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HomeMy WebLinkAboutMiscellaneous - 124 BRIDLE PATH 4/30/2018 (2) / 124 BRIDLE PATH 210/104.- C-0073-0000.0 \` BUILOU" ING FIL ME 1 )IC,%rf AMERICAN CLAIMS SERVICE A5�°TION INDEINSURANCE PENDENT MULTI-LINE ADJUSTERS D��ys DMAIED 10 S RVI(E BUILDING COMMISSIONER OR BOARD OF HEALTH OR INSPECTOR OF BUILDINGS BOARD OF SELECTMAN 1600 Osgood Street North Andover, MA 01845 RE: INSURED: William and Margaret Orlansky PROPERTY ADDRESS: 124 Bridle Path, North Andover POLICY NUMBER: 1062133 LOSS OF: 7/23/13; Skylight Leaked FILE/CLAIM NUMBER 30526 PD Claim has been made involving loss, damage or destruction of the above-captioned property, which may either exceed $1, 000. 00 or cause Massachusetts General Laws, Chapter 143, Section 6, to be applicable. If any notice under Massachusetts General 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 file number. Tim McLaughlin Claims Representative On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail. Unless we hear from you within the next 10 days, we will not be obligated to pay any portion of this claim to you. Date 8/2/13 7 KIMBALL LANE, BUILDING C, LYNNFIELD, MASSACHUSETTS 01940 TELEPHONE (781) 245-9516 • FAX: (781) 245-1077 Date.%� .4 �� ., . 9529 TOWN OF NORTH ANDOVER I p PERMIT FOR PLUMBING s o� ,�•�a ,sSACNUS This certifiesthat . . . . . . . ... . . . . . . . . . . . . . . . . . . . . has permission to perform . . . . . . .�V. . . . . . . . . . . . . . . . . plumbing in the buildings of .oAkc �4)'ryo�v�. . . . . . . . . . . . . . at. ,�'�-.`�': . .��.✓?��e..�,Ffi�. . . . . . . . . . , orth ov6rM ss. Fee . . . � r PLUMBING INSPE TOR r� Check'•" � '4 ti r ti � .. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK V V ,CITY 4- MA DATE I PERMIT# JOBSITE ADDRESS ! Z r% a i OWNER'S NAME P OWNER ADDRESS ( TEL 1 — FAX I TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL Q RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION: REPLACEMENT: ©I PLANS SUBMITTED: YES� NO FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM DEDICATED GREASE SYSTEM -1 _.____! E ______l ___P ___J I _.____I _____6 DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM 1 ____--._( DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER wl - _! -j FLOOR/AREA DRAINi INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES ; __( WATER PIPING OTHER INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESO M( IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Q/ OTHER TYPE OF INDEMNITY Q 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 Ell SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate! best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliant ith�tprovisionf the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME _ E LICENSE# 2� 6 0 { SIGNATURE MP 0 JP��' CORPORATION 0# _ t PARTNERSHIP -I#tJ LLC COMPANY NAME ' o� s — �iJADDRESS[ v CITY C3 - - _.._I STATE ZIP pl ��1 _� TEL FAX CELL ]EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT Z] chi 3 L FEE: $ PERMIT# PLAN REVIEW NOTES f A i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly r� Name(Business/Organization/Individual): -ZZ) Address: QC, v r City/State/Zip: O Phone#: I Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. E]JFe�construction employees(full and/or part-time).* have hired the sub-contractors n�� 2.[Xam a sole proprietor or partner- listed on the attached sheet.t �• odeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 13.❑Other *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 aie doing all work and then hire outside contractors must submit anew affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name:. 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 requiredunder Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify under the pains and pe alties of perjury that the information provided ab ve 's true and correct. Simature: Date: i Phone#: v 2. 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#: Q 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 em to er is defined as"an individual,p y 1,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 too operate a business or to construct buildings in the commonwealth P g 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 LiabilityCompanies(LLQ or Limited Liability Partnerships( LP) i th 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 n rs 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealtb of Massachusetts Department of industrial Accidents Office of Investigations 6,04 Washington Street Boston,MA,02111 Tel,#617-727-4900 ext 406 or 1-877,TMASSAFF, Revised 5-26-05 Fax#617-727-7749 v vw-mass,gov/dia Date . . - -1.?— TOWN OF NORTH ANDOVER PERMIT FOR WIRING r I This certifies that . . . . . . f.�'!� has permission to perform . . . . . wiring in the building of . . . . ©GArV .5.4 . . . . . . . . . . . . . . . . . . . f at . . .�.Z . . . v�`.�. �? . . . . . . . . .No h Andover, Mass. + . 7 �D h E Fee . . . . . Lic. No. . .7 . . . . . . . . . ���. E ELECTRICAL INSPECTOR" Check# 11017 Commonwealth of Massachusetts official use only Department of Fire Services Permit No. 1-7 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked ev.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 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: � )Z City or Town of: k)O rtygj To the Inspector of ices: By this application the undersigned gives notice of lus or her intention to perform the electrical work described below. Location(Street&Number) &CIRMap: Lot: Owner or Tenant 11 \ �1 � !(�, Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ Building Permit# 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: [k DYE'- batkXj1NA 01/ bUF fytC, pE,ft1✓ - Com lesion of the following table may be waived by the Inspector of Wires. No.of Recessed Fixtures No.of CeiL-Susp.(Paddle)Fans No.of Total Transfor mers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA No.of Lighting Fixtures 3 Swimming Pool Above ❑ In- ❑ o.of Emergency Lighting grad. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. .Tl.000tal No.of Alerting Devices ns No.of Waste Disposers Heat Pump I Number ITons JKW No.of Self-Contained Totals: t tl e vices No.of Dishwashers Space/Area Heating KW 14cal Municipal Other Coaftecdon Nof Dryers Heating Appliances KW cur° yste s: N f DeviSeLor E ivalent No.of Water KW No.of No.of Data Wiring. Heaters Signs Ballasts No.of Qeyices,,2r trivalent No.Hydromassage Bathtubs No.of Motors Total HP IlTelecommunicationsWiring: No4 ot`DLevices or Equivalent OTHER: Attach additional detail if desireit 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 coverage is in force,and has exhibi ed proof of same to the permit issuing office. CHECK ONE: INSURANCE ( BOND ❑ OTHER ❑ (Specify:) ouLA U I3 (Expiry' Date) Estimated Value of Electrical 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 pains and penalties of perjury,that the information on this application is true and complete- FIRM ompleteFIRM NAME:�Dl n15 CJ PL' f! &?C_ LIC.NO.: � Licensee: p junq ,Dl-176 Signature IC. NO.: (If applicable,enter" mp "in the li ense number line. Bus.Tel.No.: Address: �A 3�S J0 od(, M,4 19(0 Alt.Tel.No.: OWNER'S INSURANCE WAIVER: I am aware that lhe 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's agent. Owner/Agent FPERMITFEE.-$ Signature Telephone No. �� �� q )-7 z-31 7/ a 7 r �� The Commonwealth of Massachusetts t Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: DmISFIe-r4ae— X703 Address: City/State/Zip: 0/9(d) Phone 4: 4 I Are you an employer?Check the appropriate box: Business Type(required): EKi 1. am a employer with 7 employees(full and/ 5. ❑ Retail i or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales(incl.real estate,auto,etc:) employees working for me in any capacity. [No workers' comp.insurance required] 8. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing no employees. [No workers' comp. insurance required]* 4.❑ We are a non-profit organization,staffed by volunteers, 11.❑ Health Care with no employees. [No workers' comp. insurance req.] 12.0'0ther jy1,5-`rye *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: 41...-6 orawe e I Insurer's Address: �� "Pi dW City/State/Zip: Qka )P ©,3q,3 J Policy#or Self-ins.Lic.# C����q1 , `�3 Expiration Date: J 3 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section.25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify�ths andpenalties of perjury that the information provided above is true and correct Si ature: Date: 12 Phone#: 9 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia Date. . . ��. . :. .v. �i NORTM pf .ao 641 o� TOWN OF NORTH ANDOVER ' PERMIT FOR GAS INSTALLATION . h 'ISS "S t t This certifies that . . . .�. : . . :.' .. . ... . . . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . . . .{ . . .�..... . . . . . . . . . . . . . . . in the buildings of . . . . . . . . . . . ."'. . . . . . . . . . . . . . . . . . . 84 . . . .r �!. . . . . . .. . . . ., North Andover, Mass. Feer. . . . . . Lic. No.. : . .�� . . ,,.�.�� --� ... . . . . . . . . . . GASINSPECTdR Check# /rS ✓ V 4 , 512 MASSACHUSETTS UNIFORM APPLICATON FOR PERAUr TO DO GASG (Type or print) Date 7,, NORTH ANDOVER,MASSACHUSETTS &--J, Building Locations 1 LA Zt,1, W, Permit# Y Amount$ e Owner's Name New❑ Renovation Replacement ❑ Plans Submitted ❑ � w � � W�a U z O c w �, � H a a �10 3 A G7 U a > A a F 0 SUB-BASEM ENT BASEMENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR j STH. FLOOR (int ortype) one: Certificate Installing Company Name, "' �1 u M ` tAu Corp. Address g.-G\ Jv &J S, v T ❑ Partner. Business Telephone ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter i INSURANCE COVERAGE Check one I have a current liability Insurance poli or it's substantial equivalent. Yes No❑ If you have checked yes please ir6k6te the type coverage by checking the appropriate box. Liability insurance policy IffOther 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 e: Signature of Owner or Owner's Agent er ❑ Agent .❑ I hereby certify that all of the details and information I have subqteCode tered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installated under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachus and Chapter 142 of the General Laws. By: turef Licensed Plumber Or Gas Fitter Title Plumber 2s'+-mo City/Town ❑ Gas Fitter License Number ❑ Master APPROVED(OFFICE USE ONLY) 0 Journeyman Date. . G. . . .L: . . . ".0 RT:'� TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACMUS� This certifies that . .. . (�. . . . has permission to perform . . . . . . . . . . . . . . . . ( plumbing in the/buildings of . . ^ v . . . . . . . . . . �. . . at . "'.7. . ., North ndover, Mass. Fee . . . . . .Lic. No. .7��. :. ...ter• . ✓ . . . . . . . . . PLUMBI Z I PECTOR € Check # 5266 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASS CHUSETTS Building Location Date,1 t� W Permit# Amount Owner New Renovation Replacement 13 Plans Submitted Yes ❑ No ❑ FIXTURES rf 581E R4SE"M M HDM M HfM M FUM 4M Hi" 5M FL" 6M HDM 7M HAQ2 SUFIHfM (Print or type) ` Check one: Certificate Installing Company Name V`.A 1 �uM�ti t�h Corp. Address �J Son ��" - A'4 Partner. p Business Telephone CA-> W17 El Firm/Co. Name of Licensed Plumber: W-C14 r—c"(1 Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy El" Other type of indemnity F-1 Bond ❑ Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Vitions Agent ❑ I hereby certify that all of the details and informa (or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work rformed under Permit Issued for this application will be in compliance with all pertinent provisions of the MPlumbing Code and Chapter 142 of the General Laws. By: Signawre-UT Licansecium er Type of Plumbing License Title - rok t CityffownLicense Aumver Master ❑ Journeyman ONLY APPROVED(OFFICE USE IIIJJJ Location %� 1 yt !.( E Yh TF/ No. Date ,►OR'M TOWN OF NORTH ANDOVER Ott � u �1ti0 0 C? k A Certificate of Occupancy $ * Building/Frame Permit Fee $ 4 j E�� Foundation Permit Fee $ S/1CMUs r Other Permit Fee $ Sewer Connection Fee $ VED PAYMConnection Fee $ , cCEITOL $ /. NOV 121991 :�,�Ir,�: , ►; Building Inspector �.Andover Collector Div. Public Works PERMIT NO._ APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. MAP -NO. APPLICATION NO. _ PAGE 1 _ 2 RECORD OF OWNERSHIP DATE ZCj'VE SUB DIV. LOT NO. �IBOOK PAGE LOCATI e-' PURPOSE OF BUILDING OWNER' NAME �- Zj OWNE �� ,�� C yr DIVRIES ( SIZE ADDRESS — BASEMENT OR SLAI ARCHITECT'S NAME B SIZE OF FLOOR TIMBERS IST 2ND f BUILDER'S NAME 3RD v SPAN { DISTANCE TO NEAREST BUILDING { DISTANCE FROM STREET DIMENSIONS OF SILLS A POSTS .---.- --- DISTANCE FROM LOT LINES—SIDES REAR GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION I IS BUILDING NEW THICKNESS 19 BUILDING ADDITION SIZE OF FOOTING X � TION _ `` ,, 1RD OF HEALTH I `y P.J MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND { WILL BUILDING CONFORM TO REQUIREMENTS OF CODE Ll- BOARD f- IS BUILDING CONNECTED TO TOWN WATER OF APPEALS ACTION, 1 �j c IS BUILDING CONNECTED TO TOWN SEWER i IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION `ANG INSPECTOR SEE BOTH SIDES LAND COST I! I PAGE 7 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST i PAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER SQ. FT. I' EST, BLDG. COST PER ROOM ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING BEIC PERMIT NO. LING INSPECTOR i I ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS 4 APPROVED BY I' PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR 1 i 1 DATE FILED ` yli- 't SIGNATU OF OWNER OR AUTHORIZED A�NT 80i OF HEALTH �AL INSPECTOR i OWNER TEL. FEE 'C}'� CONTR.TEL, CONTR.LIC.# � PERMIT GRANT D PLANNING BOARD I I NSPECTOR I I BOARD OF SELECTMEN BUILDING IyS CTOR `DEPT. "OniM OF 1, OFFICES OF; Town Of 120 Main Street APPEALS NORTH ANDOVER North nn(tc)ver. r3U11.I�ING ;,'•:;' :-'0 Mi lssi l 'h usctt5 O I iT4 C()NSI RVA'I'10N ss„” °` I)IVISR)N OFr ((i 17) 177.,fiti.� f HEALTH PLANNING PLANNING & COMMUNITY DEVELOPMENT KAREN H.P. NELSON, DIIIEC-1.011 I I In accordance with the provisions of MGL c 40, S 54, a condition of Building Permit Number E/-2— 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 ill, S 150A. The debris will be disposed of in: Locati ( on of Factltty) Signature of Permit Applicant 11"• IleD e NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. A 3 7 5 Date:.�?..........�'... ........ f NORT1�, :°•_';�``°-1'�."°o� TOWN OF NORTH ANDOVER PERMIT FOR WIRING ACNU This certifies that • i �-c_- L, � has permission to perform ...:.- '� �-Z, ............ ...I......................................... �+ wiring in the building of * �w ................................. .............................................. t`- '�j ,North Andover,Mass. at......... ....................................... Fee`-?...-.............. Lic.No.? .........................�� ELECTRICAL INSPECTOR Check # �� / �/ -SIN- 777EC0MM0NWE4LTH0FM4S.SFja11M '?.Y' Office Use only DFPARTiY WOFPIIBLICS4FETY , �7 Permit No. � BOARD OFFmPRffvW0NRF�GUTAT[0I1iS3ramIZ'f�D f kVA Occupancy&-Fees Checked � 71APPUCATIONFOR PERW TO MFORMELECMCAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE wmi THE MASSACHusSTS ELECTRICAL CODE,527 CMR 12.0 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Town of North Andover To th sp r of Wires: The undersigned applies for a permit to perform the electrical work described below. Location(Street&Number) Zd Z ���� Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: Yes Q NoJ4mJ (Check Appropriate Box) Purpose of Building ��6 Utility Authorization No. Existing Serviced 1� grnps/A? Volts Overhead ED Underground F2J No.of Meters z New Service Amps/�Volts Overhead [ZI Underground C:3 No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work C,: iJA" No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total ICVA No.of Lighting Fixtures Swimming Pod A e e ow Generator KVA grI No.of Receptacle Outlets No.of oil Burners No.of Emergency Lighting Battery Units No.of Switch Outlets No.of Gas Burners No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones Tons No.of Disposals No.of Heat Total Total No.of Detection and Pumps lobs KW Initiating Devices No. Dishwashers Space Area Heating KW No.ofSogadmS Devices No.of Self Contained Detection/Sounding Devices No.of Dryers Heating Devices KW Local Municipal Other No.of Water Heaters KW No.of No:of Connections Signs Bailasis No.Hydro Massage Tubs No.of Motors Total HP OTHER Gnu-,noeC��Prrtxrancbthetequiana��Ga�aliaws . [haaeawwtliabtTtylr>a==FtiCYni&gCaripkie Co►aWQisah3p"Int YES NO (haC suhnhedMddponfd§ffWlD Ie0>W YES NO FjmbmcdmdmdYE4splmmd iet ctA)eafw=WbYdw&ffglhe NSU ANCE ( 01HER 'f EsrnriedVAxdHmkjdWC&S 7VozkbStart a/` Inj�ieR�esiad ) r�rFrd IRMNAME AttTUNa ►WNER'SINSURANCEWAIVER;Iarnm4wetAdrLice=doesMthec>.strato awmmgeorft eWn;gmtasrogm dbYNbmadrrsczCcn2aiLam idtliatmy rnt wpem wpIirmMWM,Mt ZmW,wnert 'lease check one) Owner Agent Telephone No. PERMIT FEE$ Location ��` ��� `� "T3r'4 No. Date ( 1 �— NORTH TOWN OF NORTH ANDOVER FjO•,,`•o .•,hOw 41 Certificate of Occupancy $ _ ��JS ACMUBuilding/Frame Permit Fee $ 62S 3 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ �s Check # 3 y 156 '15 i Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: � � � DATE ISSUED: SIGNATURE: I - Building Commissioner/I for of Buildings Date Z SECTION 1-SITE INFORMATION O s�1.1 Property Aftess: 1.2 Assessors Map and Parcel Number: C)q C Q 3 Map Number Parcel Number (� 1.3 Zoning Information: 1.4 Property Dimensions: V Zoning District Proposed Use Lot Areas Frontage ft 1 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided ReqWred Provided v 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 ❑ J SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT rn 2.1 Owner of Record ame(PPrint) Address for Service: f r Signatur Telephone M / � C 2.2 Owner of Record: � O Name Print Address for Service: m Signature Tel hone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed CAnstruction Supervisor: O License Number o Address 4 Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ v -Q ih' p L r c,a g&—VIA. -<�,-C cAw—zlt Company Name (0� Registration Number r Address-�& —i ce 23 �-:2 1 o Expiration�D to ^ Signature Telephone G) 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.......0 No.......0 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: SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant 1. Building (a) Building Permit Fee Multi Tier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)x (b) 4 Mechanical HVAC �- 5 Fire Protection 6 Total 1+2+3+4+5) , Check Number SECTION 7a OWNER AUTHORIZA ION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUELDING PERMIT L 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 OWKER/AUTHORIZED AGENT DECLARATION I, ,as Owner/Authorized Agent of subject property Herebv declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name Signature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SLLE OF FLOOR TIMBERS iST2ND 3RD SPAN DIMENSIONS OF SILLS DM ENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY 1S BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE S } IN,` "CONTRACTING SERVICES 56 Main Street North Andover, MA 01845 1-978-423-7105 q CONTRACT This Agreement is made between bill&Meg Orlansky of 124 Bridle Path Lane in the town of North Andover, in the state of MA and General Contracting Services this 22nd day of April in the year 2002. Description: See proposal as attached document I� Job Total: $ 39,498.22 Deposit: $1114 94JR, 2z Payment: As needed Balance Based on allowances It is understood by Bill& Meg Orlansky and by General Contracting Services, that the above Job Total includes material and labor as per attached proposal on!y. Any additional, costs to the above Job Total,whether by necessity or by the request of Bill& Meg Orlansky will be considered an extra charge and therefore governed by paragraph (V) of this Contract. I. All jobs accepted by General Contracting Services are subject, wever, to strikes, accidents, or details occasioned beyond the control of General Contracting Services. II. All sketches furnished by General Contracting Services shall remain the property of General Contracting Services and no use of same shall be made, nor any idea obtained therefrom be used, except upon compensation to be determined by General Contracting Services. III. By signing the acceptance,the customer (or his/her representative) agrees to all terms and conditions as outlined, and binds him/herself to accept the contract in its entirety. IV. The customer also promises to pay any and all attorneys fees and/or cost(s) associated with the collection of the amount stated herein this contract. V. All materials are guaranteed to be as specified. All work to be completed in a workman like manner according to standard practices. Any alteration or deviation from 1 North Andover Building Department Tel: 978-688-9545 i 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: �0401,Aet, S'�ryIc2 y 10-3 Nl -f-huen (Location of Facility) i Signature of Permit Applicant 6b //o 05 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector i The Commonwealth of Massachusetts J Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 workers'Compensation Insurance Aff1davit Please Print Name: Location: CiPhone 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 jab. Company name: Address City: Phone#- eu NrIev.# Qg—n1p nv name: Address City: Phone-4- Insurance Co. Policy# Failure to secure commme as requited under Section 25A or WL 1.52 can lead totNe a0�d criminal . and/or one peneitfes.d a fine eip to 81;500.00 years imprisonment as well as ciHl penalties in the form of a 5i OP VVM and a fine of(3100.00)a d ay understand that a copy of this statement may be forwarded to the Office of against me. l . boas of the f�iA for coverage verificaBon. I do herby certify under the pains and penaties of perjury Mat the kftmatiat provided above is brie and-caned Signature Date Print name Phone# Official use only do not write in this area to be compieted by city or town official' ll Building Dept. .' Orheck if immediate response is required Building Dept (] Licensing Board Contact person: Phone El Selectman's office # 0 Health Department 001er ?St WORKMAN'S COMPENSATION. F NORTH An Town of _.:.;.. ., 0ver �O No. 450, - - _ o� COCL � � dover, Mass., �S RATED P`P G��� 7 H `• BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT.........t ..t i/ t " 4 (fay BUILDING INSPECTOR . Foundation � IIL.. has permission to erect.. . ...M�. ........... buildings on ..... �� ....... .. �. .... ... ........... Rough to be occupied as........,<� r s t4 �q& S �'w C 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 B -Laws relating to the Insp tion, Alteration and Construction of Buildings in the Town of North Andover. ' eq C 3 a 4 OWN PLUMBING INSPECTOR � 3 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION ST S ELECTRICAL INSPECTOR C Rough .................................. ............. ..... Sery ce ... .. .. . . . . ... 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 o - Street No. SEE REVERSE SIDE Smoke Det. MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) l cy(''IL`t n�el61 LKZ-, Mass. Date J03Permit# 6 ii nn A 11 Building Location lQZJ&f j'd/e -T6 Owner's Name Qr Inn S 4 � � Type of Occupancy Residential New ❑ Renovation ❑ Replacement 09 Plans Submitted: Yes❑ No ❑ FIXTURES z 14 f- to rn O z � �" :� O I'm W Y J N -f . Q t� O C7 0 2 to a a Q Z cc 0 Z O 2 N 6 u{ v{ u{ O — w F- W W H U a t. U. Z :, t�� ,1���1�(t id 3: W ,( w 0 ± C a O a 6 a i++ i�-i � m ) Z a w _ o a to cc n ¢ W O r W 3 O a a J to Ja. 0 z O ¢ aW U. LL H U > H 0d. ] N H Z O O N = Y W H O t) Q ►_ a Q s N W Q Q O a J J Q cc oc a a 0 Q S-I 3 Y J m N O q J 3 = N N LL O O O Q >� M a) 33 33 �' i SU8—BSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company,Name_Heritage Htg. &Pig. CO. Inc.' Check one: Certificate Addressi Pleasant ,Street _ _1_EX Corporation 714 ' _ - — -'...35 _ n Partnership } Date. U ! 171 Firm/Co. f 40 RT:�tio TOWN OF NORTH ANDOVER lets the requirements of MGL Ch. 142. 0- c? Y PERMIT FOR PLUMBING propriate box. Bond ❑ i ,SSACHUS� n the insurance coverage required by t 7�G�(� - J�(1 f v 4pplication waives this requirement. This certifies that�!� • • • ' ' ' Check-,one: ,) J 7 Ail( !/� �G/'L�r ❑ Agent❑ has permission to perform . . .� •�• •r• • kl. � -�'• • • • ��; %: ! . . . . . . . . . . . I plumbing to the buil rugs of . . .C,` •�-• • ! ication are true and accurate to the best of my Mass. its application will be in compliance with all . at/ �� J:r . . . . .�. . . . . . . . , North Andover, ws. Fee !%. .r. .Lic. No.. . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR C l man 0 Check # — < 5 � 3 � • BELOW FOR OFFICE USE ONLY FINAL INSPECTIONS SKETCHES -PROGRESS INSPECTIONS FEE — _ NO. APPLICATION FOR PERMITTO DO PLUMBING NAME&TYPE OF BUILDING ;I LOCATION OF BUILDING it ... PLUMBER PERMIT GRANTED DATE 19 c _ IV C PLUMBING INSPECTOR y ( t