENEWAL TRANSACTION EFFECTIVE 03/21/03 POLICY PERIOD FROM 03/21/03 TO 03/21/04 12:01 A.M. STANDARD TIME AT THE LOCATION OF THE DESCRIBED PREMISES THE NAMED INSURED IS: INDIVIDUAL BUSINESS OF THE NAMED' INSURED: CARPENTRY-NOC LOCATION OF DESCRIBED 68 GLENCREST DRIVE PROTECTION CLASS IS: 04 PREMISES NO. 01: N ANDOVER MA 01845 CONSTRUCTION IS: FRAME PREMISES 01 BLDG 01 BUILDING MATERIALS / EQUIPMENT STORAGE BUSINESS PROPERTY COVERAGE: LIMITS OF TERM ADDL/RTN INSURANCE PREMIUMS PREMIUMS BUILDING 0 0 0 BUSINESS PERSONAL PROPERTY 5,000 46 46 BUSINESS INCOME AND EXTRA ACTUAL LOSS SUSTAINED NOT EXPENSE EXCEEDING 12 MONTHS INCLUDED INCLUDED BUSINESS LIABILITY COVERAGE: BUSINESS LIABILITY — PREMIUM IS SUBJECT TO AUDIT BODILY INJURY/PROPERTY DAMAGE 500,000 PER OCCURRENCE 1,000,000 AGGREGATE 500,000 AGGREGATE FOR PRODUCTS — COMPLETED OPERATIONS HAZARD MEDICAL EXPENSE 5,000 PER PERSON FIRE LEGAL LIABILITY 50,000 PER OCCURRENCE CODE DESCRIPTION PAYROLL TERM PREM ADDL/RTN 91342AA CARPENTRY—NOC 20,000 379 379 THE LIMIT OF INSURANCE FOR THIS BUILDING SHALL BE AUTOMATICALLY INCREASED BY 5% ON AN ANNUAL BASIS DURING THE POLICY PERIOD. ACTUAL CASH VALUE (ACV) — BUILDING OPTION DOES NOT APPLY. DEDUCTIBLE: $250 DEDUCTIBLE APPLIES EXCEPT WHERE NOTED IN THE POLICY OR ENDORSEMENTS. COUNTERSIGNED BY: BF 30 05 01 98 INSURED COPY PROCESSED DATE: 02/14/03 ✓�ie�aomz�narnuecLll� a��-`laysar�uaetla BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR. Number: CS 027489: Birthdate: 07/16/1953 Expires: 07/16/2003 Tr.no: 12035 MW • Restricted To: 00 STEPHEN M KEISLING 68 GLENCREST DR [•�'"'� ♦inkonnvco RAn n�oec •�- _- r gze �anz rnaa o`' `aa�ao�ucaetta —= Board of Building Regulations and Standards — - HOME IMPROVEMENT CONTRACTOR Registration: 101846 Expiration: 6/29/2004 Type: Individual STEPHEN M.KEISLING Stephen Keisling 68 Glenncrest Dr. t N.Andover, MA 01845 Administrator r Town of ikndover No. AIL -OCHICH WICK L LAO y dover, Mass., "ted °'`?ATE D P? S H E BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System THIS CERTIFIES THAT... O „KA41ItY BUILDING INSPECTOR l0 ' ' � � I f0 Foundation has permission to erect..... . ........................... .. bu' di son . .........................................................................:...... Rough sl� �.er- w �l hew wJ� pows h to be occupied as Chimney :...................... ...................................... ........................................................................... y 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 B -Laws relating to the Insp ction, Alteration and Construction of Buildings in the Town of North Andover. /_ ® PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids his Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUCTION ST TS 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 s Street NO. SEE REVERSE SIDE smoke Det.