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Home My WebLink AboutMiscellaneous - 119 BLUEBERRY HILL LANE 4/30/2018 1�ERRY HILL LANE � ll 210/098.0-0094-0000.0 _ i 4 Phone: 978-342-2660 Fax: 978-342-2699 JAMES A. TRUDEAU Adjustment Service Inc. P. O.Box 942 Fitchburg,MA 01420 Notice of Casualty Loss of Building Under Massachusetts General Laws, Chapter 139, Section 3B October 15, 2009 Building Inspector 120 Main Street North Andover,MA 01845 Board of Health 120 Main Street North Andover,MA 01845 Fire Department Dept. of Records 124 Main Street North Andover,MA 01845 Insured: Cort Szafarz and Nancy Smith Loss Location: 119 Blueberry Hill Ln.,North Andover,MA 01845 Insurance Company: Preferred Mutual Insurance Co. Policy No.: PHOO100785400 Date of Loss: October 6,2009 File Number: 09-08112 Claim Number: 09015335 Type of Loss: Water Damage Claim has been made involving loss, damage, or destruction of the above captioned property, which may either exceed 51,000.00 or cause"Mass. Gen. Laws, Chapter 143, Section 6"to be app Y applicable. If an notice under"Mass. Gen. Laws, Chapter 139, Section 3B" is appropriate, please direct it to the writer and include a reference to the captioned insured, location,policy number, date of loss, and file or claim number. On this date, I cause copies of this notice to be sent to the person(s) named above at the address indicated by first class mail. Sincerely, Thomas Murphy Claims Adjuster 7753 HORTM °F o? °� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION SS CH SES C_7 h S This certifies that . .��.4. :}f:U\ . . . . �.u�?��-�- . . . . . . . . . . . . . � has permission for gas installation .0�.Ot 10 6 �44. . . . . . . . . in the buildings of T. . .52— 1?C=.AA-?-z. . . . . . . . . . . . . . . . at . .0.5 .(d.I.Q:-.f. .`! `.y, -. . . . . ., North Andover, Mass. Fee?v�. . . Lic. No..'-3.o z.�� . . . . . . .G GASINSPECTOR Check# &( � vQ ` ,U.; 19�tD�1 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) NORTH ANDOVER ,Mass. Date JULY 25, 2011 permit# r� = Building Location 119 BLUEBERRY LN. Owner's Name CORT SZAFARZ Owner Tel#978'685-4580 Type of Occupancy RESIDENTIAL New 7 Renovation❑ Replacement Plan Submitted: Yet No❑ FIXTURES r � x w w U l:. W a W f W U) 940 q0 O OU x x rn z ¢ n O A O F U) U ¢ x z O a O A > w W ¢ w w H x a Q ug > of w ¢ x ¢ ¢ o o w o w W 2 0 CD x w x 3 A C7 a U i>r > A a H O w SUB-BSMT BASEMENT 18T FLOOR I 2"D FLOOR 3RD FLOOR 4T"FLOOR 5T"FLOOR 6T"FLOOR 7TH FLOOR ; 8T"FLOOR Propane ro ane & Oil Inc Installing Company Name P � Check one: Certificate Address 131 Water Street Corporation Danvers, MA 01923 Partnership Business Telephone# 800-322-6628 Firm/Co. I Name of Licensed Plumber or Gas Fitter BENEDICT BREITUNG INSURANCE COVERAGE: I have a curfal liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. ye sNo ❑ If you have c ecked yts,please indicate the type coverage by checking the appropriate box. A liability insurance policyF,(] Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the 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 ertinent proAsions of the Massachusetts State Gas Code and Chapter 142 of the eneral Lgyvs. �CJ i By ,r Type of License: / • -Plumber Si nature of Licensed Plumber or Gas Fitter Title i20 -Gas fitter 3 O 3 • -Master License Number `/ City/Town •-Journeyman APPROVED(OFFICE USE ONLY) li I 7 4J�i Date—77 •D OF aHORTM TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION gs,SSAG MUSESA This certifies that has permission for gas installation in the buildings of . .(.10-. t ? ./ .4!+ .? . . . . . . . . . . . . at . . . . . ., North Andover, Mass. Fee. .d.U-7 Lic. No.. a 7U4�-::� . . . . . . . . . . . . . . . . . . . . . . . . GAS INSPECTOR Check# �01 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: Poc�nyer MA. Date: aat ko Permit# �e Building Location:_ l\S \Q,1L,., 40. cr., lAzk,� ►.�_.� Owners Name: Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: U/Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes ❑ No❑ FIXTURES LU Uj co H ca U x W �/ w W W O co M ~ co m x O W W V N O x Ix w cc,, O Z g z 0 W w w OR 0 1- D rn N W W W m 0� Q a H O w X C U Z U) (7 W (n OW H D Lu f' Q W W u1 z U) x w f- z OC x �_ � U W Z J ~ H O Z --I (� LL W x w W w w 4— z W } tY (n J Q Q m w O z 0 ~ != > z H V o o LL _ _ O a. H > > > O SUB BSMT. BASEMENT 1 FLOOR 2 FLOOR 3 FLOOR re, FLOOR 5 FLOOR 6 FLOOR -;,7p FLOOR 8 FLOOR Check One Only Certificate# Installing Company Name: �- ❑Corporation Address: ii oil-g- City/Town:ZjA5:�,,f dk State: Ll Partnership Business Tel:�Qb:j� Fax (,o:�) ❑Firm/Company \ l Name of Licensed Plumber/Gas Fitter: '-ak• e1-, S, Me INSURANCE COVERAGE: 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 of coverage by checking the appropriate box below. A liability insurance policy E� Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Signature of Owner or Owner's Agent Owner ❑ Agent ❑ By checking this box❑;I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Typ16 of License: By Plumber `ZriL- ❑Gas Fitter TitleElSignature of Licensed Plumber/Gas Fitter Cityrrown 5tiourneyman License Number: Z7 02 APPROVED OFFICE USE ONLY ❑ LP Installer i i COMMONWEALTH OF MASSACHUSETTS -. :.•-. . cnQ UCENSED AS A JOURNEYMAN PLUMBE� ISSUES THE ABOVE LICENSE TO: MICHAEL J MCMULLEN JR yl m 4447 BROWN AVE ib -MANCHESTER NH 03103-7050 i .27027 05/01/12 803917�� wimmim mummoAp �m 7563 Date..Oh/. .... . ... HORTM TOWN OF NORTH ANDOVER p PERMIT FOR GAS INSTALLATION SSACHUSE This certifies that . . .!~�.� has permission for gas installation in the buildings of . ��'l�/�1�� '4 . . . . . . . . . . . . . . . . . . . . . . . . at ` l. �: . fir. . . ., North Andover, Mass. Fee. .34. Lic. No..?.�. G� INSPECTOR Check# `7 v 1 0100 Pa Iotola . MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) T - —' , NORTH ANDOVER ,Mass. Date DEC. 232010 permit# 119 BLUEBERRY HILL LN. CORT SZAFARZ Building Location Owner's Name i Owner Tel# 978-655-4580 Type of Occupancy RESIDENTIAL New RenovationF] Replacement Plan Submitted: Yet No[:] FIXTURES w x E- U U z w Cn x w w a o ° z a F ¢ y z z o W Q m V) F W 04 Q O O W F W Q x W H 9 Q z r W W fn W Z ¢ a W W OF W F x W a n I - Z Q W Q a F F" v� Z O z O N W W s o = 0 ( = w : 3 Q � a U W > A a H o w SUB-BSMT BASEMENT 1sT FLOOR P 2ND FLOOR 3RD FLOOR F 4T"FLOOR 5T"FLOOR 6T"FLOOR 7T"FLOOR 8T"FLOOR Li Installing Company Name Eastern Propane & Oil, Inc Check one: Certificate Address 131 Water Street Corporation Danvers, MA 01923 Partnership Business Telephone# 800-322-6628Firm/Co. Name of Licensed Plumber or Gas Fitter JOHN COOMBS INSURANCE COVERAGE: I have a cures liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. Yesl ✓ I No ❑ If you have c iT—e"cked es, lease indicate the type coverage b checking theappropriate box. Y p L YP 9 Y 9 A liability insurance policy F✓ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: O ElA Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted(or entered)in above a I cati are true d accura he est of my knowledge and that all plumbing work and installations performed under the permit issued for plicati 11 bei with all ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General L s By Typ of License: umber Signatu of Licensed Plumber or Gas Fitter Title -Gas fitter �_ 3 O� • -Master � nse Number cf City/Town •-Journeyman APPROVED(OFFICE USE ONLY) Location /! ? �`u ��t� r`( 1411 4 'c- No. 3 S Date /'078_ Oa. MORTIy TOWN OF NORTH ANDOVER 3? O O - w Certificate of Occupancy $ sACMUSF'�A Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ a Check # 528 '} C} Building Inspector / f TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUC REPAIE,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: D 0 a SIGNATURE: Building Commissioner/lETector of Buildings Date SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: �C4A--CJ-YJ-W .,1/J .2, wV� t 9" g // f] Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: ( w Zoning District Proposed Use Lot Area 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.4_0. 54) r ` 1.5. Flood Zane Information: 1.8 Sewerage Disposal System: Public JV Private ❑ Zone Outside Flood Zone Municipal On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT m 2.1 Owner of Record Name(Print) Address for Service ' AJA. & 9.7Y - ago Signature Telephone 91 2.2 Owner of Record: 04 v'i d �i` L) R AM t? 11> Name Print Address for Service: 01>s a 6q m Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Constntctio-3 Supervisor: License Number 1 Address Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ / ✓l!�D cz n3 "'.9 q Company Name /p2 �! M Registration Number !'� c,1-�s'C�/'J� G'/I' r Address Expiration Date Signature Telephone s 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.....A No.......0 SECTION 5 Description of Proposed Work check au applicable) New Construction ❑��^^ Existing Building ❑ Repair(s) ❑ AlteratJions(s) ❑ Addition C. Accessory Bldg. ❑ Demolition ❑ Other ❑ -Specify . Brief Description of Proposed Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be a }�C� A. Completed b permit applicant �'� ,.:.,. R 1. Building (a) Building Permit Fee �/Slrot o Multiplier 2 Electrical (b) Estimated Total Cost of 3 CV Construction 3 Plumbing d''!7 Building Permit fee(a)X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 p Check Number SECTION 7a OWNER AUTHORIZATrCfN TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT f I, fvl (.(y f-e 4-V rJ f �-� as(9/Authorized Agent of subject property ' Hereby authorize_ K-J h Ya to act on L5� M behalf,in all matters rel tive to ork authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION x I, V l//a ��Ct YY�!/J �il� 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 y/ h V of k- m Print Na ' 4 Si ature of Owner/A en Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TI HERS -P, k-10 1''T 2ND 3RDi SPAN i, , f ® C DINMNSIONS OF SILLS o2 k6 e I r , DIMENSIONS OF POSTS X 6 /° d. C, DM ENSIONS OF GIRDERS , , -•., 7. HEIGHT OF FOUNDATION T r` w THICKNESS SIZE OF FOOTING / X / MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 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 or requirements. *****************************APPLICANT FILLS OUT THIS SECTION *********************** // APPLICANT L ct yo-,`y) p �D PHONE102, 9 LOCATION: Assessor's Map Number PARCEL SUBDIVISION LOT(S) STREET 6 l .P/ ST. NUMBER *****************************************OFFICIAL USE . ONLY*********************************** RECOMMENDATIONS OF TOWN AGENTS: CONSERVATI AD INISTRATOR DATE APPROVED /-2- 6 Z DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9\97 jm PECAppleton Land Surveying, Inc. rIMORTGAGE itRVEYdtG°DUnM•LAND MANN lW ` 234 OM MW tAWNDO Cq, V toee�aae-4ea+ (sar;'Wa� MORTGAGOR r �'d ADDRESS OF PRINCIPAL BUILD X 2.73 a•o •erg /� Is09� YOFQE owe= ago�v�auq 1 I - P4 11V &m"mom"tea am � �b W&b �.tMasd;r..t Yoie exaeAgege b!A► ,V� 1, ,®w�r»►.sjcti4r��1 1 owr«�t hum A1Si_»wloata " ,• = wo�,o,,.i Frsr�sac�s�fir.7 Tc.s.3 A&&M iedeid nm 9nMw In Gooatdaeoe w1h to tsumbede der medoor fano b- s4� 29 �cs3 �t9j/''y7 ilte +YweYw P M'6�B K OP m �_ io•.�/ mss./t .r sio.aa6*A tun I Q sa. ohm Nero Dsdbg s aat boded.bin a Hood Noted Zane kdbq 0 boded&Vm fbod Mmwd Zan ® WKN W b hkAbist to dAusim Rod Nems figod Nomerd deed item PXAA food y eroeafee�p.a 2A'roca.*t3 r�oe'a G C �� of *t Scall: ode of at Deed oksL Q B'{ — fit" CeA. Ls'---^-� Date of PAL 3 as-97 lei � Plan N't"'"m PL Ib�- North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. The debris will be disposed of in: S UJ 0, W c 0 r S"Ct dL (Location of Facility) a Signature o�fmit) Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations j Boston, Mass. 02191 Workers'Compensation Insurance Affidavit Please Print Name: tf ,- 7 Location: Gity Phone (—� am a homeowner performing all work myself. �I am a sole proprietor and have no one working in any capacity E I am an employer providing workers' compensation for my employees working on this job. Company name: Address 3 City: Phone#. Insurance Co. Policv# 9 Company name: Address 4 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$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 herby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature Date -A 0/ I Print name ". ti1v, /ha rrt V? I�'y Phone# �`�?n� (; � 9 j i Official use only do not write in this area to be completed by city or town official' ❑ Building Dept ❑Check if immediate response is required Building Dept E] Licensing Board % m Selectman's Office Contact person: Phone#: ❑ Health Department 0 Other FORM WORKMAN'S COMPENSATION i [3cc- 19-01 10: 23A P_01 Town of North Andover ��..; ;.; Building Department F 27 Charles Street m North Andover, MIA. 09845 C. Robert Nicetta d xs�CceWSs� Building Cornmissicner (978) 686-454.5 978 588-9542 Fax 4 HOMEOWNER UCENSE >~XEMPTION Please print, DATE JOB LOCATION_ / Number 5tee ddress /f� Map;lot "HCMEOWNIER-1%V/ r m Q Lx Y_r-t h- -"_J_ _(•l�' ��= _._�_ r` Name Rome Phone-- VJortc Phane 'RESENT MAILING AWi3Eu,S��9 City Town State Z,P Codec The current exemptDon for-"hpmeGMmem"was Wended to include owner-oxupied dwellings of two units or less and to allow such homeowners to engage an individual W hire who does not possess a license, pro•;ded that the owner ads as supervisor. (State Building Code Section 105.;3.5.1) DEFINITION OF HCMEWOWNER: Person(s)wrc owns a pamei of land cin Which he/she resides or intends to reside,on whim there is,or Is intended to be, a one or two family dwelling,attached or detached striuctures ac- cessory to such use and/or harrn stn.,ctures. A person who cxmstruets more than one home in a two-year period shall not be corsidered a homeowner, The undersigned•'h=eovoner' assumes respons biiit'/for compliance with the State Building Code and other Applical%v codes,bHUM, ruies and regulations, The undersigned"homeowner"cert,'f'ies that he/she understands the Town of No.Andover r Building Depar"ent minimurn Mpe<Aion'P=edures and requirements and that he/she will corrrply with said procedures and requirements. HUMECWNER's SIGNATURE= APPROVAL OF BUIL DING 0FFlC1At_ r i t i I i j 5 ,1.. � � �. `.lm�; r•- � ? � `a'�4y' ,t,�.. aSa.S�" y,". [� a •� }: S f +:{, �' tx •�r i. �.,1!-. •�� `'! 3�;.tits i j� '..F '� t. `^• .�i� i'�s�•�1S'�� y L;��`r �r� 1 �Ff � t 'w+ f t- Y �I � �3 � Y 'Y � r 'V � _,' .., :,�;1 a�� t .� r. 4 •„ Z l <c > •v � [t x �t,t�` ti�A ,��,.\��,+�Ll �� x��;,'�� A�`�C, � �� s;` ,�L`• a.,,je A'4�.y,. •�„ k�.��.�,.� 4 r '�,�- Etc r title.. �1 'P h � t t 'tA(��,_'� .'� ��3 � ��1�£CITl!�.?Y';t�\.�::..ti�il..°�-:t�6,t.$.�i.._�'��'!�{blCr:.X..'x:714�ir`7.;Z�k`•�.n+.`�'.,.7.�.rm'ti:: , +r.>�5�'t.'r!f'.�'r 4..Irt,..:�.:,2�r.1..r�.t. ..,..,., ti e,.,-A•. 2x � 6 I 1 ' � i 9 i s { 1 3Cx f7 Z 34 s7 " � a L4 t- i ' I � I ( i � a • 1 CL -- T-J- 4 I { 47 F,-, LAI 1 - -- d w},�,.. t i �: �J < t l_u:Yt t ',.y 1,� l: t1. * > r�: t;F y _'h.`+•.' _i. a;� i #1 S l an�A l hz .j 1 , ' c s ) �, ) � '. �t .i4 a. C'13�'�{y+,•�Y r�jat 6`'��1�'�,r � ��, ta"'Y�+,�1� r S- i � 1 i s . ' Dao 0�• Al A- t ; it 4A .axe r .,_ -.._ •..e. .4 .. - _. ..�..._... :... •ri u0.fit„�A a,s ry � fLe ,_• � . � �. � �W _ it .a � l { i o _-r-roP)�-,� �w�� s,�e F -------------- i ;- �T� �bx91-7 Z s � - oi J , i i o r t oaf,-y Zr i L--A L NORTH Town of over �O LA O dover, Mass., COCr ICNEWICK ARRA7ED P? Cl '4S BOARD OF HEALTH Food/Kitchen PERMIT T Septic System BUILDING INSPECTOR THIS CERTIFIES THAT..., �...�....�i4 U .v r ��'�- Foundation permission G 'x� C/ `' �1�/o a r... . / .4Ye� has ermission to erect... ................ ............. buildings on .... ... ..... ...........n. . ....... .. ...t.. ................. Rough to be occupied as....... a m.'eo o�....0-..G a ^d Sr � 1q c%d/�/d� 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. of 8 C/0/ �F' J`�3 Aa. _ PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUCTION aTARTS ELECTRICAL INSPECTOR Rough toe.... .................... .C........................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. i SEE REVERSE SIDE �; Smoke Det. 6 FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits frorl Boards and Departments having jurisdiction have been obtained. This does not relieves the applicant and/or landowner from compliance with any applicable or requirements. *APPLICANT FILLS OUT THIS SECTION APPLICANT iDOvV Gy w ! Y f aA_L re j j_ ey r 1 Q PHONE 9?ov0 5 a a" Q LOCATION: Assessor's Map Number 9 C PARCEL ( SUBDIVISION'!C / LOT (S) STREET R/CU- r ri C Gl Y1 ST. NUMBER. j USE ONLY ►** RECO ENDATION OF OWN AGENTS: or CON ERVATION ADMINIS ATOR DATE APPROVED DATE REJECTED COMMENTS ►� TOWN PLANNER DATE DATE R COMMENTS /R/�_ / /�� n Cd11,cl a-/ LrCf- ,,�.N.s a9 a wiVi ENyl sti Qgfwv 7—ZZ ro�W c tr-4 uvt/ FOOD INSPECTOR-HEALTH DATE A ,� ,�,,crt cc, ,jc ,.o(� DATE Fi SEPTIC INSPECTOR-HEALTH DATE APPROVED. DATE REJECTED COMMENTS PUBLIC WORKS- SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm t ' Town of North Andover Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. FOR ROOFING, SIDING, INTERIOR REHABILITATION PERMITS 1)BUILDING PERMIT APPLICATION 2) DEBRI REMOVAL FORM 3) WORKERS COMP AFFIDAVIT 4) PHOTO COPY OF H.I.C. AND/OR C.S.L. LICElNSES 5) COPY OF CONTRACT 6) FLOOR PLAN OF PROPOSED INTERIOR WORK FOR ADDITIONS /DECKS 1) BUILDING PERMIT APPLICATION 2) FORM U 3) MORTGAGE PLOT PLAN (MINIMUM) s 4)DEBRI REMOVAL FORM 5) WORKERS COMP AFFIDAVIT 6) PHOTO COPY OF H.I.C. AND C.S.L. LICENSES 7) COPY OF CONTRACT 8) FLOOR/CROSSSECTION/ELEVATION PLAN OF PROPOSED WORK WITH SPRINKLER PLAN AND HYDRAULIC CALCULATIONS (if applicable) 9) MASCHECK ENERGY COMPLIANCE REPORT (if applicable) FOR NEW CONSTRUCTION (SINGLE AND TWO FAMILY) 1) BUILDING PERMIT APPLICATION 2) FORM U 3) GROWTH MANAGEMENT BYLAW 4) CERTIFIED PROPOSED PLOT PLAN 5) PHOTO COPY OF H.I.C. AND C.S.L. LICENSES 6) WORKERS COMP AFFIDAVIT 7) TWO SETS OF BUILDING PLANS (one to be returned) TO INCLUDE SPRINKLER PLAN AND HYDRAULIC CALCULATIONS (if applicable) 8) COPY OF CONTRACT (if applicable) 9) MASCHECK ENERGY COMPLIANCE REPORT In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the board of appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One.copy and proof of recording must be submitted with application. Town of North Andover Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. FOR ROOFING, SIDING, INTERIOR REHABILITATION PERMITS 1) BUILDING PERMIT APPLICATION 2) DEBRI REMOVAL FORM 3) WORKERS COMP AFFIDAVIT 4) PHOTO COPY OF H.I.C. AND/OR C.S.L. LICENSES 5) COPY OF CONTRACT 6) FLOOR PLAN OF PROPOSED INTERIOR WORK FOR ADDITIONS /DECKS 1) BUILDING PERMIT APPLICATION 2) FORM U 3) MORTGAGE PLOT PLAN (MINIMUM) 4) DEBRI REMOVAL FORM 5) WORKERS COMP AFFIDAVIT 6) PHOTO COPY OF H.I.C. AND C.S.L. LICENSES 7) COPY OF CONTRACT 8) FLOOR/CROSSSECTION/ELEVATION PLAN OF PROPOSED WORK WITH SPRINKLER PLAN AND HYDRAULIC CALCULATIONS (if applicable) 9) MASCHECK ENERGY COMPLIANCE REPORT (if applicable) FOR NEW CONSTRUCTION (SINGLE AND TWO FAMILY) 1)BUILDING PERMIT APPLICATION 2) FORM U 3) GROWTH MANAGEMENT BYLAW 4) CERTIFIED PROPOSED PLOT PLAN 5) PHOTO COPY OF H.I.C. AND C.S.L. LICENSES 6) WORKERS COMP AFFIDAVIT 7) TWO SETS OF BUILDING PLANS (one to be returned) TO INCLUDE SPRINKLER PLAN AND HYDRAULIC CALCULATIONS (if applicable) 8) COPY OF CONTRACT (if applicable) 9) MASCHECK ENERGY COMPLIANCE REPORT In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the board of appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with application. 6 FORM U - LOT RELEASE FORM —3 - 30 -ago- INSTRUCTIONS: This form is used to verify that all necessary approvals/permits fron Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements APPLICANT FILLS OUT THIS SECTIOtV APPLICANT_JDGW(GY l {'f GALL Y`Q, R o r �0 PHONE9?N 6 Y 5 QJ' o LOCATION: Assessor's Map Number 9 c— PARCEL / SUBDIVISION t C/ LOT(S) STREETi 71 La ;q ST. NUMBER 13 ********OFFICIAL USE ONLY*****"************** RECO ENDATION OF OWN AGENTS: CON ERVATION ADMINIS ATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER DATEa.��.,-�• -- DA'FE R --- COMMENTS 1041L) Cdltecl '7--" Lr"rf w.V4 F ibti -ow�-,- ur0 H9 r.w+� 'G 2l/.tcQ trl�f FOOD INSPECTOR-HEALTH DATE/ DATE Iq SEPTIC INSPECTOR-HEALTH DATE APPROVED. DATE-REJECTED COMMENTS PUBLIC WORKS- SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm - MbRTGAGE INSPECTION Appleton Q• Land Surveylns, Inc. \�\ piGM1E JM a UM PiAN1 K 234 rant sleeu UAWC L WUSACI s+s•s tssefsw-w� tea4w�Nw AWRESS OF PAL MOING l r_ �G/derxdA�oo� ' .00 " G`�?• _ �� Qvl MWS m6 f ! ) «�pr+pa.d mac' �[ for OMPP Mme+ �i i FA to 40 o wv* AM Oalfbw ' � `� srpeu�l 4a wwNMf iranl edd rkwoe j ^ __ by&VM elm Im to aid moAgog sad b i V (iJ! a�irr•U ows dkn WIh is piopned wlol11 1 *mwqIke WEAN b ams Ow 6091PP of% b V SL sem or th"do"r - O,oebtd ed nap be able t b bial.alis eslws 1 par sire otsseet the A c l b ai4ousl CBMFUM ft 3. iP /p�s•B8 arm+ yap wd CkA fa{bidmti b �seaeJdsn to i ld elxews ed—am*wb-/e m dam ® Mmbg b ad bodes Wthk o food KaNd Ims O Wdbf b boded Om Eked ak and Ime Q INseoslbn b WmAw t b&wwim Rwd Hawd bm ar'1 d.7 q Fq�p TAU CL _ JPDAWM J� sr app P Dead R data= 3r'-5 Dde d blyleolbe ' 7 �q ' cat w,-zz Es S NO of Plan 3 ZS-97 t Pre Rdas�e K 610. —— 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 Perrnit Number is-that..the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A.. The debris will be disposed of in: C9ex, m pK 7q (Location of Facility) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through.the Office of the Building Inspector _ w The Commonwealth of Massachusetts Department of Industrial Accidents Office of investigations Boston, Mass. 02111 °�M 5,•'' Workers'Compensation Insurance Affidavit Name Please Print Name: Ba Ll J e U f- Location: v,-e-49-p- rr C La r\.o _ City '" -A f d ow r A 0 1Y CV�) Phone # -7 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 cxunrnal penalties of.a fine UP to$1,500.04 arKVor one years'imprisonment_as_welLas-ax penaities3o-thelms-BAST?PYAORKDRDER and afx�e�f�$7110�o)��ay�gainst me I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verircation. I do hereby certify under Me pains and penalties of perjury bw the infa nm tion provided above is true and correct. Signature pate Print name pie f Official use only do not write in this area to be completed by city or town cfficiar City or TownPer R&icensina ❑ Building. Dept []Check if immediate response is required -0 licensing Board E] Selectman's Office Contact person: Phone# ❑ Health Department Ei Other Ae 9- 0 1 F)-A l y-) AXIA A/ Gq A eY a Ire AO it -ro, I,'oor+tiagf'� r�be� lgs ,1 nus( 1��ar►h� r-4 (L', 1,11 t v I IMe t2 NE, I ut f i A Ilk i i r� Co/Fit- pyl ----- TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVAT5 OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: ic SIGNATURE: Building Commissioner/Inspector of Buildings Date z SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: O I Iq r use 6zrr� � n� 9119 C- M n a Q Map Number Parcel Number �"IT� 1.3 Zoning Information: 1.4 Property Dimensions: i i Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided RcquiEiProvided 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 ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes No rn 2.1 Owner of Record David q Naur-" v► Burk-.- Name(Print) Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: z rn Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ K� uiv1 VdrrlP1q 4 Licensed Construction Superviso. License Number mn Address Expiration Date ic Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name rn Registration Number Address z Expiration Date ^ Signature Telephone !1/ SECTION 4-WORKERS COMPENSATION(1VLG.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.......0 SECTION 5 Description of Proposed Work check ad applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other X Specify Brief Description of Proposed Work: LA l'l d 1'r'v/4 P O'r C1i /0 S'�"w�c�c k G/�''�; �R C J__-) Fov_V Cal"" _r 1-1,44 1^oiil/h0 ver u�ncC l�oa �_ SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be rte. }FF�CXA Lc7GJSY '' ' Completed b rmit a licant r 1. Building (a) Building Permit Fee Multi Tier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(e)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, f"1(A V Vk �(� r as Owner/Authorized Agent of subject property Hereby authorize Ke (//P) r�c�/�r/s7g�— p to act on half,in all matters lat'ive to work authorized is building permit application. � ?4 aVu 4?A �lT Io n Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION E 1, /'1"'e v r/ cL lid J 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 '' // ,(�Yi� f��tnr 'kiQI-J ooq Pnlit.Name Si ature of Owner/Aent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS iST 2 ND 3 RD SPAN DEVIENSIONS OF SILLS DINIENSIONS OF POSTS DEVIENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHININEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 3 I Date...�......3................ f pORTN, 3?;•_,�`'°-:•-:"�,� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ass^cMusf� t This certifies that .... • G' has permission to perform .................:...: f -' - ar wiring/in the building of......._.-- -'..� .............................................. at ........................................ ............. "North Andover,Mass. Fee% .............. Lic.Nd'� - ............... ............................................... j ELEGTRICALINSPECTOR Check # �-''�� (/� !j, OmmnnWEZ1114 ar Zft3ssaC4USZrM Office Use Oniy Department of Public Safety Permit No. 1 BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 -v�'i Occupancy b fee tTeciced� 3/90 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code,527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dat City or Town of via Ie,I, To the Inspector of Wires) The undersigned•applies for a permit to perform the electrical work described below. / ,q Location (Street 6 Number)_/ /9 "� /j)° / e Owner or Tenant a/ 1/-r<-1 1111 4 i.1 �fl ihl-to '/) /.,/� ^'rhate e2 Owner's Address o / 4" Is this permit in conjunction with a building per it: Yes No FJ (Check Appropriate Box) Purpose of Building � � l�� Utility Authorization No. Existing Service c2iQo—Amps J ';ZW Volts Overhead ❑ Undgrd lYJ No. of Meters�— New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work TOTAL No. of Li htin Outlets 13 No. of Hot Tubs No. of Transformers KVA Above In- No. of Lighting Fixtures Swimming Pool grnd. ❑ grind. ❑ Generators KVA No. of Emergency Lighting No. of Receptacle Outlets No. of Oil Burners Battery Units NT. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones TotalNo. of Detection and No. of Ranges No. of Air Conditioners Tons Initiating Devices Heat Total rotalNo. of Sounding Devices. No. of Disposals No. of Pumps Tons KW No.of Self Contained Detection/Sounding No. of Dishwashers S ce/Area HeatingKW MuniDevices Municipal No. of Dryers HeatingDevices KW Local�"'y. MuniciConnection ❑Other No. of No. ot Low Voltage No. of Water Heaters KW Signs Ballasts Wiring No. Hydro Massage Tubs No. of Motors Total HP OTHER: , INSURANCE COVERAGE: Pursuant to the requirements of Massachusttes General Laws 1 have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent.YES iNO O 1 have submitted valid proof of same to this office. YES 13 NO L1 If you have chec YES,please indicate the type of coverage by checking the appropriate box. INSURANCE 10 BOND ❑ OTHER❑ (Please Specify) (Jxpirdficin Date) Estimated Value of Electrical Work $ Work to Start Y1,A, 9J;?Q0,L Inspection Date Requested: Rough Final Signed under the alr of pe rju ry: FIRM NAME t�`r'►"�� / " "�� GC �t C:A LIC. NO. Licensee `a 11114- Signature LIC. NO. Address cJ - Bus. Tel. No. All Tel. No. OWNER'S INSURANCE WAIVER:I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) Telephone No. PERMIT FEES r 'S (Signature of Owne.or.gent) 6280 AO Date... TOWN OF NORTH ANDOVER '0 PERMIT FOR WIRING This certifies that ............'rp6A... ...................... has permission to perform ....... wiring in the building of..'M....... E .......................................... at...... 1.64. 4ACWy...... North Andover,Mass. Fee... Lic.Nos 7��....X!�/ . :-�. ......... ELECTRICAL INSPBZ,---�R-- - Check 13514 Offtcia Use Only Commonwealth of Massachusetts -- ; ; ;4 Permit 1 2— 00 Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 11/991 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.0 (PLEASE PRINT IN INK OR TYPE_ L IN O WA TION) Date: 1 City or Town of. _ VOL To the Inspector of fres: By this application the undersigned gives notice of his or her intention top rfir the ml �trical work described below. Location (Street& Number) Owner or Tenant elephone No. Owner's Address Is this permit in conjunction with a uilding permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of thefollowing table may be waived by the Inspector of Wires. No. of Recessed Fixtures - No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No. of Lighting Outlets No.of Hot Tubs Generators KVA r No. of Lighting Fixtures Swimming Pool Above ❑ In- ❑ o.ot Emergency ig ►ng arnd. rnd. Batte Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No.of Zones No. of Switches No. of Gas Burners No.of Detection and Initiating Devices No. ofa Total R nges No.of Air Cond. Tons No.of Alerting Devices No. of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems: No. of Water No. of No. of No.of Devices or Equivalent Heaters KW F Data Wiring: Signs Ballasts No.of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may,issue unless the licensee provides proof of liability insurance including"completed operation" coverage or its substantial equivalent. The undersigned certifies that such cove ge is in force,and has exhibited proof of same to the issuing office. CHECK ONE: INSURANCE [1 BOND ❑ OTHER ❑ (Specify:) ,� �l s 3 as (�, atiot ate) Estimated Value of Elec rical Work: (When required by municipal policy.) Work to Start: `� Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under the pair td penalties of perjury, that to info on on this application is true and complete. FIRM NAME: �� 'Gid. 'C LIC. NO.: C Licenseex�i �/Yt .d Signature LIC.NO.: (If applicable, evgg Femt the ense number line Address- L/h i011r e Bus.Tel. No Alt.TO,,No., OWNER'S INSURANCE WAIVER: I a aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one)❑owner Owner/Agent ❑ owner's agent. t. Signature Telephone No. PERMIT FEE: $