Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Miscellaneous - 116 HIGH STREET 4/30/2018 (2)
116 HIGH STREET 210/053.0-0022-0000.0 I 'r p�19-Ycwr % —— - - - - -- ---- - --- --. .. - t- = C uh s:i,'nortliardoverma.viewpointrloud.com/PIrecordirtloe:S Tovm of Nortin Andover,YA 4 sea c 20819 -Gas Penni[-In conjunction with a Building Permit lCommercial or Residentiary TIMELINE ® Submis=ion received Jun 30,2016¢ibl0pm Gas Permit Review Du ; }{ytce.z O Penalc fee Dana Ursillo 116 HIGH STREET,NORTH ANDOVER, <978609-7949 MA p ursillopi—bing@g.- Owner OC rniY<5uancc MANDLE REALTY TRUST Attachments -- Primary Contractor Search for your contractor using the search bar below.Either the Firm's Name or licensee t is required mm;f=�s:nssi Name .:cmb<rSa;fF.x.rleme tu:�.rsazl Dana Ursillo e (rt (� !�,.i(� J © W®a^J 10 W(b R lklNNl6� v I Thursday,Jun 30,2016 12:14 PM ' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK t I r CITY uJcl Com+- MA DATE PERMIT# JOBSITE ADDRESS St. _ OWNER'S NAME GOWNER ADDRESS TEL =FAXL TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES� NO Q APPLIANCES 7 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER l BOOSTER CONVERSION BURNER COOK STOVE l DIRECT VENT HEATER DRYER - FIREPLACE FRYOLATOR FURNACE - GENERATOR GRILLE._ INFRARED HEATER ^ LABORATORY COCKS MAKEUP AIR UNIT _ OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER I �_ WATER HEATER OTHER INSURANCE COVERAGE �/ -- I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES IIf NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [� OTHER TYPE INDEMNITY BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT 0 SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information 1 have submitted or entered regarding this application are tr n ccurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co pliance ith all Pertinerovisio e Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASATTER NAME 404 U✓Ls(Lc 6 j LICEN SE# SIGNATURE MP 0 MGF 0 JP 2JGF 11 LPGI© CORPORATION©#=PARTNERSHIP®#=LLC[ #= COMPANY NAME:_ L2S 1 Li C) ��ADDRESS CITY {��C I^ _ _ _ —� STATE �(- ZIP ITEL _-- 7 -7 `f � . FAX CELL — - EMAIL L-(r-S&_ 0 krp) �1��✓� ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES e The Commonwealth of Massachusetts f Department oflndustt'ialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information i 1Please Print Legibly Name(Business/Organization4ndividual): L t y Address: S 'T�1 C M.0 A VkA LJU V tt^ City/State/Zip: M C kl J H , A 01 'tf Cf Phone Are you an employer?Check the appropriate box: Type of project(required): 1.❑I m a employer with employees(full and/or part-time).* 7. ElNew construction 2. I am a sole proprietor or partnership and have no employees working for me in 8. F1 Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 4.F1I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 E]Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ . 13.F1 Roof repairs These sub-contractors have employees and have workers'comp,insurance.$ 6.❑We are a corporation and its officers have exercised their right of'exemption per MGL c. 14.F1 Other 152,§1(4),and we have no,employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they 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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name: VkA V '�U Vk- S Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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 viol copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verific on. I do hereby c tii under t e pains and penal i of pe 'u a information provided above is true and correct. Signature: Date: 35 4 Phone#: q *7 F 0 CI ' q c Official use only. Do not write in this area,to be completed by city or town official.. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract ofhire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you'are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should'enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia e - - - - - C -------------------- — - - ,�h;?;s.jJrlortllardoverma vievrpoin7zloud comji;Jrecccds/7f.5.'.0 AM Nexeti't . To\vn of North Andover,MA 4 Search 20820 -Plumbing Permit•In Conjunction with a Building Permit ICommerclal or Residentlall TIMELINE - P ® Submission recei\ed Jun 30,2016 a 12n 5pm T Plumbing Permit Reetew In Progress ® Cr ...__...........,._._. ApPixans O Permlt Fee Dana Vrsilllo 116HIGHSTREET,NORTH ANDOVER, MA ,r\\ PcN<Sml w\\ua<ry\MmDEVBICON gybing@g,_ ?caner -� CWNU I WINDLE REALTY TRUST QPemlit Mu"We ESE Attachments -OTXDC01001F Thujun 30 2016 16:20:.PDF VN..,At,) .,3'... Primary Contractor Chaagn_ Search for your contractor using the search bar below.Either the Firm's Name or licensee B is required. .rm's 19•_sinessl Nartw P mb<rs N"'.e Iuce:,see7 Dana Ursillo 30604 Journeyman Plumber ..cern'Eapir<si er< Ucense Aa', MliMniP ''TT 0/} t� .moi(.tt tr.�� • V m 4 8!1�!�FY W rO fi(3DJ3a16 I220fM1 Thursday,Jun 30,2016 12:20 PM I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY Cb�E �� MA DATE , PERMIT# JOBSITE ADDRESS S1 . OWNER'S NAME POWNER ADDRESS L TEL -- FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL © RESIDENTIAL PRINT CLEARLY NEW: MI. RENOVATION: REPLACEMENT:Q PLANS SUBMITTED: YES® NO[11 FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13_i€ _14 BATHTUB _ — CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM l DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM f DEDICATED WATER RECYCLE SYSTEMJ=!'= DISHWASHER [II DRINKING FOUNTAIN ( ---.__1 _.____._I .__._..J I _.._.__I __....__J ._ � --_-.---( --._...I . _ .__1 FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) I [ _._ _l _J ._.._ f f 1 f I _._._..1 ._..__J _____J KITCHEN SINK I . -J f i _.__....! _____{ __`I F--- __I _J __-__J -_- J .-._._J LAVATORY _ ! _ ._I ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET I __. I __T_I ..,_6 I j _I. ____.J .___ I .— J URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER I € l _...._-J —I ,-- ---€ ---j INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ;_..f NO _ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY D OTHER TYPE OF INDEMNITY D BOND P OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT IDI SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application rue d accurate tot best o knowledge and that all plumbing work and installations performed under the permit issued for this application will be' complia a with al a nt n f the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. a. PLUMBER'S NAME v_A v vLst L LO _ ---IILICENSE# ���Ca�l I SIGNATURE MP El JPr CORPORATION RI PARTNERSHIP D# LLCD� COMPANY NAME �V� 1 L.iLa — i AC -SS _ 11 E,"L©N'i S+ I CITYy _i STATE _; ZIP 6 40 TEL FAX � _ CELL MAIL u S,f_I o-o y n1 �� i ,. o� ..__... — -- _ _ h- -g- _.... ._r^� ._..__ _._._...---- ---- - - --- - I ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES h T The Commonwealth of Massachusetts z Department of Industrial Accidents I Congress Street,Suite 100 = Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): �(/�y11), U k_g ,l L L a Address: t L-- eco S4 City/State/Zip: -M Lk cv` Phone#: 7 O Are you an employer?Che k&appropriate box: Type of project(required): 1.❑I a employer with :.. employees(full and/or part-time).* '7. 0 New Construction .2.F,_.; sole proprietor or partnership and have no employees working for me in 8. F1 Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.Q I am a homeowner doing all work myself[No workers'compAnsurance required.]t 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 n Building addition ensure that all contractors either have workers'compensation insurance or are sole I L❑Electrical repairs or additions proprietors with no employees. - 12:E]Plumbing repairs or additions 5.n I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.irmirance. 13. Roof repairs 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 152,§1(4),and we have no..employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they 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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site information. 'n^ Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year' ent,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 iolator. copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage ve ' cation. I do hereb certify unde the pains a peva f et j ry that the information provided above is true and correct: Si ature: G (�"`� G ins Date: 3 Phone 4: -`7 F - 6 01 ' 1 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#: I . 1 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill-out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and-phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees'other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you.'are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should'enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.#617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia 7/14/2016 Date: July 14, 2016 20915 This is an e-permit.To learn more,scan this barcode or visit northandoverma.viewpointcloud.com/#/records/20915 . ^ TOWN OF NORTH ANDOVER Ell PERMIT FOR WIRING F 0� This certifies that Mark T Swett has permission to perform wire kitchen and bath wiring in the buildings of WINDLE REALTY TRUST at 116 HIGH STREET , North Andover, Mass. Lic. No. 34631 1/1 7/11/2016 A Date:July 11,2016 20819 This is an e-permit.To learn more,scan this barcode or visit north andoverma.viewpointcloud.comm/records/20819 UL, . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ❑■ This certifies that Dana Ursillo has permission for gas installation Kitchen and Mudroom Renovation in the buildings of WINDLE REALTY TRUST at 116 HIGH STREET, North Andover, Mass. Lic. No.30604 1/1 7/11/2016 Date:July 11,2016 20820 This is an e-permit.To learn more,scan this barcode or visit northandoverma.viewpointcloud.comfit/records/20820 ' StT�UZ'Q+'s . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING D This certifies that Dana Ursillo has permission to perform Kitchen remodel plumbing in the buildings of WINDLE REALTY TRUST at 116 HIGH STREET, North Andover, Mass. Lic. No.30604 1/1 I � Location � -�� A G 4 S No. `J Date /_/A UO c�NO,oT" �ti TOWNR'OF NORTH ANDOVER • Certificate of Occupancy $ : �' . Building/Frame Permit Fee $ Q� Foundation Permit Fee $ i Other Permit Fee $ TOTAL $ 1:57 00 F Check # P - 14334 Building.Inspector =`V AL ic OT 4.�r t d. q! 4F y F• - .- TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: rn /02-- 07 1 /- q- X SIGNATURE: 0kr&4A06W- Building Commissioner/Ifor of Buildings Date z SECTION I-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 0 Number "SS map umber Parcel', umber 1.3 Zoning Information: 1.4 Property Dimensions: Zoning Diiiict Proposed Use Lot Area(sf) Frontage(ft) 1.6 BUILDING SETBACKS(ft) Front Yard Side Yard Rear Yard Required Provide Required Provided Reqwred Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.9 Sewerage Disposal System: > Public D Private 0 Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System 0 -q 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 Scrvice: 0 Z M Signature Telephone 90 SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable 0 Licensed Construction Supervisor: License Number Wn Address > Expiration Date ic Signature Telephone fam 3.2 Registered Home Improvement Co �or Not Applicable 0 Company Marne M Registration Number r Address z Expiration Date Signature— Telephone 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 Workcheck all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify t A A Brief Description of Proposed Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be _ OM,,CIAL'USE";ONLY Completed by permit applicant _ 1. Building (a) Building Permit Fee ` Multi lier 2 Electrical Lao (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 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 i ature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR T]MBERS 15 2 ND 3 RD SPAN DMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION TIIICKNESS SIZE OF FOOTING X MATERIAL OF CIMANEY IS BUILDING ON SOLID OR FILLED LAND IS BUII,DING CONNECTED TO NATURAL GAS LINE The Commonwealth of Massachusetts Department of Industrial Accidents i;d — = Office nlinvesti 211ons =_ 600 Washington Street Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Me I catio - city �I� ephone# I am a homeowner performing all work myself. C3 I am a sole proprietor and have no one working,in any capacity F1 I am an employer providing workers' co m ensation for my employees working on this job. comp an a e. 5 1 G h Ucense 'i sddress:.7t V _ phone#- insurance co: •'���� aS C- ,. " policy#MR I , C] 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` Rhone#• i►�u�ncc co: policy# .. company name: address• cih' phone# .insurance co'; policy# 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 S 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 5100.00 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 enallies of perjury that the information provided above is true and co recL. Signature/ �l2 < ��Cz42CQ Date mav Print name Phone# Official use only do not write in this area to be completed by city or town official city or town: permitAicense# OBuilding Department pLicensing Board O check if immediate response is required oSelectmen's Oft;ce 011ealth Department contact person: phone#;nOther (revised 3195 PIA) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the."law", an eniployee.is.defined as every person in the service of another under any contract of hire,.express or implied, oral or_written: , An employer is �efined as an individual;.partn�TS ip,1associaliQn, corportjtion.9rpther legal entity, or any two or more of the foregoing engaged in a joint enterprise, end jgyl�udia�,ilta.lrega�repre:eglatives of a deceased employer, or the receiver or trustee of an individual , partnership,-association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance , construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally, neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names, address and phone numbers as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the"law"or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. 1 City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. Tile Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, Ma. 02111 fax #: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 � f 1 ' � GJ/� �osw�nosuoea�!/i�./uaaaac/u�aelle I j HOME IMPROVEMENT CONTRACTOR Registration 103311 Type - DBA Expiration 07/07/4000001- CASTRICONE ROOFING & SIDING C Marro T. Castricone G� �ourt St. ADMINISTRATOR N. Andover MA 01845 - ��ie �amn,.arauieall�•a���aaacu.•�u6ella BOARD OF BUILDING+REGULATIONS yLicense: CONSTRUCTION SUPERVISOR Number:•CS 034049 Birthdate: 12/08/1923 Expires: 12/08/2001 Tr.no: 10391 Restricted To: 00 MARIO T CASTRICONE � ! 31 COURT ST N ANDOVER. MA 01845 Administrator F NORTH Town of 4Andover 0 Y o - o dower, Mass., • COC MIC HE WICK ADRATIE D S H BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System �oNi�� �/��� � BUILDING INSPECTOR THISCERTIFIES THAT..................................................................................................... Foundation has permission to erect.... ....... buildin nN0 s g ....... '. ................ ..... Rough to be occupied as %S4 Pf... R '� /�Q 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. M W6 03 PCX a PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final ELECTRICAL INSPECTOR UNLESS CONSTRUCTION START C Rough ..................... Service BUILDING INSPECTOR Final Occupancy Permit Required t0 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. Date. . . . �.. 1. HORTh TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SA S This certifies that--rl� . . . . . . . . . . . . ... . 7• has_permission to perform . . , plumbing in the 0dings of��'ff,� . . . . . . . . . . . . . . . .. North.Andover, Mass. iFee . . . . . . .Lic. No.. . . �l�.l�>.!l "1. !./J ..: . . . PLUMBING INSPEC,IOAJ Check .H / 6491 V' MASSACHUSETTS UNIFORM APPLICATIONFO PERMIT TO DO PLUMBING (Print or Type) n L nrM jdV ass. Date Permit # // ✓ ` Building Location Owner's Name l e D n a f -d j'lOrj le- -- Type of Occupancy Residential . 9 7c9 y New ❑ Renovation O Re acement Plans Submitted: Yes❑ No ❑ IXTURES ZN xN 1/'z O z W x J Illcn ++ n z cc O - w h w N 1- 0 W to x Q a W - 6 ZO 7 2 Q N R Q W N O a J Z p p LL x x �++ 2� w = a i 3 3 o z = 3 x a o h z x a W U. Sa h u = a w h o _ _ w F- O u a h a a = N 2 a a o a j a ¢ ¢ a .a O a 3 x J fC N O O J 3 = h N S-1 U. V O O Q 3 CC 1U R� (O R� • d 33 33 � SUB-BSMT. BASEMENT IST FLOOR 2ND FLOOR 9RDFLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company Name Heritage 'Htg. &Pig- . C8. InC.. i ; Check one, Certificate Address 35 Pleasant 'Street iIX Corporation 714 ' ` Stonehamy 'Ma 02180 ! ;El Partnership, ' Business Telephone t 781 '-432-7776 i I I n Firm/CO. ' • ` Gordon`Switzeri Name of Licensed Plumber INSURANCE COVERAGE: - �L I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes ® No ❑ If you have checked Yes, please indicate the type coverage by checking the appropriate box. A liability Insurance policy Is Other type of indemnity ❑ Bond ❑ t 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❑ Signature of Owner or Owner's 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 the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts Stale Plumbing Code and Chapter 1 of the General laws. Signature o cense um er �f Title s t -'Typ'e of License:Master Ix Journeyman❑ City/Town APP ONLY)- - `-U^ense Number - —- - - -- -- '/2"Watts 9D bfp on water line to water boiler .• LocationJ(�I�(ot%� �t6i;-�- ax :No Date 3 s f4NpRr"�� * yvTOWN OF NORTH ANDOVER "�p 'Certificate of Occupancy $ 'Building/Frame Permit Fee $ a: ArKUSE<�. Foundation Permit fee $ th r Permit Fe $ TM �• fi�llEG !. Connection Fee $ 55 Ffi .j.. Water Connection Fee $ tit Y rX• T+swb' � L $ �S 1 Building Inspector •7 9 61 Div. Public Works { PERMIT NO. Ces- APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1 MAP K-4O. LOT NO. 2 RECORD OF OWNERSHIP IDATE BOOK iPAGE ZONE I SUB DIV. LOT NO. i OCATION PURPOSE OF BUILDING 0 ;OWNER'S NAME NO. OF STORIES SIZE jOWNER'S ADDRESS BASEMENT OR SLAB ARCHITECT'S NAME J SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME () Q]7/rJ SPAN 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 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 LAND COST SEE BOTH SIDES EST. BLDG. COST PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM PAGE 2 FILL OUT SECTIONS 1 - 12 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 3z�zg� (ig BUILDING INSPKCTOR SIGbLATURE OF OWNER AUTHOqllZED AGENT FIE E OWNER TEL.# • PERMIT GRANTED CONTR.TEL.# ',A(2A 19 a .- CONTR.LIC.# `` ^-� H.I.C.# 103 ` 1 BUILDING RECORD 1 OCCUPANCY 12 T SINGLE FAMILY S"OPIES 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 I RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION -I 8 INTERIOR FINISH CONCRETE 3 1-12 13 CONCRETE BL K. PINE BRICK OR STONE HARDW D PIERS PLASTER _ DRY WALL UNFIN. 3 BASEMENT AREA FULL FIN B M T AREA _ '/ 1/2 1/1 FIN. ATTIC AREA _ NO BMT FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 7 3 DROP SIDING CONCRETE �_ WOOD SHINGLES EARTH _ ASPHALT SIDING HARDW D _ ASBESTOS SIDING _ COMMON VERT. SIDING ASPH. TILE _ STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. & FLOOR _ BRICK ON FRAME CONC. OR CINDER ELK. STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIOR POOR ADEQUATE I-i NONE 5 ROOF 10 PLUMBING GABLE HIP BATH 13 FIX.) - GAMBQEL 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 ti 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. 1 TIMBER BMS. 6 COLS. STEAM STEEL BMS. 3 COLS _ HOT W T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING RADIANT H'T G UNIT HEATERS 7 NO. OF ROOMS GGAS BytA T 1 ( I NOELECTRIC 3HE TING NORT Townof 2 s r 4Andover 0VIP IL No. o85 - -ort, dover, Mass., YY1 A e5cw Zl 19 g.C coLAK C NIC NE w ICK ��- ��ADgATED E BOARD OF HEALTH Food/Kitchen PERMIT T . D Septic System �,f�ortr�rzx� . BUILDING INSPECTOR THISCERTIFIES THAT...............................................................�,t• .........................................................................:................ Foundation has permission to erect..l QM..9....... g ....... ........... buildings 0.b.....Atb....... ............................... Rough tobe occupied as..4. 4 . ... ......?_*J ,X14.... + : '+............................................................................................. 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 CON T TS _ _ Rough .. . ..... ..... .... .. . ......... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display* in a Conspicuous Place on the Premises — Do Not Remove RouFinagh 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 FINAL DRIVEWAY ENTRY PERMIT 10-1o !_ t Location No. Date / 5 ".OR7M �a TOWN OF NORTH ANDOVER " ' 9 Certificate of,Occupancy $ a Building/Frame^Permit Fee cHust<� Foundation Permit Fee $ Other Permit-Fee $ I Sewer Connection Fee $ Water Connection Fee $E. �- TOTAL $ c Building Inspector � 13064 Div. Public Works J.: ..._ -_.. .a_Smi.'<`:.�5�1:eKlisi4`•`•._ _ �a..r'1L�..._ _ .�.__aY ..-''- -ter±.. _�w•.ari. �-• Lim,.,,.,,,, � ��.: . F.I��� ",b � �x %'... k` •y f •1� PI?RMIT NO. APPLICATION FOR Pf RMIT TO BUI ********NORTH ANDOVER, MA MAP NO. LOT.NO. 2. RECORD OF OWNERSIIFP DATE BOOK PAGE "ZONE SUB DIV. IAT NO. LOCATION PURPOSE OF BUILDING OWNER'S NAM NO.OF STORIES SIZE OWNER'S ADDRESS BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS 1 2 D 3R BUILDER'S NAME SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET DIMENSIONS OF POSTS DISTANCE FROM LOT LINES-SIDES REAR DIMENSIONS OF 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 IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD 01:APPEALS ACTION, IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL.GAS LINE INTSTUCTIONS 3. PROPER"I'Y INFORMA77ON LAND COST (3cloY ESI'. BLDG.COST PAlE I FILL OUT SECTIONS 1-3 U `C EST.BLDG.COST PER SQ. FT. EST. BLDG.COS"r PER ROOM ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING SEPTIC PERMIT NO. ATTACI IED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS 4. APPROVED BY: C PLANS MUST BE PILED AND APPROVED BY BUILDING INSPECrOR BUILDING INSPECTOR DATE FILED OWNERS TEL# / CONTR.TEL# CONTR.L I C# SIGNATURE OF OWNER OR AUTHORIZED AGENT C J H.I.C.# FEE $ V . PF.. IT GRANTED i Re��ised I I/97 JM Lc-�, 19 r Town of North Andover NORTH io f 1 OFFICE OF 3�°,<`�•� 6.6 0G COMMUNITY DEVELOPMENT AND SERVICES 0 . . p 27 Charles Street North Andover, Massachusetts 01845 Ssgc,HuS��ty WILLIAM J. SCOTT Director (978)688-9531 Fax (978)688-9542 In accordance with the provisions of MGL c 40 S 54, a condition of Building Permit J cy Number Z / l is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. The debris will be disposed of in: rs a'6w h/ 4 C�/d' �' (Location of Facility) 1 Signature of Permit Applicant Loe� �� Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 t.%ORTH Town of ` L dover No. Z o C/91 o�� dover� Massf RATE D AP 9S 15 BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT......... !lrA..R'.... ............. ' Foundation has permission to erect. r.'p...' .......... buildings o .....� ..`. t.8............� �..... ..... Rough to be occupied as...... .r. !m. .............. r S s v C�`I"'"�� Chimney pj.............. ..f..................................... 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 fee C PERMIT EXPIRES IN 6 MONTHS Final 1304 � UNLESS CONsTRucrjoN R.#' T 1 ELECTRICAL INSPECTOR Rough ....... ..................................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Inspected and Approved b the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det.