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HomeMy WebLinkAboutMiscellaneous - 125 LANCASTER ROAD 4/30/2018 125 LANCASTER ROAD 2101104 0000.0 �/ 1 7/22/2016 Date:July 22,2016 20964 This is an e-permit.To learn more,scan this barcode or visit northandoverma.viewpointcloud.com/#/records/20964 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION �kr7'E11 A>l1�, This certifies that Bruce J Lipinski has permission for gas installation Replacement of Gas Pool Heater in the buildings of SKLAR, MICHAEL E at 125 LANCASTER ROAD_, North Andover, Mass. Lic. No.3735 1/1 1> i�v ,p Mtys((m*.Ybndo•�enne.viewpot�uhud cant freturu'2095s PD it D-c-P—t A2a961-ftp...R Town of North Andover,MA CL 2©964 "Gas Permit-Replacement of Existing FixtureslAppliances(Commercial of Residential TlAfFUNE ® Submission received Your request Is in progress Ju121,2016&3:31pm we'll let you know of any updatesvla email.Feel free to check the status at any time by coming back to this page. ® Gas Permit Review In prograss 0 Permit Fee. .. G, i PerrrA Isswnce Appti--, Lra-- Bruce Lipinski/New England 125 LANCASTER ROAD,NORTH Gas Systems Inc. ANDOVER,MA Q-- SKLAR.MICHAEL E Attachments LJ -0T94PCIG0TF_Thu_jui 21_2016_19:30:.PDF Q m to 0 1W ®'R 0))rd 7,12iltMPM16 Thursday,Jul 21,2016 03:31 PM MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY INORTH ANDOVER MA DATE 7/21/2016 PERMIT# JOBSITE ADDRESS 1125 LANCASTER RD OWNER'S NAME MIKE SKLAR GOWNER ADDRESS ISAME TEL[17-413-8108 IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[J] PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:[�] PLANS SUBMITTED: YES❑ NO[V] APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 1 9 10 11 12 13 14 BOILER BOOSTER ^� ��� ❑ CONVERSION BURNER (� COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE p INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT ��0�(� 0 OVEN ���� �0❑� ❑ POOL HEATER 1 ROOM/SPACE HEATER ..___, ROOF TOP UNIT TEST _... _.. _ UNIT HEATER _ UNVENTED ROOM HEATER �❑� WATER HEATER I OTHER � ���❑ I Cj INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NI NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY FAI 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 ❑ AGENT ❑ 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 to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will bei pliance Nith all Pertinent ovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMB ER-GASFITTER NAME I BRUCE J.LIPINSKI I LICENSE# 3735 I N URE MP❑ MGF C] JP❑ JGF❑ LPGI r--j CORPORATION A]# 99 PARTNERSHIP# LLC❑#0 COMPANY NAME:NEW ENGLAND GAS SYSTEMS INC. ADDRESS 1102 LOCUST ST CITY JDANVERS I STATE MA ZIP 01923 TEL 978-774-7030 FAX 978-739-4302 CELL 508-843-4724 EMAIL OFFICE@NEGAS.US 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 u. The Commonwealth of Massachusetts F Department oflndustrialAccidents = = X Congress Street,Suite 100 ` .Boston,MA.02114--2017 "t www mass.gov/dia s�• Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED MTM THE PERMITTING AUTHORITY. A licant Information Please Print Le 'bl Name(Business/Organization/l'ndividual): Address. ���, City/State/Zjp: � q&S OPhone eyon an employer?Check '"e apliropriafe box: Type of project(required); 1 I I am a employer with s employees(fall and/or part-time).* 7.. []New construction 2.Q I am a sole proprietor or partnership and have no employees working for mein 8. Ej Remodeling any capacity.[No workers'comp.insurance required.] ❑Demolition I Q I am a homeowner doing all work myself[No workers'comp.-insurance required.]t 9. 10 [�Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.E]Electrical repairs or additions proprietors with no employees. 12:Q Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 1 ' Roof re air These sub-contractors have employees and have workers'comp.insurance.1 Oe 6.Q We are a corporation and its officers have exercised their right of'exemption per MGL c. 14. th 152,§1(4),and we have no.,A cyees.[No workerscomp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showingtheirworkers'compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such tConiractors that check this box mus t•attache d an additional sheet showing the name of the sub-contractors and state whether or not those entities ha_ve employees. If the sub-contractors have employees,fliey must provide their workers'comp.policy number. X am an employer that is providing workers'co enation insurance for my employees'Beloiv is thepolicy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: ��L Expiration Date �� C--C�SV�C O►�, Ci /State .,•� 4 � \� Job Site Address: �' /Zip• Attach a copy of the woykers' 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 violator.A copy of y this statement may be forwarded to the Office of Investigations of the DIA for insurance a coverage verification. X do her erti,fy u r tli insand aloes ofperjury that the informationprovid d ahowe e is True and correct: Si ature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town of iciaz City or Town: Permit/License# Issuing Authority(circle one): i 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for them 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 anotherwho 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 common-Tealth,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=contractors)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. lie advised that this affidavit may be submitted to the Department of•Industrial Accidents fok 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-iizisure_d companies shouid'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 areference 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"rob 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. Anew 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 '`eco CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) ✓ `� 8/18/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Sarah Goyette Cross Insurance-Peabody PHONE Ertl: (978)532-5445 _ F No►:(978)532-2217 139 Lynnfield Street ADMDRESS:sgoyette@crossagency.com _ INSURER(S)AFFORDING COVERAGE NAIC# Peabody MA 01960 INSURERA:Main Street America Assur. Co 29939 INSURED INSURER B:NGM Insurance Co 14788 :NEW-ENGLAND GAS SYSTEM INC - INSURER C 102 LOCUST ST INSURER D: INSURER E: DANVERS MA 01923-2204 INSURER F COVERAGES. . . .CERTIFICATE NUMBER:CL158184787.5 REVISION NUMBER:.. .: - THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES:LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF. POWCY EXP l LTR TYPE OF INSURANCE POLICY NUMBER MM/DD MM/DD LIMITS X COMMERCIAL GENERAL LIABILITY I EACH OCCURRENCE _ $ _ 1,000,100 � DAMAGE TO RENTED A CLAIMS-MADE X OCCUR 1 500,,00 T_J I PREMISES(Ea occurrence $ _ MPB67478 8/18/2015 8/18/2016 MED EXP(Any one person) i$ 10,00 PERSONAL 8 ADV INJURY I$ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: i GENERAL AGGREGATE $ 2,000,00 X POLICY! JE LOC ! PRODUCTS-COMP/OP AGG $ 2,000,00 OTHER: Employee Benefits $ 1,000,00 L AUTOMOBILE LIABILITY EO aBcINdEeDiSINGLE LIMIT $ 1,000,00 J ANY AUTO BODILY INJURY(Per person) $ B ALL OWNED SCHEDULED AUTOS R AUTOS M9B67478 8/18/2015 8/18/2016 BODILY INJURY(Per accident) $ Ly-J, HIRED AUTOS XJ AUTOSED I PROPERTY DAMAGE $ r(-- a----)- - i Uninsured motorist BI split limit $ 100,00 LUMBRELLA LIAR I OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE! i AGGREGATE $ DED 1 ! RETENTION$ $ WORKERS COMPENSATION ' PER IH- AND EMPLOYERS'LIABILITY /N _i STATUTE I I ER _ ANY PROPRIETOR/PARTNER/EXECUTIVE ;-- , E.L.EACH ACCIDENT $ 500,00 OFFICER/MEMBER EXCLUDED? N/A; '"" B (Mandatory in NH) --' W2B67478 8/18/2015 8/18/2016 j E.L.DISEASE-EA EMPLOYEE $ 500,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1 $ 500,00 I � i i DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) CERTIFICATE HOLDER CANCELLATION (978) 688-9542 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of N. Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Rick Danforth, Plumbing & Gas Inspector ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood St. , Ste #2-36 Bldg #20 AUTHORIZED REPRESENTATIVE N. Andover, MA 01845 Glendaly Gomez/MD1 ©1988-2014 ACORD CORPORATION. All rights reservef ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INRn9F OnInn1N Cunningham Lindsey U.S.,Inc. P.O.Box 703689 Cunnzn ham- vv Dallas,TX 75370-3689 Lindsey Telephone(888)738-8714 Facsimile(214)488-6766 CLCAT@CL-NA.COM ***********************AUTO**3-DIGIT 018 759 T3 P1 95000058949 Building Commissioner or Inspector of Buildings 120 MAIN STREET N ANDOVER,MA 01845 Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS Ch. 139, Sec 3B MEN ON Claim Number: 2670535 Policy Number: 2670535 20 Company Name: MERRIMACK MUTUAL FIRE INS Cause of Loss: ICE DAM co Lr) Date of Loss: 2/22/2015 Insured: MICHAEL& LESLEY SKLAR O Property Location: 125 LANCASTER RD Claim has been made involving loss, damage, or destruction of the above captioned property, which may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6, to be applicable. If any notice under Massachusetts General Law, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer. Kindly include a reference to the captioned insured, location, date of loss and claim number. Section 313. No insurer shall pay any claims (1) covering the loss, damage, or destructions to a building or other structure, amounting to the one thousand dollars or more, or (2) covering any loss, damage or destruction of any amount, which causes the condition of a building or other structure to render section six of chapter one hundred and forty-three applicable, without having at least ten days previously given written notice to the building commissioner or inspector of buildings appointed pursuant to the state building code,to the fire department or arson squad of the city or town and to the board of health or board of selectmen of the cit or town in which the same is located. If at an time prior to thepayment Y Y p the said city or town notifies the insurer by certified mail of its intent to initiate proceedings designed to perfect a lien pursuant to section three A, or to section nine of chapter one hundred and forty-three, or section one hundred and twenty-seven B of chapter one hundred and eleven, the said payment shall not be made while the said proceedings are pending; provided, however,that said proceedings are initiated within thirty days of receipt of such notification. 9 Any lien perfected pursuant to section three A, or to section nine of chapter one hundred and forty-three or section one hundred and twenty-seven B of chapter one hundred and eleven, shall extend to and may be enforced by the city or town against any casualty insurance policy or policies covering any loss, damage, or destruction pursuant to which the proceedings to perfect the lien were initiated. No insurer shall be liable to any insured owner, mortgagee, assignee, city or town, or other interested party for amounts disbursed to a city or town under the provisions of this section, or for amounts not disbursed to a city or town under the provisions of this section. 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. Cunningham Lindsey Catastrophe Department cicat@cl-na.com 800-867-3885 Date..' ....... ..4................. - °3?' TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ° 88'�CMU5�4 This certifies that ........................................... . '.... L—t' , ......................................................................... has permission fornstallation ............................................................................ v in the buildings of.gas i..............:-�C, . ............................................................................................. at.....12 Fee./ Lic. No.��Av.l........ GAS INSPECTOR Check# % 745 -` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY 0✓4,1? MA DATE JOBSITE ADDRESS rl Gam . U*& -I{OWNER'S NAME GOWNER ADDRESS TEL — FAX I �1 TYPE OR OCCUPANCY TYPE COMMERCIALF-] EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:D REPLACEMENT:® PLANS SUBMITTED: YES D NOD APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER ! - .- BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATERY DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR 1 OLt GRILL INFRARED HEATER LABORATORY COCKS I _ I ! r- -. - h- . MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER I WATER HEATER OTHER�� t ........_................... . ...... .....�... .... 771 INSURANCE COVERAGE have a current liability insurance policy or its substantial equivale which meets the requirements of MGL.Ch.142 YES 1.._ NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY D 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 0 AGENT �( 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 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 _1 Massachusetts State Plumbing Code and Chapter 142 of the General Laws. V N.V _ # PLUMBER-GASFITTER NAME G' _ °� LICENSE SIGNATURE_- MP D MGF D JP JGF[ILP91' –GI® CORPORATION # � PARTNERSHIP®I# �� LLC D# COMPANYNAME:� J•--L_l�l_� _AADDRESS - CITY _� STATE MZIP TEL O FAX __ CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No b -7 /,4 n li THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ 91 FEE: $ PERMIT# PLAN REVIEW NOTES • i . .Ue commonwealth of.Massachusetts , - ,DeOarttnent ofIndustriglAccid nts Office ofInvestigationy 600 LDashington.Sheet Boston,.ISA 02111 U1 www massgovldra Workers' Compensation bsurance Affidavit:Builders/Contractors[Fleet] b� Please Pr�SatLe .�,. lZeaant Information . Tame(Business/Org ' ationtlndividual): Address: N 9, /V� - �� City/Sfa�e/Zip: 4 Phone#• / Are you an employer?Cbieck the appropriate box: Type o£pxoject(x egnired): 1.❑ I am a employer with q. [11 am a general.contractor and 1 6. E]New construction ______ have hired the sub-contractors employees(full and/orpart-time).* listed on the attache d sheet.T I. El Remodeling 2,❑ 1 am a sole proprietor or partner These sub-contractors have S. [(Demolition ship and'have no employees workers'comp.insurance. g, ❑Building addition working forme in any capacity. [N'o workers' comp.insurance 5• �We are a corporation audits 10.[]Electrical xepairs or additions required.] officers have exereisedtheir 0 right of exemptionperMGL 1X. Plumbingxepaixs oradditions 3.E] X am a homeowner doing all work c.152,§1(4),and we have no 12,p Roof repairs s co , o worker mp• myself.[N• employees.j�1'oworkexs 13.❑Other insurance required.] nLscomp.insurance required.] xAny applicant that checks box*1 must M outthe section below showing their workers'compensaaonpoucy information. i gomeowners who submit this affidavit indzcatang they gra doing allworlc and then hire outside confractors mustsubmit a new afCdavit indicating such. tContractors that eheAthis box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information. I am an employer that is providing wo,-kers'compensation insurance fof my employees: Below is the parley anti jolt site information. hmauce Company Name:. I } Expiration Date: Policy if or S elf-ins-Lic. City/State/Zip: Job Site Address, .Attach a copy of the workers'compensation-policy declaration page(showing the policy number and expiration date). Failure to secure coverage as require under Section s5w jlas c��naltie iethe f z�mg f a STOP WORK ORDEP and a fmo fine up to$1,500.00 and/or one.yearImprisonment, ofup 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. ^ do Hereby eerti tier tliepains and'venaliles ofpePjury Mat floe information provided above is tate a d correct. Date: 2 Si ature• Phone#- ofcial use only. Do not write in this area,to be completed by city Or town official. City orr Town: Pei znitll icense# Issuing Authority(circle one): x.Board of Health .9,Building Department 3.City/Town Clerk 4.Electxicat Inspector 5.Plumbing Inspector 6,Other r Phone M. s Information and Instru flons ' 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 oxwritten." An ern,�loyer is defined as"an individual,partnership,association,corporation or other Legal entity,or any two oxmore of e thfoxegotng engaged in a,loxnt enterprise,and including the legalrepxesentatives 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 moxa than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,ance construction oxrepair work on such dwelhng 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 lxeensmig agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for an. applicant pplicant 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 p olitical subdivisions shall enter into any contract fbr the p erfotmance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have bcon 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),addresses)and phonenumber(s)along w ith their certificates of insurance. Limited Liability Companies(LLC or Limited Liability Partnerships(LLP) with no employees outer than the members or partners,are not required to tarty workers'compensation insurance. If au LLC ox LLP does have employees,apolicyis required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents fob confirmation of insurance coverage. Also be sure to sign and date e g gn the affidavit. The affidavit should be returnedto the city or town that the application for thepermit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are requiredtoo ' . � g g Y btamaworkexs 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 Okcials Please be sure thattheaffidavit iscomplete andpxiatedlegibly. noDepattmenthasprovided aspaceatthebottom of the affidavit for you to fill out in the event the Office of Invest? ations has to contactyou re ar ' g y g dmgthe applicant. Please be sure to fill in the permit/license number whichwill be used as a reference number. In addition,an applicant that must submitmultiple permit/license applications in any given year,need only submit one affidavit indicating curxent Policy information(ifnecessary)and under"Jab 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 fatuxe permits or licenses. A new affidavit must be filled out each year.Where ahome owner or citizen is obtaining a license oxpermit not related to any business or commercial venture (i.e.a dog license orliermit to burn leaves etc)said person is NOTrequired to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any ciuestions, please do not hesitate to give us a call. The Department's address,telephone aiid fax number: no commorlealth ofUnuarhwofts DePaxtwmtoff dmWal,A,ccldotta 60(kah�.eta$ BWon,M-.421x1 ` ,#617-7.27,4900 QA 40,F or 1-$77WA.M Revised 5-25-05 Fax 617"727"7749 WN '.Ma0,a,gov/dia i 1 1 t i x :COMMONWEALTH OF MASSACHUSEn BOARD-OP PLUMBERS ,A.Np>; GASFITTERS ISSUES THE FOLLOWING LICENSE s LICENSED"AS A JOURNEYMAN PLUMBER t l4 PETER„J MARADIANOS P 52 SUMMER'STREET APT ), NATICK MA 0176o-4572-' � . . 3184 05/ot/t.b:., 203692 GENERATOR APPLICATION DATE: I (1 I1 LOCATION: OWNERS NAME: GENERATOR kw NO INSTALLATION OR GROQIND DISTURBANCE BEFORE APPROVALS CONTRACTOR: of%p- ��UJrPb �L PHONE NUMBER: ELECTRICAL GAS RESIDENTIAL COMMERCIAL TEMPORARY LOCATION OF GENERATOR: *ZONING DISTRICT: i)lk *PLANNING APPROVAL (IF IN WATERSHED) *CONSERVATION APPROVAL11 Cul T ,i .: ti:. •'Y�4` ; f.f { 3h'• T,4,r 'C•* 'l Z3 S' „+ :� R w r �.�::. ^+ x'44 L s nsI- N w wk ' ..5t ^y ' r ���Y. '�► ,dy $xa-n'n' '-'�`Lx,� .. ,^�'' `�� ti"`�� �v fi l t :1 �l i •. � ti `e., �.��( �is t.{'+6'.�,� .,, yy ?��.:tn� ��,�*:�.+a. i 1 � � c� •fix '"a� '''�4c _ WET s �-. �' a�"±. S���.,'Te- -':V a��i'� ��{•� }�' a r ' •� t7 A :� its r F J S ,} !�*Jey, .� '^4 'll �� .2� $.i`, µ•ms•� i� •� �'. .. "'a°_ _� .,� S ,� �,.: r4,L. 6:. v -�'RiY '�3� E..fi i'. a^Si b fir_ � :'S�:..-,py $ x., �.:�' •ATF.•:.={ a- y ,� iE. m r't� :, ?Fa��'� � •`�'�j'�.��„`sa`t•�. � � .�� qti <._.�'� .. "s•'. • a a ' �: ", &,. �`q `s. S'L tom,�'� .h !`',, N t+• u n r .' •-�w�s .v y .:' +.,,, .� y�s l'<'��r•� T�a�, a�. _ •if+. .. mak' f ���� r`.rq . 1 >' ` .dam qk�ar,��S -• ay��'' '��5 ` �b�tqp . e 4,1 ' _�r - �� r�V<� �: a�r L'•�,"'v.. .xcn yam"•' o `'r''xi„`. "� 4�1 '+f aa�� kms' k �e � 'Tal��� •.�,•� � .:ty�• P � �S hi. � M�1•. SR Roads C3 MVPC Boundary Ll Parcels &•,�;� �i�i'�" e -'fr $r '�q .��l� ! '� 4•�»+'aTi�a�.,� '�s 9{� .r r a't �.. r �,,� �` 'Y �k. `� "c'3a.. !•�,+� .��� ��'�d#� .�'� �.�tS.�':. k.�.� .e` .. n�f.��.<?k�`dx�-a�`.`'"�.n} +�t.a�.. .:��:,. x �. �• •.•. • • •• •• • •• • • •• •• ••• • 119 �- BAY STATE ADJUSTMENT SERVICE 45 New Ocean Street, Swampscott, MA 01907 Telephone Numbers 24 Hour Emergency Number(781)858 1075 (781)599 9922 (800)865-2206 FAX(781)599 9099 Town Fire Department Inspector of Buildings Board of Health Town of North Andover Town of North Andover Town Hall Town Hall North Andover, MA 01845 North Andover, MA 01845 Re: Michael Sklar Company: Merrimack Mutual Lesley Sklar Fire Insurance Company Property Address: 125 Lancaster Road Date of Loss: 4/11/2003 North Andover, MA 01845 Cause of Loss: windstorm and water damage Policy Number: HP1700446 File Number: 3283 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 Law, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Law, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captoned insured, location, policy number, date of loss, and file number. This is not a request for a report, this is to comply with Masschusetts notification laws as set forth above. Paul R. Nestor, Jr. j Adjuster On this date, I caused copied of this notice to be sent to the persons named above, at the ad ses ' icated by first class mail. April 14 2003 Signatur Date Date Ar.. .moo......... ........ ...... ... .. TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING S C14US . This certifies that . ............. ......................... ........................ has permission to perform —'2-20.�.. ..................................................... wiring in the building of ........................................................................... at/,;2x5.... ............ .North Andover,Mass. Fee.'/ .... .. ....... Lic.NoA.�'101. .........X4— .......... ELECTRICAL'INSPECTO r Check 4 6969 Commonwealth of Massachusetts /Official Use �c� UseOnly Department of Fire Services Permit No. �' Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9/05] (leave blank) APPLICATION FOWPERMIT 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: �Cy �3rC City or Town of: To the Inspector of Wires: By this application the undersigned g ves notice of his or her intention to perform the electrical work described below. Location(Street& Number) Owner or Tenant ,.411 qe .+J Telephone No. 9)S-, 994- 9V6 Owner's Address Is this permit in conjunction with a building permit? Yes a No ❑ (Check Appropriate Box) Purpose of Building Rf3,-dih,, 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: &rG J,1J f (Virg Completion of the followingtable ma be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- o.of Emergency Lighting rnd. grnd. Battery Units { No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners o.of Detection and Initiating Devices ' No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers eat um umber ons o.o el - ontame Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ un�c�pa ❑ Other Connection No.of Dryers Heating Appliances KWy Security Systems: No.of Devices or Equivalent No.o aterKW o.o o.of Data Wiring: Heaters 'Signs Ballasts No.of Devices or Equivalent No. Hydromassage Bathtubs No..of Motors Total HP a ecommunic �r�ng: Devicceses oorr Equivalent OTHER: Attach dditional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: ;k LAo (Who6lr6quired by municipal policy.) t Work to Start: 10 4-4t� Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless j the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cover ge is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: G- Cu ) LIC. NO.: Licensee: �zS(�ray Vj,KSignature r . LIC. NO.: (If applicable, enter "exempt"in the license number line) Bus.Tel. No.: 721-q 17 V&4 Address: 61 Af/p� LTi .14 all elV Alt.Tel. No.: *Security System Contractor License required for this work; if applicable,enter the license number here: OWNER'S INSURANCE WAIVER: I am 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's agent. Owner/Agent �- Signature Telephone No. PERMIT FEE: $ J o-�Is 0< 1(9 (mss PER3frr NO. 62APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE i MAP "0. 70 y LOT NO. O � � � 2 RECORD OF OWNERSHIP JDATE BOOK 'PAGE c ZONE I SUB DIV. LOT NO. OCATION S Lvv4c)cra s �j'` PURPOSE OF BUILDING OWNER'S NAME �/1 ` , V ,. IA.2 NO. OF STORIES SIZE OWNER'S ADDRESS 11` CL � �+�. YL BASEMENT OR SLAB ARCHITECT'S NAME J J SIZE OF FLOOR TIMBERS IST 2ND !RD BUILDER'S NAME 1(•1 r,�� � ,�� SPAN - DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES—SIDES REAR GIRDERS i 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 �tv-s IS BUILDING CONNECTED TO TOWN WATER ,e BOARD OF APPEALS ACTION. IF ANY i+yG: IS BUILDING CONNECTED TO TOWN SEWER Y--e I IS BUILDING CONNECTED TO NATURAL GAS LINE 7`e S INSTRUCTIONS a PROPERTY INFORMATION LAND COST SEE BOTH SIDES EST. BLDG. con - � �, Ofd Q PAGE / FILL OUT SECTIONS 1 - 2 EST. BLDG. COST PER SQ. FT. EST. BLDG. COST P" 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 J I DATE FILED 9/\-7 1 9 -7 e SIUILDING IItBPtCTOR SIGNATURE OF OWNER OR AUTHORIZED AGENT OWNER TEL/ 1 r[RM IT SRAMZD er , r � J,��CGt c�✓�auxa�i,me� HOME IMPROVEMENT CONTRACTOR Registration 120296 Type - INDIVIDUAL Expiration 11/19/97 JAMES TESTA _ JAMES M. TESTA 120B HILL ST ADMINISTRWOa TOPSFIELD MA 01983 .__.,_w._ _ _"✓!ce �asn�rraocurealb�i o�✓��avan..,/u�,/,�s I �_ _ ...._...._._..� ., � n 7 2341 TP;F. r, a u?q 59'1 ► r Imo——14'10 17'6 6' T 16'5 4'4 9'6 6'4 4'10 7'7 5'1� 2'9 7.11 5'9 r a 36 sq R of wlndovrs BATH CLOSET LIVING/ PLAYROOM Lo 1111 UP e STORAGE UP WH CLOSET UTILITY CLOSET 137 16'3 21 227 4'4 59'1 LIVING SPACE 671 sgIt CONTRACTOR SKLARBASEMENT JAMES TESTA 125 LANCASTER ROAD 75 SURREY DRIVE NORTHANDOVERMA NORTHANDOVERMA 59'1 -, 14'10 17'6 6' 16'5 44 8'6 6'44'107'75'1� 2*9 7'11 5'9 Y so 36 sq R of windows BATH Ll N CLOSET LIVING/ a PLAYROOM UP STORAGE UP ao WH CLOSET UTILITY CLOSET N 137 16'3 1 24 227 4'4 k 59.1 LIVING SPACE 671 sq CONTRACTOR SKLAR BASEMENT JAMES TESTA 125 LANCASTER ROAD 75 SURREY DRIVE NORTH ANDOVER MA NORTH ANDOVER MA -14'10 17'6 6' 16'54'4 / , 6'6 6'4 4.10 7'7 5'1� 2'9 7'11 5'9 e a 36 sq ft of windows BATH Ll CLOSET LIVING/ PLAYROOM FFTT UP o STORAGE LULL I UP H/h CLOSET UTILITY CLOSET 137 . 16'3 2'4 227 44 L- 59'1 LIVING SPACE 671 sq It CONTRACTOR SKLAR BASEMENT JAMES TESTA 125 LMJCASTER ROAD 75 SURREY DRIVE NORTHANDOVERMA NORTHANDOVERMA C1ORTjy Town of Andover No. LAKE 19 q� doves, Mass., _,Qt Z*' �,C OCMICMEWICK Y ` '9 °AAr E o Pavy ,�y S E BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System 1 BUILDING INSPECTOR THIS CERTIFIES THAT........M..i LkAt�..........&.U!� S -................................................................................................ Foundation has permission to erect..... 1?.Af. buildings on ...... X . ............................ Rough to be occupied as........,,�a �Y............,BSc.�j.iZvery ..................�..�`-w�,�� RN►., ....13c� -. chimney provided that the person accdoting this permit shall respect conform to the terms of the application on The 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. R I'Vt al kC � • C�' PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. ►wy �Y '''� Rough PERMIT EXPIRES IN 6 M �e�' Final MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION TARTS Rough .......... .. Service ........................ .. ... . . .... .. ............ . BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. 1 �j Burner 'tC4 t ` ` �1��S Street No. G t 37,5-1 Smoke Det. ` MASSACHUSETTS UNIFORM APPLICATION:FOR.PERMIT, i'ObOVLUMBING (Type or Print) r , NORTH ANDOVER ,Mass. 1> e ,,3Y7'ZBuilding Location S h cs5 ei' Permit ' Owners Name Vh,'L 4 / ja� New Renovation Replacement Plans Submitted FIXTURE z as zx < i N O z a (- al J W le J W < tl < N a d ¢ ¢ N Z N Q ¢ d h = O Z W a K J Q of x ¢ ~ •Q W al X a a C a d 3 K u z CG ¢ a) y( �- l- w ,, cc 4 of ¢ a fG O k ,.,, ••. lr W O 7 W Q al ¢ < W a) CC J = p Cl 0: J W X Z• O z z 5d a t•- < z < N. W Y F' O CL O N F- W k X W s( H N N 2 O Q of 2 Y W l., O V < Q = Q < O < -.1 J Q ¢ F Cr. < O 3 X J m ai a to J h 4. a o < 3 ¢ to o SUB-8St4T. • ' Y, BASEMENT �' J 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR `S 7THFLOOR 8TH FLOOR (Print or Type) Check one: Certificate Installing Company Name L 9 C,✓ PA tA, Y" 170c�_ [7) Corp. Address a 3 C egS o U 71 /Q Partner. 0/1.7- 4 7 - Firm/Co. Business Telephone 7g / S YIL/- 788a- Name of Licensed Plumber: A19 t-�, 3`�y r/`.p e 1'S e j Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type ,of indemnity Bond Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. ' S Signature of owner/agent of property Owner E] Agen,f,. I hereby certify that all of Ute details and information 1 hive subjaiticd(or en(ered)in atneve application are true an4\AFu1ale to Ute best at my -• - knowledge and(hat all plumbing work and installations 11crfnrnicd under Pcnuit issucd(or this application will be in compliance with all perlinept pro• wisioas of the Massachusetts Stale Plumbing Code and chapter 142 of the(:metal Laws, By Title . Signature of Licensed Plumber City/Town: pe of Plumbing License APPROVED (OFFICE USE ONLY) License Number L- Master 11Journeyman Date N= 3497 HORTM �6 <,,,_•° .'+ - TOWN OF'NORTH ANDOVER 49 PERMIT FOR PLUMBING 8 ,SSACow This certifies that .�. �?.4�, . .,�h.t .�-n /.N.f. . . . . . . ... . . . . . . . . . has permission to perform . PAC", . . . . . . . . . . . . . . . . . . plumbing in the buildings of . . . . . . . . . . . . . . . . at. ��. S. . . .�,�t. .<. ry.t. c/�. . . . . . Aorth Andover, Mass. � o Fee.k3, - . .Lic. No..C/. '�/ . . . . . . . . . . . . . _PLUMBING INSPECTOR WHITE:Applicant, CANARY: Building Dept. PINK:Treasurer Ir-rrncor type) rcnmrr rU IUU UANFITTiNG NORTH ANDOVER2—, Mass. Date /a - - 3G, 19 g 7 Building � c PermR t.ocatlon_la-.� L s s S''�rr • Owner's Name c4 e T New Renovation ❑ Replacement ❑ Plans Submitted:. Yes (a No ❑ I1 K N M O N N h T� 2 J N w o V d H= O pp� ~ 4 �' s M � b M 0 O = H N M N X v r = = h N O M � .� n w = s at d H i h F 1 ZIM430-1r1yC "a � � . o � o ° > do sus-as1lTe • sASEM)ENT 1sT FLOOR , 0-6 !NO FLOOR I SAD FLOOR 4TH FLOOR ITHPLO on I � STH FLOOR i t 7TH FLOOR t sTH FLOOR Installing Company NameCheck one: Certificate _ �9 w j.4`U � �, a 3 c e ¢ Corp. Address d Partnership e A-t 9 �� 6 ❑ Flrm/Co. Business Telephone Name of Licensed Plumber or Das Fester /LI9y I 11<7t j--,r e vl INSURANCE COVERAGE: one 1 have a current liability Insurance policy or its substantial equivalent. Yes ckQ,— No ❑ If you have checked yes, please Indicate the type coverage by checking the appropriate box. 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: %nature of Owner or Owners Agent Owner ❑ Agent ❑ I=hereby certify that an 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 Inslellalions performed under the permit Issued for this application vNll be In compllance with all parUnant provisions of thhe Massachusetts State Gas Code and Chapter 142 of the General laws. Type of Ucense: Title [Haste( umber pna uta o nse um er or as er asOttet �,n� Ucense Number // k S t/ Mourneyman MPnOWD(OFFICE USE ONLY) i f 6 5 i Date,/%'Zq? .. ........ A NpRTN TOWN OF NORTH ANDOVER a 0 � op PERMIT FOR GAS INSTALLATION SS CU p� M N This certifies that . . . . . . . . . . . . . . . . has permission for gas installation . . . r. . . . . . . . . . in the buildings of .1. :� /..:q/.? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .a. at . . . . . . . . . . . . , Npilh Andover, Mass. Fee. . ?.ta. . . . Lic. No.P. }. . . . . . . L'. . . . . . . . INSPECTOR" WHITE:Applicant CANARY:Building Dept. PINK:Treasurer Location ��� � �� �7�• No. Date .V ,.OR7M TOWN OF NORTH ANDOVER A Certificate of Occupancy $WZ ?'O 7 _g 7 # Building/Frame Permit Fee $ PD Foundation Permit Fee $ ' LL, svc14 t n Other Permit Fee $ 4 6 57 Sewer Connection Fee $ a _ 353 Water Connection Fee $ TOTAL $ a U ' 0,- tnu 6033 Z46r,r Building Inspector 7444 Div. Public Works /� 3$ Location No. AV Date -44- e jORTh , TOWN OF NORTH ANDOVER O o A Certificate of Occupancy $ ` Building/Frame Permit Fee $ Foundation Permit Fee $ v" s�cHusE _._ R Other Permit Fee $ +A10 Sewer Connection Fee $ j �"✓' 3 Water Connection Fee $ a TOTAL $ ISO od ldillg In ector. •` 6975 Div u is Works PERJIIT NO. Z11 APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. ✓j� PAGE 1 41 MAF;KJO. I LOT NO. 2 RECORD OF OWNERSHIP —'DATE BOOK 'PAGE — #E ZONE.: SUB DIV. LOT NO. LOCATION/;< PURPOSE OF BUILDING OWNER'S NAME � �T' � �� o ,7 � NO. OF STORIES 41ZE a OWNER'S ADDRES BASEMENT OR SLAB Ad O� ARCHITECT'S NAME SIZE OF FLOOR TIMBERS 1ST Of/1 2ND sOL) " 3RD � BUILDER'S NAME � �.�,_/ SPAN / DISTANCE TO NEAREST BUILDING J �' DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS --- DISTANCE FROM LOT LINES-SIDES REAR Z,�0_10f- " " GIRDERS AREA OF LOT j AsC FRONTAGE HEIGHT OF FOUNDATION TOS oG /F THICKNESS y, IS BUILDING NEW J �J� SIZE OF FOOTING O� l/ X IS BUILDING ADDITION MATERIAL OF CHIMNEY / IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE j,-/ IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY _ I �y IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LIN INSTRUCTIONS 3 PROPERTY INFORMATION PERMIT FOR FOUNDATION ONLY LAND COST SEE BOTH SIDES REGULATED BY PARA 114.8-. B.C. _ ,x'-3 odo EST. BLDG. COST IC2O PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT. PAGE'2 FILL OUT SECTIONS I - 12DATE ; FEE PAID JD EST. BLDG. COST PER ROOM /�, WEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED BOARD OF HEALTH SIGNATURE OF O NER OR AUX95-R-rZED AGENT 09 FEE a'21 �'7. 00 h FDA FEE" v ' - PLANNING BOARD PERMIT GRANTED T UUF FRQMF -7-7-94 !/ BOARD OF SELECTMEN PERMIT FOR FRAMUBUILDINGle DATE. '7'/J l`/ BUILDING INSPECTOR FEE PAID:�q7• �9 S 7, -- 3 ! BUILDING RECORD 1 OCCUPANCY,- ; ' " + t �►"^±fie ►� � rx � 12 SINGLE FAMILY sroRlEs THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- APARTMENTS RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION I 8 INTERIOR FINISH CONCRETI" W B 1 2 I3 CONCRETE BCK. PINE _ /' _ }, };�, _,.L , BRICK OR STONE HARDW D PIERS PLASTER DRY WALL _ UNFIN. 3 BASEMENT AREA FULL 6" FIN. B'M'T' AREA _ '/ 1/7 '/+ FIN. ATTIC AREA _ NLd B M FIRE PLACES _ HEAD ROOM MODERN KITCHEN �4 WALLS I g FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE �_ WOOD SHINGLES EARTH _ ASPHALT SIDING HARD'✓'D �� ASBESTOS SIDIIIc; _ COMMCN H KE �:�� VERT. SIDING ' ASPH. TILE _ STUCCO ON MASONRY STUCCO ON iRAME BRICK ON MASONRY ATTIC STRS. & FLOOR I_ BRICK ON FRAME Er(:nrvjrD CR buff Ilft?. 8,c. _ CONC. OR CINDER BLK. iiv, {/4!F i./�(►1/; �(t� ` +}� STONE ON MASONRY WIRING L 1 kog Convi V a L STONE ON FRAME _ SUPERIORI� POOR _ ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE I HIP 400 BATH 13 FIX.) GAMBREL MANSA:J TOILET RM. 12 FIX.) FLAT SHED WATER CLOSET _ ASPHALT SHINGLES 4,0 LAVATORY WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST III PIPELESS FURNACE _ FORCED HOT AIR FURN. TIMBER BMS. &COLS. _ STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ ELECTRIC Ist 13rd I NO HEATING F a s FORM U - IAT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Ap- ed' �cn�pllicant fills out this s.,,cection***************** APPLICANT: c/z �� � Phone !�6 =��� LOCATION: Assessor's Map Number �� Parcel O Subdivision Lots) Street �►a . �'% � St. Number Z ************************Official Use Only************************ RECO DATI0 TOWN AGENTS: Z_ _ y Date Approved Cons rvation dministrator Date Rejected Cc ents Date Approved (b�9 aq Town Planner Date Rejected Comments Date Approved FoodInsp c4-or Hesztb,— Date Rejected PP Date Approved Septic Inspector-health Date Rejected Comments Public Works - sewer/water connections - driveway permit Fire Department Received by Building Inspector Date 3 0 1q94 l S cyto f o2 ou e-, tc 7-e 14 •sf 1%/-�s,� �c�J� 37 , / SX � � 1Sx 3Z 17x o24X 3 z x / c . S �F� x6s = 3� 3 -Z 2-c> 2- 3S� d2,o 312,0u 1 � o t1 5 � 2� b �b-'.�r:�*�..7n�rAygt+ 7�bA6}fiF'.s-n.•::tom.mesc{toF,l1! y- •.a t.•v�p .r,F.„e�q e�,.. ^ro '•'t't. .. , � ,s - ,. •r;:.,� ... .. PLAN OF LAND NO. ANDOVER MA . SCALE. /' 40" DA TE,l/-'8--93 SCOT TL.G/LES R.PL.S 1 NO: ANDOVER,MA: 708.00 W LOT 38w� • � I 44 5`3<o S.� `V s�/" �V . / / •/� \ .�.\ \ � �, ��j.{ a w 1140 let of R�PQsED W ILD C" F S2 77- 11-. 8- 93 /50:0$ LANCASTER ROAD i CERTIFIED FOUNDATIONPLAN I 54 LOCATED /N NO. ANDOVER, MA. �.U!f .E)[`lG DEPART E-� ENT SCALE /"= 40' DATE: 6/30194 � Scott L. Gi/es R.L.S. 50 Deer Meadow Road North Andover,Mass. LOT 36 �. 44,596 S. F. o 0 LOT4O ' 4 r L. O T 36 t9 N N r u n N s EXISYING FOUND. 401 52' � 1 L, A19CA6T�" � R0 A D / CER T/FY THAT OFFSETS SHOWN ARE FOR THE USE a THE OFFSETS OF THE BUIL DING/NSPEC TOR ONLY { SHOWN COMPLY AND SUCH USE IS FOR THE t WITH THE ZONING DETERM/NATION OF ZONING BY LAWS OF CONFORM/T Y OR NON-CONFORMITY &Q, ANQ 0VERt,�9A WHEN CONSTRUCTED. WHEN BUIL T. 6/ 9 4 Town of 0 Andover No. r- 271 .� zo - -1=`�=AINortip Andover, Mass., 19W AoR^TEo S 'L BOARD OF HEALTH �I PERMIT T LD Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT................ ..... -o..'"Ir 72.5-4!4 1.1........................................ Foundation , � ' . ... . . . .has permission to erect........ ".b............ buildings onCoT3a -�1.5 .,40c *%ML..P.. . Rough to be occupied ... ! ! f f:. v� .... J 3 .CR .. .. tQ ....&AJ0& Chimney provided that the person accepting this permshall 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. PERMIT 'K FOUNDATION ONLY PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. REGULAR i_D BY PARA. 114." &C. Rough i y. � PERI F EXP1.1UHS IN 6 MONTI-16, '1-�-g FEE PAfD�/O0►�� Final IVI r,- ELECTRICAL INSPECTOR UNLESS CN [ RUC � I(IT 1 SPI". ,RTS Rough I PERMIT FOR FRAME/BUILDING , ......................................... Service BUILDING INSPECTOR 7 S-��r PARD* •.nFinal DATE.___.� FEE PAR D.. 1. Uccup(lt1C'y' .l'c 1'1"111 t Regit l i'vd (.() C -c-i f 11}' N?Lti ld i)Ig GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner PLANNING FINAL CONSERVATION FINAL Street No. Smoke Det. SEWER/WATER FINAL DRIVEWAY ENTRY PERMIT CERTIFICATE OF USE & OCCUPANCY Town Of North Andover Building Permit Number 271 Date NOVEMBER 17 , 1994 THIS CERTIFIES THAT THE BUILDING LOCATED ON 125 LANCASTER ROAD - (Lot #38) MAY BE OCCUPIED AS SINGLE FAMILY DWELLING W/3 CAR IN ACCORDANCE GARAGE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. CERTIFICATE ISSUED TO A T Mai l l P t Cnn c t ri i c t i on 4 Wescott Rd. ADDRE S k 61A Building Inspector i - - -+� —-- - - --- -- - - _ - - --------- ---- _-- - - -_-- _ _ Nolst - .fi II i W_1 =171 IS ,Z)�� 7 PL - - - ---------- �A n aT l'1 t. N- Town oo Andover 1711 1 2 7 .`Nortih, Andover, Mass., S4 LY G. 199- � 'Vq'f E D BUILD BOARD OF HEALTH Food/Kitchen PERMIT TO Septic System BUILDING INSPECTOR THIS CERTIFIES THAT................ .•5...... .�44► ..`........do A>�'l 2u.c'T'�. .... ..............................;....... Foundation D K� has permission to erect........�!!� .�............ buildings on -!� .. .3 .-�.�1. !!f .. Rough ��— to be occupied as... CF#2... 4 ...L1N.ac�c• Chimney Fran. F,.eat provided that the person accepting this permit shall in every respect c nform 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 tI 1' Buildings in the Town of North Andover. PERMIT :rt FOUNDATION ONLY PLUMBIN I P 'I`O VIOLATION of the Zoning or Building Regulations Voids this Permit. REGULA11D BY PARA. 114.8,5. &C. � ou na �l /d 9� PERMIT EXPIRES IN 6 MONT ` _ _ Al DATE 7 g FEE PAIQ /oa vo - t1N LESS CONSTRUCTION STAN'l'� EL IC INSPECT • oug PERMIT FOR FRAME/BUILDING ' �t.�. :............................................ Service ^v BUILDING INSPECTOR ��� 9 Fina / DATE: RE rHiv�7 V (_)c::c qTj;jcy Permit Required to Occupy Building GAS IN V1_7�� 91 Display in a Conspicuous Place on the Premises — Do Not Remove u P Y P No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Ins eptor. FI DEP TMENT 1 � i Burner PLANNING 6(- L,"�I �AL CONSERVATI N ' INAL Street No. Ls _ Smoke Det. SEWER/WATER_ FINAL DRIVEWAY EN RY PERMIT l