HomeMy WebLinkAboutMiscellaneous - 130 HICKORY HILL ROAD 4/30/2018 (2) 130 HICKORY HILL ROAD
210/062.0-0106-0000.0
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Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS, Ch. 139, Sec. 3B
To: Building Commissioner or
Inspector of Buildings
1600 Osgood Street
North Andover, MA 01845
I
RE: Insured: Paul & Lisa Marie Jepson
Property Address: 130 Hickory Hill Road
Policy Number: HP1642478
Date/Cause of Loss: 3/24/2015, Water/Ice Dams
File or Claim Number: 31620-W
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 or
file number.
Wade Anderson
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 /4
ignature and Date
ANDERSON ADJUSTMENT CO., INC.
50 Nashua Road, Suite 303
PO Box 1098
Londonderry, NH 03053
Date.?
NORTH TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
sSACHUS�
This certifies that .. ... . . . .�.I.. .. . .. . . . . . . . .
has permission to perform . . . . ... . . . . . . . . . . .
plumbing in the buildings of . .I �u l- Q,1 $�.!1 . . . . . . . . . . .
at .134. .��?.G.��-� ./.7 .//. .•. . . . . . . . . , North Andover, Mass.
Fee.@0 .,---Lic. No...//.w. . . . . . . . . . . . . . . . . . . . . . . . . .
^ /�^ PLUMBING INSPECTOR
Check # (�/,(�b 71..
X64
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or Pte)
NORTH ANDOVER,MASSACHUSETTS f
Building Location 0 Date jW7-b0
Permit#
Owner Amount
New ❑ Renovation ❑ Replacement Plans Submitted Yes ❑ No
FIXTURES
IPf M1y
L E2
k. SUNRa
>��Iv>avr
Z Hom
3M 1QOat
4IH Hf=
5M N
61HROM
71HHDM
SIB KDM
(Print or type) Check one: Certificate
Installing Company Name ' f V1 i V-1
Corp.
Address a �, �-+q C_ V
❑ Partner.
Business Telephone CJ ❑ Firm/Co.
Name of Licensed Plumber:
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurffice policy` Other type of inemnty ❑ Bond
LTJ di ❑
Insurance Waiver: L the undersigned,have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner ❑ Agent ❑
I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Pelmit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Plumbing Code Cha 142 of the General Laws.
By:
Signatureof Eicensad-PIUHM-5=7
Title Type of Plumbing License
City/Town M I I SSS C)
rcense lNuMber Master Journeyman
APPROVED(OFFICE USE ONLY
it
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, AM 02111
www.mas&gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Appheant,Information
Please Print Legibly
Name (Business/Organization/Individual):
17
C/L
Address: I
�l L
City/State/Zip:— rp1dZPhone#: �I�� ? c�O3
Are you an employer?Check the appropriate box-
Dr
ox:D m a employer with "L_ 4• Type of project(required):
❑ I am a general contractor and I
employees(full and/orpart-time).* have hired the sub-contractors 6. [1 New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 1 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers' comp,insurance.
com . insurance 5. 9. Building addition
[No workers
' p ❑ 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 I I-[J} umbing repairs or additions
myself.[No workers' comp. c. 152,§1(4),and we have no
insurance required.] t 12.❑Roof repairs
q ] employees. [No workers'
comp.insurance required.] 13-El Other
g=ny applicant that checks boy;4I must also fill out the section btlow sh^uW*t:" :.
t ation
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'omp policy information.
I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#:
Expiration Date:
Job Site Address: �� �iL IL cry W_ V rJ
City/State/Zip: (V Yq eAWC K.—
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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ido hereby c nder the pains and penalties of perjury that the information provided abo a is ue and correct
Si ature.
Date: l/ 7 11 ,$
Phone#: 2 (p
Official se only. Do not write in this area, to be completed by city or town off ciaL
Cite or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person:
Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract 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 aparhnents and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority." '
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC) or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be mtwmed to the city or town that the application for the permit or license is being requested,not the Department.of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business.or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit
T1ne 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 Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 021.11
Tel. # 617-727-4900 ext 406 or 1-877-MASSA-FE
Revised.5-26-05
Fax#617-727-7749
v���u�.mass._gov/dna
Date. 7. . .'. .� .�. .. .
HORTM
pf „ao
L TOWN OF NORTH ANDOVER
• PERMIT FOR GAS INSTALLATION
�9SSACMUSE�
This certifies that �?'!! !'�'. r .! !"ti.�. !!�. . . . . . . . . . .
has permission for.gas installation Y 'l .C?"''!'`} . . . . . .
in the buildings of . . !�.4�1. . .� � ,�. . . . . . . . . . . . . . . . . .
at . /7?-4- r-- . . . . ., North Andover Mass.
Fm:.-::; . /
Lic. No..//. . . . . . . . . . . . . . . . . . . . . . . . . . .
GAS INSPECTOR
Check#
7255
� r
MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FTrrIN
(Type or print) Date li d
NORTH ANDOVER,MASSACHUSETTS ii 1
Building Locations C) k CC-iL G., Permit#
^�
Owner's Name Amount$
- ��� �1 D�•. �!�y�
New❑ Renovation Replacement Plans Submitted ❑
Eli
vI
a c H
x z U w x �, z a o w
w C� p > w FU
w a rx z o z o w
s o x w "L< c o x° > a a p
SUB -BASEM ENT
B A S E M ENT
a 1ST. FLOOR
2ND . FLOOR
3RD . FLOOR
4TH . FLOOR
5TH . FLOOR
6TH . FLOOR
7TH . FLOOR
8TH . •FLOOR Eli] F-1 I
(Print or type—
�
Name /Vvt Check one: Certificate Installing Company
1 Corp.
Address Panner.
Z
usmess e ep one cy 7 7 zT 3 7 0 E] Firm/Co.
Name of Licensed Plumber or Gas Fitter ✓-,,x -7oy\-�
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes No
13
If you have checked yes,please indicate the type coverage by checking the appropriate box
Liability insurance policy ®i► 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:
Signature of Owner or Owner's Agent Owner El Agent 0
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 perfo ed unde/Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Gas ode an hapter 142 of the General Laws.
By: Signature o L' ensed Plumber Or Gas Fitter
Title [ " 'lumber _� ` tJ1�0
City/Town 1:1 Gas Fitter License N umber
aster
APPROVED(OFFICE USE ONLY) Journeyman
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Kashington Street
Boston, AL4 02111
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information
Please Print Legibly
Name(Business/Organization/Individual):-:T;11
x
Address:
City/State/Zip: GIs z t
l�. 1 �. — ►1'w Phone
F2.
you an employer?Check the appropriate box:
OT am
a employer with_ 4. ❑ I am a general contractor and I Type of project(required):
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
I am a sole proprietor or partner- listed on the attached sheet t 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers' comp.insurance.
[No workers' comp.. insurance 5• 9• ❑Building addition
❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
i 3.❑ I am a homeowner doing all work right of exemption per MGL 11.[311^umbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no
insurance required.] t 12.❑Roof repairs
Q ] employees_ [No workers'
comp.insurance required.] 3.[1 Other
`Any applicant that ch=k--boy.#1 must also,III out the section belowshowing���wo. s'compensation policy nfo^nation.
t Homeowners who submit this affidavit indicating they are 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
information. insurance for my employees Below is the policy and job site
Insurance Company Name:
Policy#or Self-ins.Lie.#: I
Expiration Date:
Job Site Address: 3l7 h-j2 �
City/State/Zip: '
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under 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 under the pains and penalties of perjury that the information provided above is true and correct
Sio-nature:
Date.:
Phone#:
FOther
only. Do not write in this area, to be completed by city or town official,
Town: Permit/License#
hority(circle one):
Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
son:
Phone#:
y.
Information as d Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartmLents and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of coxnpliance with the insurance coverage required."
Additionally,MGL chapter 152, §25CM states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be-ret irned to the city or town that the application for the perffiit or license is being requestsd,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would Ince 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 Commonwealth of Massachusetts
Department of Industrial Accidents
Office of lnvesiigatons
600 Washington Street
Boston,MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax#617-727-7749
,Arvrw.mass..gov/dia
Location /3 Oat-
No.
07 5� Date 7A 5 9-3
40RTM TOWN OF NORTH ANDOVER
Certificate of Occupancy $ !f
Building/Frame PerFnit Feed
,SSACMUSEt Foundation Permlt Fee $ AR.)
Other Per it Fee $
Sewer tion Fee it 113
7 j°� Water Cannection Fee
d � v
TOTAL
C IC Building Inspector
'' ? Div. Public Works
r' a a--
Location / 12
No. oZ y_S Date
NORTH TOWN OF NORTH ANDOVER
p Certificate of Occupancy $
` y Building/Frame Permit Fee $
r
sth Foundation Permit Fee $ /,i - d 0
�CU EHuS
Other Permit Fee $
lam,
Sewer Connection Fee $
Water Connection Fee $
A
TOTAL $ /.5-t%, o c)
�t Building Inspector
619 4 4? .7993 Div. Public Works
Ld'cation
No. Date _
TOWN OF NORTH ANDOVER
F p Certificate of Occupancy $
y Building/Frame Permit Fee $
,SSACMUSEt Foundation Permit Fee $
Other Permit Fee $
`
S7:5 ` Sewer Connection Fee $ /�m
Waiter-Con nktion Fee $
TOTAL _?!
Building Inspector
1993
6430 Div.R bli orks
�T�
PACE 1
PERMM-'NO. . . yl S APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. J
MAP d,10. I LOT NO.- Z M 2 RECORD OF OWNERSHIP iDATE (BOOK 'PAGE —
ZONE SUB DIV. LOT NO. '711_ s-D 6 ? q
•iOCATIONt I PURPOSE OF BUILDING S AJ 6 t g 'C p per,
OWNER'S NAME I NO. OF STORIES21 1
SIZE
OWNER'S ADDRESS g-� iJs' 1� I BASEMENT OR SLAB fa 5 r �}.GSI- b
ARCHITECT'S NAME I �l.D'MA.S "9 (� 1,� SIZE OF FLOOR TIMBERS ISS+N�+erTX17_ 2ND UIn 3RD
J BUILDER'S NAME SPAN
TSI s D. Z.I Oyu/
►�t �-r�� —
DISTANCE TO NEAREST BUILDING �. �..r f DIMENSIONS OF SILLSPIT-
/
DISTANCE FROM STREET /i� l " POSTS 1/��/ s/� cy.4�z
a DISTANCE FROM LOT LINES-SIDES REAR /Do/ ,. GIRDERS
AREA OF LOT 1 t 1 L? s,� FRONTAGE j/�� J HEIGHT OF FOUNDATION 27 /G� ( THICKNESS ld>�
IS BUILDING NEW [7 4/ SIZE OF FOOTING Z!/
J Yes 7
IS BUILDING ADDITION N� MATERIAL OF CHIMNEY
Bri v
IS BUILDING ALTERATION f IS BUILDING ON SOLID OR FILLED LAND Sd-LI17
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER Yo
t�
BOARD OF APPEALS ACTION. IF ANY JG' IS BUILDING CONNECTED TO TOWN SEWER Y605
IS BUILDING CONNECTED TO NATURAL GAS LINE x
INSTRUCTIONS 3 PROPERTY INFORMATION
LAND COST / t- OO 'Ob
SEE BOTH SIDES frEEam few _/. ,�S EST. BLDG. COST b IJ)OSI�?® .OD
PAGE I FILL OUT SECTIONS I - 3 !L'l� pF if���51�/D�M�I�,wi�11 /, EST. BLDG. COST PER SQ.1FT. rc�
PAGE 2 FILL OUT SECTIONS 1 - 12 DUE FRAME PERMIT$�,�:�d EST. BLDG. COST PER ROOM i/. 'n
SEPTIC PERMIT NO. I�.I IA
eo
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 /
DATE FILED 6�Q/
i
BOARD OF HEALTH
IGNATURE OF O OR AUTHOR ED AGENT
FEE 7
Al w�D OWNER TEL.N `-r1PLANNING BOARD
PERMIT GRE
/ CONTR.TEL#
_02--/ 19 CONTR.LIC.# SSI/�
rr _ BOARD OF SELECTMEN
BUIL"FNQ INSPECTOR
BUILDING RECORD
1 OCCUPANCY 12
SINGLE FAMILY SroulEs THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM
MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA-
APARTMENTS RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN.
CONSTRUCTION
2 FOUNDATION 8 INTERIOR FINISH
CONCRETE a I 2 13
CONCRETE BL K. --11 PINE
BRICK OR STONE HARDw D —
PIERS PIASTER
_ DRY WALL _ V _
UNFIN. T
3 BASEMENT
AREA FULL FIN. B M AREA _ I
FIN. ATTIC AREA
NO BMT FIRE PLACES
HEAD ROOM — MODERN KITCHEN
4 WALLS I 9 FLOORS }'
CLAPBOARDS B 1 2 3
DROP SIDING CONCRETE �—
WOOD SHINGLES EARTH _
ASPHALT SIDING HARD�VJ'D _
ASBESTOS SIDING _ COMMCN _
VERT. SIDING ASPH. TILE _
STUCCO ON MASONRY _
STUCCO ON FRAME
BRICK N MASONRY ATTIC STRS. b FLOOR _
BRICK ON FRAME
CONC. OR CINDER BLK.
STONE ON MASONRY WIRING •? ='".^ 'f t
STONE ON FRAME
SUPERIOR I� POOR
11 ADEQUATE NONE
5 ROOF 10 PLUMBING ,
GABLE HIP BATH 13 FIX.) 2 '
GAMBQEL MANSARD TOILET RM. 12 FIX.)
FLAT SHED WATER CLOSET
— t
ASPHALT SHINGLES LAVATORY _
WOOD SHINGES KITCHEN SINK
SLATE NO PLUMBING _
TAR 8 GRAVEL STALL SHOWER
ROLL ROOFING MODERN FIXTURES
TILE FLOOR
TILE DADO
6 FRAMING 11 HEATING
WOOD JOIST PIPELESS FURNACE .,w.►.K
FORCED HOT AIR FURN.
TIMBEV'BMS.1 CCILS. V STEAM
STEEL BUS-4,eCOLV HOT W'T'R OR VAPOR
WOOD RAFTERS AIR CONDITIONING
RADIANT H'T'G
UNIT HEATERS
7 NO. OF ROOMS GAS
OIL
B'M'T2nd ELECTRIC
1st 13rd NO HEATING
ry r
1
r
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 local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: � �� ��i�lS67�1
Phone -6V-7,63-5-
LOCATION:
V-7,63-5LOCATION: Assessor' s Map Number _ Parcel
Subdivision Lot(s)
Street St. Numbe�� V
************************Official Use Only************************
RECOMMENDATIONS OF TOWN AGENTS:
Date Approved
Conservation Administraat,', Date Rejected
Comments �C" �✓`�t�
Date Approved Q�
TownPlanner Date Rejected
Comments
" _ Date Approved �/ y
Health Agent Date Rejected
Comments
Public Works - sewer/water connection
- driveway permit A-V <<
Fire Department
r 0 W'ec;eived by Building Inspector Date
r 5
. 5S 00 t
Ih
ry
N N
• N ry
r
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Is
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Lot Z2 •`
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Lor
OT 2 3 2I �
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0 a :i
FMM.
f9o• �? 'Co foo d)
.7 0 'mac+ raT ► ; , .
.3 521-21
PROPOSED SITE PLAN
tK dF
N 0 RT Fi A ND O V IE M A
iC JOHN F
ZAHORU11C.0 =1',
'
SC R I.ti - `10/ �o
No. 20563
1)P"T
X93 OX,
`�UNA,L Q �
CERTIFIED FOUNDA TION PLAN
LOCATED /N Uoru-ru , MA. I `
SCALE:/". 4o' DATE 21 q3
Scott L. Giles R.L.S.
50 Deer Meadow Rood
North Andover,Moss.
N
� N
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42.40 I DIINC- DEP''.�A---'
I CERT/FY THAT OFFSETS SHOWN ARE FOR THE USE ��
THE OFFSETS OF THE BUIL DING/NSPEC TOR ONL Y
SHOWN COMPLY AND SUCH USE IS FOR THE
WITH THE ZONING DETERM/NATION OF ZONING
BY LAWS'OF CONFORMITY OR NON-CONFORMITY
_u0g,-r14 A-joovr--� WHEN CONSTRUCTED.
WHEN BUIL T.
7 &1q3
i
• •
NORTH
� t E
Town of over
0
No. . 245
+ O � "COCHIC � dover, Mass., Sy I u x� 19�,�
S
H E
BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
`j
01,0101M BUILDING INSPECTOR
THIS CERTIFIES THAT...�.r.��. � .:...j � Q. •�•. ..0.....
�.... .... ....
Foundation
has permission to erect. r.I1PAN Wuildings on .M.a.#1am-y.NW 4.#A.••.•.••.•.••• Rough
to be occupied aSS�. i .� .1 ./� / /.L..t.. AAO.Aflot► Y_t�pFftoC�IR>� It.1� Chimney
provided that the person accepting this permit shall in every respect conform to thf he application on ile in ap Final
this office, and to the provisions of the Codes and 11�8$r
B -Laws re ating to the Inspectc� e � � of
Buildings in the Town of North Andover. 60 d � REGULATED BY PARA. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough -
PERMIT EXPIRES IN 6 MON FEE PAID��"� Final
S CONSTRUCTION START S7
d ELECTRICAL INSPECTOR
PERMIT FOR FRAME/66 L4'
Rough
i
SATE'.......�.� • .. ... .. .B...
FEE PAID.
Service
....�.. UILD&G �i&i6i
.,_ Final
Occupancy Permit Required to Occupy Building
GAS INSPECTOR
— Do Not Remove Rough
{ Display in a Conspicuous Place on the Premises se 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.
CCIAMD /IAIATCD FiniAi ��9y ct"m DRIVFWAY ENTRY PERMIT __ __. —
CERTIFICATE OF USE & OCCUPANCY
Town of North Andover
Building Permit Number 245 Date AUGUST 30, 1993
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 130 HICKORY HILL ROAD (Lot #22)
MAY BE OCCUPIED AS SINGLE FAMILY DWLELING W/2 CAR GARAGE IN ACCORDANCE
& DECK
WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND
SUCH OTHER REGULATIONS AS MAY APPLY.
CERTIFICATE ISSUED TO Thomas D. 7_.ahorui ko
o? °; 185 HICKORY HILL RD.
ADDRESS NORTH ANDoyER, MA
°sACHUS Building Inspector
` NORTH
0"
0f 0 over
r
o.
J�&JUSA/-190P.?dower, Mass.,
Y O � lA O
COC MIC I`�
ADRATE D
S HE
BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic Syste f,
�Iowa
� BUILDING INSPECTOR
THIS CERTIFIES THAT.. .Iy. ..... .:...�. . /�0-o. w.tv.10.........
"" """"""""""""" Foundation
has permission to erect 040.r.l0#0#1ffluildings on . .d. � � .y.y�«. .............. Rough .lG��
t0 b8 occupied aSS�. i�. /y.I...L.. .Q.�/. �.�.�. � �C�1lR� � Chimney G
provided that the person accepting this permit shall in every respect conform to the terms of he applicati��on[[uon ile in Fin 1J
this office, and to the provisions of the Codes and iBiLaws re ating to the Inspectce � � tf o �Buildings in the Town of North Andover. � � REGULATED B P PLUMBING SPECTOR
BY APDL u� L&
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough �` S3
PERMIT EXPIRES IN 6 MON 1 " �Pao
_ r�zc�Yv-
INLkGSS CONSTRUCTION STARTS ' clELECTRIEAL INSPECTOR
PERMIT FOR FRAME/66Rough ,
Services
DATE; FEE PAID:..`.�I.,._. BUILDING SPi6T6k Final
w.... /
` Occupancy Permit Required to Occupy Building
CCAS IN ECTOR
Display in a Conspicuous Place on the Premises — Do Not Remove Rough I
P Y P Ffn)' ` 2
No Lathing or Dry Wall To BeDone FIRE PARTMENT
Until Inspected and Approved by the Building Inspector. '1
f� Burner .
*i_: Street No.8 Z CON ERVATIONA PLANNING "I( AL 's �' S . ) L
Smoke Det. (�
SFWFR/WATFR isVJ g45S- FINAL ��9y cx.b�� DRIVEWAY ENTRY PERMIT
— �
Location_,, diarbe—V
Nq.
Date
A
+ M°R°TM TOWN OF NORTH ANDOVE�
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
s�cMUBE -ter
Other Permit Fee $
Sewer Connection Fee $
Water Connection Fee $ co
I TOTAL $
17--�
Building Inspector
V $
Div. Public Works
PEH,111T rQ6. APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1
MAP h40. -� I LOT NO. 2 RECORD OF OWNERSHIP :DATE BOOK :PAGE
ZONE SUB DIV. LOT NO.
I
LOCATION PURPOSE OF BUILDING
f o NyznT scr���l� (Llrn
OWNER'S NAME - + �+� crnwiES
AuL
OWNER'S ADDRESS 1 Q `Icl � 11 R4 BASEMENT OR SLAB
ARCHITECT'S NAME t SIZE OF FLOOR TIMBERS IST 2ND 3RD
BUILDER'S NAME SPAN
DISTANCE TO NEAREST BUILDING I DIMENSIONS OF SILLS --_
DISTANCE FROM STREET POSTS
DISTANCE FROM LOT LINES-SIDES REAR '" GIRDERS
AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW SIZE OF FOOTING X
IS BUILDING ADDITION MATERIAL OF CHIMNEY
IS BUILDING ALTERATION IS BUILDING ON SOLID OR FIL D LAND
WILL BUILDING CONFORM TO REQUIREMENTS CODE IS BUILDING CONNECTED TO T WN WATER
BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER
IS BUILDING CONNECTED TO NATURAL GAS LINE
INSTRUCTIONS 3 PROPERTY INFORMATION
LAND COST
SEE BOTH SIDES EST. BLDG. COST
PAGE 1 FILL OUT SECTIONS i - 3
EST. BLDG. COST PER SQ. FT.
PAGE 2 FILL OUT SECTIONS 1 - 12
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
DATE FILED
BUILDING INS It
SIGN TU OF O E R T RIZED AGENT
FE OWNER TEL.# G�Z�91.71
PERMIT GRANTED CONTR.TEL.# v •
19 --��- CONTR.LIC.J! J
H.I.C.# I o�3`a3
wo -►
BUILDING RECORD
1 OCCUPANCY 12
SINGLE FAMILY, I STORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM
MULTI. FA ILY pfFICES s ,LOT LINES AND EXACT DIMENSIONS'OF BUILDINGS: WITH,PORCHES. GA-
APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT FLAN.
CONSTRUCTION
2 FOUNDATION 8 INTERIOR FINISH
CONCRETE B 1 2 13
CONCRETE BL K. PINE
BRICK OR STONE HARDW D
PIERS PLASTER
_ DRY WALL
UNFIN.
3 BASEMENT
AREA FULL FIN. B M AREA _
1/1 1/I 1/. FIN. ATTIC AREA _
N_O B M FIRE PLACES _
HEAD ROOM MODERN KITCHEN
4 WALLS I 9 FLOORS
CLAPBOARDS B 1 2 3
DROP SIDING CONCRETE �_
WOOD SHINGLES EARTH _
ASPHALT SIDING HARDIVD _
ASBESTOS SIDING _ COMf,ACN _
VERT. SIDING ASPH. TILE _
STUCCO ON MASONRY
STUCCO ON FRAME
BRICK ON MASONRY ATTIC STIRS. & FLOOR _
BRICK ON FRAME
CONC. OR CINDER BLK.
STONE ON MASONRY WIRING
STONE ON FRAME _
SUPERIOR I� POOR
ADEQUATE NONE
5 ROOF 10 PLUMBING
GABLE I HIP BATH Q FIX.) _
GAMBREL MANSARD TOILET RM. (2 FIX.) _
FLAT SHED WATER CLOSET _
ASPHALT SHINGLES LAVATORY
WOOD SHINGES KITCHEN SINK
SLATE NO PLUMBING _
TAR & GRAVEL STALL SHOWER _
ROLL ROOFING MODERN FIXTURES _
TILE FLOOR -
TILE DADO - ..�.
6 FRAMING I 11 HEATING
WOOD JOIST. PIPELESS FURNACE
FORCED HOT AIR FURN.
TIMBER-BMS. &COLS. STEAM
STEEL BMS,.& COLS. _ HOT W'T'R OR VAPOR
WOOD RAFTERS` _ AIR CONDITIONING
RADIANT H'T'G
UNIT HEATERS
7 NO. OF ROOMS GAS
OIL
B'M'T 2nd _ ELECTRIC
1st 13rd I NO HEATING
NORTH
Town of 0 dOver
TIM
No. 3;pj(
Ort . dower, Mass, 19*
RATED �
BOARD OF HEALTH
Food/Kitchen
PERMIT T Septic System
I BUILDING INSPECTOR
THIS CERTIFIES THAT.........................................84.��J..................'TE- 10-13-0,,tV.................................................... Foundation
has permission to*feet...... k1._6,E......... buildings on ......1.73.0......... ........... Rough
tobe occupied as .....................................................r—A.14A..t. lr�. ..................................................... Chimney
provided that the person accepting this permit shall in every r pact conform to the terms of the application on file in
Final
this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of
Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
PERMIT EXPIRES IN 6 MONTHS Final
UNLESS CONSTRUCTION INSPECTOR ACLDING
ELECTRICAL INSPECTOR
Rough
Service
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. Burner
Street No.
Smoke Det.
.F.`3 'ti.ran.>�.1`.ti.�'�- '--. .`�..rk,J'•'4,- ��'t-i.�-.r—.� � -..3 L-7-r. .. _ �.
Date.. .
399
AORTH
°tt"`° °�"� TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING EE
This certifies that ........ ....... .............................................
has permission to perform p d `� Lf.���.�,� - ..' ' "•:
wiring in the building of.....4.1 J/.l ...................
,North An er,
U
Fee.c ,5..a�....... Lic.No.. .v�.5( ............ :. .. ........
ELECTRIC; PECTOR
!'
is
i;
WHITE:Applicant CANARY: Building Dept. PINK:Treasurer
f
(5o I s•� r u1w I 1
NJ9
d
BAY STATEADJUSTMENT SERVICE
45 New Ocean Street, Swampscott, MA 01907
Telephone Numbers
24 Hour Emergency Number(877)5517344
(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: Paul and Lisa Marie Jepson Company: Merrimack Mutual
Fire Insurance Company
Property Address: 130 Hickory Hill Road Date of Loss: 05/15/01
North Andover, MA 01845
Policy Number: HP1642478
File Number: 1389
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.
Adjuster
On this date, I caused copied of this notice to be sent to the persons named above, at the
7addr sses indicated by first class mail.
May 30 2001 !ryi�C� c w
Signature Date
sc'ev P ASCI Fir- /�v PY. FII,
hoc j,,We / c-- �s�i v9v,p4-J� /Asp
Cies/-J q 9 , 9990 6q,p !'p iJn�riAy�
T D a ti'/ �r �J�//g/J 7. A4 ski
NO 6�nvc �dra/ DAP"A9e � o
M",d� of th&N at-bo, .LAwc. arto-wof IndepP,vi,dentIYvAwa qAdjw erk
\ Office Use Only 0
r V1J� LjjM MGjjWEajt1 1Tf 5gZ# I.5PftS Permit No.
Ir o Occupancy& Fee Checked
�� a ^� �er�IIrtmEiri of �uhtr>: �f.itl
r 3/ (leave blank)
BOARD OF FIRE PREVENTION REGULATIONS X27 C'AA 12:00
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 1 :OD
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date
(X)� or Town of NORTH nND0VF2 To the Ins ector of Wires:
The udersigned applies for a permit to perform the electrical work described below.
Location (Street & Number) �^
Owr.er or Tenant 4& -r�
Owner's Address
r — r--
Is this permit in conjunction with a building permit: Yes — No _ (Check Appropriate Sox)
Purocse of 9uildina "'�r Utility Authorization No.
Amos L3U`kits Overhead Unagrnd No. of Meters
Existing Service
New Sar.-ice Amos _J
Volts overhead _ Uncgrna No. of Meters
Numoer of Feeders anc Amcacity
Lccacicn anc Nature of Proposed Electrical 1.11crK
le I
Total
No. of L:gr,tmg Outlets No. �, - =s No. of transformers KVA
17
--"
Above'--
No. of i..ighting FiX(LrLS i Swimming ?get grne. _ crnc. Generators KVA
i No. cf Emergency Lighting
No f ec tlers ace CuNo of OilBurners ; 3arery Units
No of Sw ton Outlets No. or GasFIRE ALARMS No. at =ones
Burners I
No. of Cetection anc
Total
No. of Ranges I No. of Air Canc. tens Initiating 0ev ces _
Heat Totai -brat
No. of Oisoosals Nc.ei Pu—^s .ons K'.V I No. of Sounding Oev ces
No. of S@tf Contained
No. of C•isnwasners ScaceiArea Heating Oetec;;oniSoundinq Cev cos
I I
_ — Muntc:oat ^Other
No. of Criers I Heazmc; Cev,ces (VV Lccat connecaon
No. or No. of I Low vottage
No. of 'Vater Heaters KIN I Signs Salasts Wir:hc
No. Hycro Massage Tubs No. of Motors Total HP
0Tri ER:
INSURANCE COVERAGE: Pursuant to the reeutrements Cr MassacnusaCs generat Laws _
I have a current Liaotiity Insurance Pottcy inducing Cz;n ateree Oceratiens Coverage or as substantial eau tvatent. YES NO —
have SU curt d vatic iiityproof same
to the office. YES _ NO _ It you nave cnecKeg YE-S. please indicate the 11. Of NO
Cy
cnecxing thea qpr�q nate cox.
NSUAANCE ( BONO = OTHER _ tP!ease Soec:y) (Exotratton Cater
/////����,,,, t
'E �rye/
stimated Value of E!ectrtcat Work S F hat
Werx :o Start Inseection Oate Racuestec: Rougn
Signed under -,n�4 naittes of perjury: Ung
FIRM NAME
Licensee Signature LIC. NO. /�—
Bus. Tat. No. �� (''�—
rV / alt. Tel. No.
Address
OWNERS INSURANCE WAIVER: I am aware that t .e Licensee aces nor nave me insurance coverage or its suostantial ecutvalenAt as`@-
auved dy Massachusetts General Laws. and that my signature on :n:s oermtt acolicauen waves this reduirement. Cw er '�
i (P!ease cnecx one)
etecncne No. PiERMIT F==
(Signature of Cwner or Agenti `�7O'