HomeMy WebLinkAboutMiscellaneous - 136 OLD FARM ROAD 4/30/2018 136 OLD FARM ROAD
210/035.0-0046-0000.0
Date..151-\.�A.\5�.............
` O�r►ORTIy
TOWN OF NORTH ANDOVER
V PERMIT FOR WIRING
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This certifies that -tp CP 0 S
............................................................................................................................
has permission to perform ............. '.. tC ..........
wiring in the building of.....:.....I ''1 - .^.............................................................................
at ....... ........�A.0. .... .............P4,' .. ........,North Andover, ass.
Fee. ? .,.....,,,.,Lic.No '�L
,X�LL ELECTRICAL INSP OR
Check# 0
a Official Use Only
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ePar ment o�,}ire �ervice9 Permit No.
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07) (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: }`/ `1 O�S'
City or Town of: 1VO T IJ fiN'D0V� To the Inspector of Wir
By this application the undersigned gives notice of his or her intention to perform the electrical w cribed belo� V
Location (Street& Number) IS& 047) I=AAp1 / 04p
Owner�u,%W irt�VlN /I•j/>�?-�i� elephone No.215-'015"'2(v+4
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No (Ch k Appropriate Box)
Purpose of Building 47MMG4� F'/3/ 14Y' p,D(, 4&1NG Utility Authorizatio No. ��„
Existing Service 200 Amps l'l O/ 2-$v volts Overhead ❑ Undgrd of Meters J
New Service Amps / Volts Overhead ❑ . Undgrd ❑ No,o ers
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: 111�K/IVIG; RF►AWAX 76 f.INC r/Z)r- DF !!%47 /L
Sockr-To ®ASE or 7Ar- Li1/a cowpocroR,S JB. g.CHfiU i egg Si4ORT- -byF_� GROtJAP
771'r ft
Completion o the following table nia be waived by the Ins ectoro Wires. —
No. of Recessed Luminaires No. of Ceil.-Susp.(Paddle)Fans No,of Total A1VsT 7qv
Transformers KVA
No.of Luminaire Outlets No. of Hot Tubs Generators KVA To Xvp"
No. of Luminaires Swimming Pool Above ❑ In- ❑ o,o mergency Lighting
3 H� W1A?E.
rnd. l4rind. Battery Units
No. of Receptacle Outlets No. of Oil Burners FIRE ALARA4S No.of Zones
• No. of Switches No. of Gas Burners o,of Detection and -
Initiating Devices
No. of Manges No. of Air Cond. TotalTons No.of Alerting Devices
Heat Pum Number Tons KW No.o Self-Contained
No. of Waste Disposers Totals " "" ' """""" ""' """ Detection/AtertinIZ Devices
No. of Dishwashers Munici al
e s Space/Area Heating KW Local❑ ❑ Other
Connection
No. of Dryers Heating Appliances K1V Security Systems:*
No.of Devices or Equivalent
No. of Nater No, of No.of
Heaters KW Data Wiring:
Signs Ballasts No.of Devices oi- Equivalent
No.
Telecommunications Wiring:
Ilydromassage Bathtubs _ No: of Motors Total HP No.of Devices ot•Equivalent
OTHER:
1 _
1V_D Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: �I�IoQLi0®6 (When required by municipal policy.) �4)�
Work to Start: J I MJ)y 2015 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
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 exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE E&/BOND ❑ OTHER ❑ (Specify:)
i certify, under the pains and penalties ofperjury, that the irtforination on this application is true and complete.
FiRM NAME: .31 A N'T'EPOS I , T-&l LIC.NO.: �'737 •
Licensee: UAIJ AP A, R#Aitk"D f 'i Signature LIC.NO.. -3,06/6
(If applicable, enter "exempt"in the license number line.) Bus.TCI.No.: 81-8 P d 691
Address: +] FOAES`T Ph-fibt �R1Vk' j�/A�l'r�lM MdSS 024-Sa Alt.'fel.No.: "a� `71
Per M.G.L. c. 147, s. 57-61,security work requires Department of Public Safety"S" License: Lic. No.
O\VNER'S INSURANCE 1VAIVER: I am aware that the Licensee aloes not have the liability insurance coverage nonnally
required by law. 13), my signature below, I hereby waive this requirement. i am the(check one) ❑ owner ❑owner's agent.
Owner/Anent
Signature Telephone No, PER/IIT FEE: $
9
The Connnonwealttt of Massachusetts
Depail-latent of Industr•ialAccidents
_ I Congress Street, Suit,,, 100
— Boston, MA 02114-2017
yc
www.tnass.go v1dia
Workers' Coinpens.ation Insurance Affidavit:Buildat's/Contractors/Electricians/Plumbers.
TO BI's FILED WITH THE PERMITTING AUTHORITY.
A))licant Inrm
foat:ion Please 11rint. I e-,ibly
Name (Business/Organization/Individual):B. A. Piantedosi; Jr, Master Electrician #A7375
Address: 7 Forest Park Drive
City/State/Zip:Waltham, MA 02452-0309 Phone #:(781) 891-6887
Are you an employer?Cl:eck the appropriate bax:
1.E] I am e employer with * Type ofproject(1'Cgl.11l'CCI):
employees(full and/or part-time). 7, [] New COIlStI'uCtiOn
2.F,(j I am a sole proprietor or partnership and have no employees working for me in $, Remodeling
any capacity.[No workers'comp, insurance required.]
3.®I am a homeowner doing all work myself.[No workers'comp. insurance required.]t 9• ❑.Demolit.ion
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 ❑ Building addition
ensure that all contractors either have workers'compensation insurance or are sole I LR]Electrical repairs or additions
proprietors with no employces.
5.7 I an,a general contractor'and 1 have hired the sub-contractors listed on the attached sheet. 1.2.❑Plumbing repairs or additions
These sub-contractors have employees and have workers'comp, insurance.t 13.F]Roof r'epair's
6.❑We area corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§I(4),and we have no employees.[No workers'comp. insurance required.]
"Any applicant that cheeks box#1 must also fill out the section below showing their workers'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.
TContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
cmployccs. If the sub-contractors have employces,they must provide their workers'comp.policy number.
f am an emplOver that is providing workers'compensation insurance for my employees. Below is the po/iety anti,job site
information.
Insurance Company Name:
Policy#or Sell-ins.Lic.4:
Expiration Date:
Job Site Address: 136 Old Farm Rd. City/State/Zip:N. Andover, MA 01845
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fne 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 this statenlent may be forwarded to the Office of Lnvestigations of the DIA for insurance
coverage verification.
/do hereby certify under the pains and penalties of peijuiy that the inforniation provided above A true and correct.
Signature: Date' May 4 2015
Phone#: (781) 891-6887
Official use only. Do not write in this area, to be canpleted by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Cleric 4. Electrical Inspector S. Plumbing Inspector
6. Other
Contact Person: Phone 11:
t
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'individuai,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary, supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial, .
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accident's. 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
y 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 burn leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number: r
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
y .COMMON WEALTH OF MISSACHUSE�'TS COMMONWEALTH OF MAaACHUSTTS
aoARD,:Cf ANS § ;
irL.£ R ICIANS
_ Pyr - ffi f
4 '
ISSUESTHE FOLLOWING 1 1 C CSE I 55 YE' TRE 1 bLLOW i NG Lt`I CENSE ASA
AS A`�REG .JOURNEYMAN El:'Edt-IdC'I ASI p " REG I SyTER D MASTER ELECT
xi
aERN # D A, i ANTEOOS I sJR ' ! BERNARD
7 EOR' 5`CxR FOREST: PARK DR W
WALTHAM MA 02452 0307 ;,j `ALTIi , MA 02452
:.. .4
20616 E.; 07/31/ <6 292.74 1 '7375. a o7/31JI6 x29273
m5Zr
The Massachusetts EI'ectricai ,
Contractors-Association -
.�. •� ..CF3 , 4 d,tn�'i' I
� &slMt(ahed
\1
"You are bound together for one cam that is to help
' each other-,to help the industry and to help yourself' 1
`wry Membership ID: 10272
11°''' • ,r B.A. Piantedosi, Jr. Master Electrician ,
TEL:(781)891-6887
i
B. A. PIANTEDOSI, JR.
CONTRACTOR/MASTER ELECTRICIAN#A7375
ECTIOW
01 ECT
MEMBERSHIP NUMBER:
BERNIE PIANTEDOSI 7 FOREST PARK DRIVE
OWNER WALTHAM, MA 02452-0309 2076865
D• 4
I
Date
. �j Le
Town of North Andover
Your permit has been sent back to you for the following reasons:
1) Check amount incorrect
2) No copy of current license
3) Insurance Binder not on file or expired /
4) No Workers'Compensation Insurance Affadavit Form
Please call with any questions 978-688-9545.,Fax 978-688-9542
Workers'Compensation Form and Schedule of Fees can be found on the Town of North Andover
Website under Building Department.
Mailing Address:
1600 Osgood Street, Building 20,Suite 2035, North Andover, MA 01845
}
)
{ +"� Office Use Only
014f Ilummunw ato of lassar4usttts Permit No.-
i9epartmeut of public *nfetq Occupancy,& Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 iso peeve blank)
7M
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code, 5277fCA 12
/
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date 1
(X* or Town of NORTH ANDOVER To the Inspector of Wires:
The udersigned applies for a permit to perform the electrical work described below.
01
Location (Street & Number)
uumber) 136 00 %X1M 'AD
Owner or Tenant ADa.IrnS
Owner's Address caMI C
Is this permit in conjunction with 4 building permit: Yes No ❑ (Check Appropriate Box)
Purpose of Building Dwti111rJG Utility Authorization No.
Existing Service Amps Volts Overhead ❑ Undgrnd ❑ No. of Meters
New Service Amps — I Volts Overhead ❑ Undgrnd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work SUN rOl m
No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total
KVA
No. of Lighting Fixtures Swimming Pool Above In-
grnd. ❑ grnd. ❑ Generators KVA
No. of Emergency Lighting
No. of Receptacle Outlets I No. of Oil Burners Battery Units
No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones
i No. of Ranges No. of Air Cond. Total No. of Detection and
tons Initiating Devices
I —
No. of Disposals No.ot Heat Total Total
Pumps - Tons KW No. of Sounding Devices
No. of Self Contained
No. of Dishwashers Space/Area Heating KW Detection/Sounding Devices
No. of Dryers Heating Devices KW Local ❑ Municipal ❑Other
Connection
j No. of No. of Low Voltage
j No. of Water Heaters KW Signs Ballasts Wiring
No. Hydro Massage Tubs No. of Motors Total HP
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES C' NO _ 1
have submitted valid proof of same to the Office. YES = NO :: If-you have checked YES, please indicate the type of coverage by.
checking the a propriate box.
INSURANCE BOND ` OTHER (Please Specify)
(Expiration Oats)
Estimated Value of Ele trical Work $ �
Work to Start '` Inspection Date Requested: Rough Final
Signed under the TPenalties of perjury: 13.11
FIRM NAME L'J h0-1 i, ckfS G LIC. NO.A
Licensee Lty'LWL4 M\Sht1 Signature LIC. NO.F 0
Bus. Tel. No.SO?361.'610S'6
Address 'i C0.014t ro 0 JNVC –F ` Swt Alt. Tel. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as re-
quired by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent
(Please check one) +\
Telephone No. PERMIT FEE $
(Signature of Owner or Agent)
x-6565
�Y Date.l...�.........—.��7...
: 12 074
NORTH
TOWN OF NORTH ANDOVER
o - p PERMIT FOR WIRING
,SSACMUSEt CJ.
This certifies that ' .....
has permission to perform_ ---. ....,............. . ... !lr�+-r-r
wiring in the building of.....................
at............................................................................... ,North Andover,Mass.
FeeT��......... Lic.NA.A- .............. .. .......... . ...........................
ELECTRICAL INSPECTOR t4
WHITE: Applicant CANARY: Building Dept. PINK:Treasurer �'
r
k
__ The Commonwealth of Massachusetts '1I``Ce UseOnl o(
__ Prrrit RoDepartment of Public Safety
Occupancy 6 Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS R 1200 3/90 (leave blank)
APPLICATION FOR PERMIT TOP7 FORM ELECTRICAL WORK `
All work to be performed In accordance With the Massachusetts Electrical Code. S27 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date 4, -- /,j — 9,�—
City or Town of _4La6LlyG&_ To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number) le
AL a lal f jr—ew X0,0
Owner or Tenant 13,1 L
Owner's Address f�
Is this permit in conjunction with a building permit: YesEll"No ❑ (Check Appropriate Box)
Purpose of Building leL 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 /!J erex1nV �Qyt
No. of Lighting Outlets No. of Hot Tubs o. of Transformers Total
KVA
No. of Lighting Fixtures SwimmingAbove In-
Pool grnd. ❑ grnd. Generators KVA
No, of Receptacle Outlets No. of Oil Burners No. of Emergency LightingBattery Units
No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones
No. of Ranges Total No. of Detection and
g No. of Air Cond. tons Initiating Devices
No. of Disposals No. of pumps Total Total Tons KW No. of Sounding Devices
No. of Dishwashers Space/Area Heating KW No, of Self Contained
Detection/Sounding Devices
No. of Dryers Heating Devices KW Local Municipal
11 ❑Other
Connection
No. of Water Heaters KW No, of No. o Low Voltage
Signs Ballasts Wiring
No. Hydro Massage Tubs No. of Motors Total HP
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws
I have a current Li i1ity Insurance Policy including Completed Operations Coverage or i substantial
equivalent. YES NO ❑ -1 have submitted valid proof of same to this office. YES or
❑
If you have ch ed YES,tplease indicate the type of coverage by checking the appropriate box.
INSURANCE BOND ❑ OTHER ❑ (Please Specify)
Expiration Date
Estimated Value of Electrical Work $
Work to Start Inspection Date Requested: Rough la,t/1 6C/ Final
Signed under the penalties of perjury:
FJRM NAME / ?t},-?LC�r4 il/ LIC. N0. EJaZJ'J
Licensee !
SignatureLIC. N0.
Address �U y,NW 1?" 4r?' ,� �/Jyv/ Bus. Tel. No.
{{Alt. Tel. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub-
stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit
application waives this requirement. Owner Agent (Please check one)
Telephone No. PERMIT FEE $
Signature of Owner or Agent
M Do Not Write In Here
3
D
N For Electrical Inspector Only
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4 Street and No.
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DName ...........................................................
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Electrician ....................................................
PermitNo. ....................................................
Comments ....................................................
r�
"Na �
r' - � � tr $ Date........��..,/..f..�.l....9:�
NOR71� "
TOWN OF NORTH ANDOVER "
PERMIT FOR WIRING
• o� >'•• � LLVVDD
V
fM
This certifies that .....Cs.!Z. ......................................
has permission to perform ........�,�. 1 c)...�........... az :.. -s":.............................
wiring in the building of.....�1f'�: G �.5............................. -
..... .... ..........................
co
0
at......./..�✓.....°.....U.. ti.eil.....jl..0............. .North Andover,Mass.
l=,�s �
2
Fee.. . ...:.<........ Lic.No....�....... . . ..........................................................
r ELECTRICAL INSPECTOR
C q s� Js . Uv
WHITE:Applicant CANARY: Building Dept. PINK:Treasurer
t
Location
No. 1 Date /*
NORTM TOWN OF NORTH ANDOVER
0
E p Certificate of Occupancy $
Building/Frame Permit Fee $ —
Foundation Permit Fee $
Other Permit Fee $
Sewer Connection Fee $
a i Water Connection Fee $
TOTAL $
Building Inspector
L 6 3 7 06/11/98 09.27 81.00 pRib, Div. Public Works
Location 4/1 U- �—
No.
� � Date
TOWN OF NORTH ANDOVER
n Certificate of Occupancy $
} Building/Frame Permit Fee $
lids',•.°
"us Foundation Permit Fee $
JACE
Other Permit Fee $
Sewer Connection Fee $
Water Connection Fee $
TOTAL $
Building Inspector
05/11/98 09:27 81.00 PAID
Div. Public Works
itiiiT NO. APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 2
MAP t40.L?3� LOT NO. 2 RECORD OF OWNERSHIP (DATE BOOK PAGE
ZONE I SUB DIV. LOT NO ;
F I —
LOCATION PURPOSE OF BUILDING , {/
OWNER'S NAME •'3r t l f PAY-, /1 la,S NO. OF STORIES SIZE
OWNER'S ADDRESS / / _ DiA qa'c� aj O BASEMENT OR SLAB
ARCHITECT'S NAME l� SIZE OF FLOOR TIMBERS IST 2ND 3RD
BUILDER'S NAME �^� i/ �S n (U _ SPAN / / ..
DISTANCE TO NEAREST BUILDING �' DIMENSIONS OF SILLS
DISTANCE FROM STREET `�O POSTS
DISTANCE FROM LOT LINES- SIDES g�,j REAR ! C+ GIRDERS
AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS
IS BUILDING W SIZE OF FOOTING x
19 BUILDING ADDITION MATER:AL OF CHIMNEY
IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER
BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER
IS BUILDING CONNECTED TO NATURAL GAS LINE
INSTRUCTIONS 3 PROPERTY INFORMATION
LAND COST
SEE 60TH SIDES
EST. BLDG. COST
PAGE 1 FILL OUT SECTIONS I - 3 EST. BLDG. COST PER SQ. FT.
PAGE 2 FILL OUT SECTIONS i - 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 I QI a
�1 BUILDING INSPECTOR
SIGNATURE OF OWNER OR AUTHORIZED AGENT G
F E E r OWNER TEL
PERIAIT GRANTED
CONTR.TEL l V ��
V 15
CONTR.LIC.# -010330 JUN
H.I.C.It
1
1j
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 t
the applicant and/or landowner from compliance with any applicable or requirements.
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MAN-11- FILLS OUT -1`111 IS SCC T R1{V�'�,rrt:hr,rr:r*ar,t*zr*ar**ter
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APPLICANT (�A� a- (�)L),- �fjPrw�S PHONE 2-z
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LOCATION: Assessor's ld�aN ..U.��.,er PARCEL
SUBDIVISION OLd 64t LOT(S) ovy b
STREET QL-D FA,2 M (U ST.s:UMBER (3k
USE
�YIEIVNAiIui a OI i OWN Al r-IN 1 j: -
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CONSERVATION ADMINISTRATOR DATE APPROVED (o S
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COMMENTS -
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TOWN PLANNER DATE APPROVED
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FOOD INSPECTOR-HEALTH DATE APPROVED _
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SEPTIC INSPECTOR-HEALTH DATE APPROVED
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^DATE REJECTE^v
COMMENTS
PUBLIC WORKS -SEWERIWATER CONNECTIONS
r% MAN/ I-E:MIT
FIRE DEPARTMENT
RECEI.EV:BY Bi;IL✓ING 111\J1�ECTV1n� Dnl�.
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506JECT TO E:A5E I,IEII 15 or RCK10RD.
tot CO of�ERATIVE g,•IJK orCotic and Its title lnaurerat I hereby certlfl that I
bat• isutdn" the prsdaea and that all bull
they do oontor• to the &ontol by l
dlnjs ars loest•d on the ground u •hoandve, d teat
( ) eu• When constructed, I also certify that this
property Is �Of located In the flood hsrard vee,
tIJ'ttt tkla e•rllUeslloo is hued ss the purr•y corkers of others, and does not represent
an selual surrey. for worttsae purposes only,
�lA 01
7 p++
!e. t4ORIIIERN ASSOCIATES, IMC,
t 13
11 6AtlAnu WAr.lwwnfr+ct.us otury te, 91$1110 e.lull 0
4fol�It*�o�
L
elk o�.��oeeaa�ueeA�
NOME IMPROVEMENT CONTRACTOR
Registration 118204
Type - PRIVATE CORPORATION
• EXPI.ration . 02/12/99
FAMILY POOLS 6 PATIOS INC
-7! RN WIGGIN
s BROADWAY
"DA !T LAWRENCE MA 01843
'(�J097t4)tdlZll/P,CLf/"J- Ow"I'(ciJJ,zfII�JPIIJ
t DEPARTMENT OF PUBLIC SAFETY
h
i CONSTRUCTION SUPERVISOR LICENSE
Number f,.' . Expires: Birthdate:
i4
I CS811331 /1/1911999 /11911960
Restricted fio: IB
WILLIAM C POULOS
92 S BROADWAY
LAWRENCE, NA 11843
°.�i.�n+n+noKuealu4�!'Jl�ae�aa4.,a�rra
NOME IMPROVEMENT CONTRACTOR
Registration 118204
Type - PRIVATE CORPORATION
Expiration 02/12/99
FAMILY POOLS 6 PATIOS INC
• I.IAM C. GIANOPOULOS
9 'l BROADWAY
AD"nMstanTon LAWRENCE MA 01843
,OV21/1998 15:46 16178465108 ELLIOT WHITTIER PAGE 02
DATE 0601100
o..... .>,.k s.>. .i.w.s...t. Lo.Ogx:,. s 2s:.>:.k.,:�.r..,:x- k:.rs:,aS.>;ik <:«'ii:•kw-G Z:x y;. A :_;:k
e
e4 ., w >• _ - s• > .3. �'��. 0�
• 1`: C '' ,c <wsw s::. >R= lRS4 F>!R>rr::e, kn 'fol.>��
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMA710N
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE '
ELL10r,111rNRYIER,NARDY A ROY HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
Answanos, Apnor be. ALTS W
sy Pahmi Street I COWANIES AFFORDING COVERAGE
/lathm MA 02152
COMPANY
A CNA INSURANCE COMPANIES
019UFO COMPANY
Eamlr reel A Rana Ca., hTe. a TranperbtJen in*. Co.
92 South Broadway COMPANY
Lawrence MA CIT43 C Tranieentfnenrof Tet. Co.
COMPANY
0
:6: :x:i':"'�
:;:>...:s.......< :>.a.e.e. ..-iR{:.,:o.a.>:>.::>.... .�.-.•. Z. ¢ kS....!
.... .........c..s:i�::>:<:>:::5;.:i::i:s•2%"1'> ,.... ..- ...R...i tw>e:.-xw<:,.R.:>.:Lk.r...>:w::es:s....,.. ..... .. .l. �:"s�aEi:e•;;
.d.e:::L>::..n(✓:•<,..<!.:a!:+... w,.e:k.k.a a.x..ac>.w.w.a ya.R.ke.>.s::a:,.. .1 S!wr.w..{.i xe.e.F?.n.,x:.:o:t.:a:r.�i:c.i.t::f:e:-:i.k�f: .:..
.s...sf:;
:•cv.>......v.........aa,
Wk
THIS IS TO CERTIFY THAT THE POUCIES 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 POUCIES. LIMITS SHOWN MAY MEN REDUC BY PAID CLAIMS.
00 TYPE OF INSURANCE POLICY NUMBER POLICY WFECTa POLICY EXVIRATON LIMITS
LTR DATE (W/DDAN) DAT! IMM1DOfM
C GENERAL LIABILITY 0164095968 12/3.1/97 12/31/98 GENNAL AGGREGATE i 1,000,000
X CQWmTIAL GENERAL LIABLITY PRO%ICT8-COMP/OP AGG i 1,000,000
CLAIMS MADE 7 OCCUR PERSONAL d ADV"JURY i 500,000
OWNER'S L CONTRACTOR'S PROT EACH OCCURRENCE i 500.000
FIRE DAMAGE(Any We ft) i 50,000
MED EXP&I aft psimoM i 5,000
B AUTOMOBLE LIABILITY 3038607 12/31/97 12/31/98 COMBO"S"G.E LIMIT i 1,000,000
ANY AUTO
ALL OWNED AUTOS BODILY MAW i
X SCHEDULED AUTOS
(F*f per—)
X HIRED AUTOS ODDLY"JURY i
X NON-OWNED AUTOS RP•f mcid-Q
PROPERTY DAMAGE i
OARAM LIABILITY AUTO ONLY-EA ACCIDENT i
ANY AUTO OTHER THAN AUTO ONLY!
i
EXCESS UABLITY EACH OCCURRENCE i
UMBRELLA FORM AGGREGATE i
OTHER THAN UMBRELLA FORM i
WORKERS COMFLtfMT1oN AND x WC STATV- 0T4
_......... ..... ....::.:..:....:
BAPLOVERS'LLMLnY 6942897 12/31/97 12/31/98 EL MH ACCIDENT i 100,000
THE PROPRIETORf X
PARTNER9MCUTIVE INCL 13 DISEASE-POLICY LIMIT t 500,000
OFFICERS ARE: EXCL EL DISEASE-FA EMPLOYEE i 100,000
OTNER
DEtSCRIP110N OF OPMTIONSILOCATIDNSNEHICLES5KCiAL ITEMS
_W�: w:<:
:;:C_<vw:: :.:.
If :e w4a iY s•R, F C^� �{(��1R:*!!lf�:Lixitx<<>>se•<�ia,np R x x > wak,RR.,T><ys.c RR9}dsie f
i>1.w.AMLi1�l1:•wx.>ewaw�.a.ox..w.......,..>.......�....'S}.....?�:i��S';
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPWUtON DATE TNEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAR.
20 GAYS WRITTEN NOTICE TO THE CERTFCATE HOLDER NAMED TO-THE LEFT,
BUT FALURE TO MAR.SUCH NOTICE SHALL IMPOSE NO OSLIGATKXN OR LINKRY
OF ANY KIND UPON lK COMP02ITS AGENTS T
AUTHOROW RBPREBENT
Gall P. Do►ea
Tk3'sss[��>�Risa::;iii>:..3[':F'>•M:.:<>i:<>< :. ......:. .. rs..): w:.Rr:
i•i L i4 R.i-ZR! -.: Mix:> .' SR Zf,:,aaa> x •{ !''R!''$f!'••f•.•,,�uRxh,.A<f
I 9
BILL OF
_T
C
8-8'Plain Panels(08-009-5) L a
34'Plain Panels(08-016-5) 71
2-2'Plain Panels(08-018-5) LE F G H J K J
4-2'Radius Corners(08-141)
11-Turnbuckle Braces(08-214) SIZE[=IS6'1.
A B C D E F G H J K" L
1-Steel Hardware Kit(08-204) 32' 16' 32' 8' 3'4" 8' 14' S'6" 1 4'6" 4'6" 7' 4'8"
B. 4' 1-16x32 Straight Coping Set 6"Radius(10-001) KPI TYPE O•NON DMNG
1-2'Radius Coping Comer Set(10-138) PMsmat PAN 16' 32' S'6" 3'4" 8' 14' S'6" 4'6" 4'6" 7' 2'2"
1-Vinyl liner(see options below) ADJUSTABLE TURNBUCKLE BRACE
STEP OPTIONS ACRYLIC FIBERGLASS
8F 6'Step-Remove 1408-009-5)8'panel and TURNBUCKLE
1408-016-5)4'panel. Insert 1-(01-006)6'step,
2-(08-017-5)3'panels and 1-(08-214) PANEL I
* turnbuckle brace.
4, 8'Step-Remove 1408-009.5)8'panel and
TME
1-(08.016-5)4'panel. Insert 1-(01-002)8'step, �A
2408-018-5)2'panels and 1-(08-214)
turnbuckle brace.
2`VERMICULITE •''• '�
STEEL PANEL OPTIONS OR SAND
S' 4'
Replace 4-8'plainpanels(08-009-5)with: co►x.RErE STAKE
1-8'skimmer panel(08-011-5) F9oTER
2-8'inlet panels(08-010-5) 6 aEPTH MN.
1-8'light panel(08-012-5) COPING LAYOUT
e' 4'
2' 3.
NSPI TYPE 11
VINYL LINER OPTIONS
8' (0
9"
2' 3'
8' iu
4' TOPAZ STERLING STONETITE
(03103-2) (03-P03-2) (03-03-2)
NON DIVING LINERS Attention Dealer. It is your responsibility to see that the safety package provided by FWP is delivered to pool owner and that the
H-6(03-R40-2) 1-8(03-P40-2) S-14(03.N40-2) NO DIVING warning labels are properly installed.
THIS DOCUMENT IS FOR ILLUSTRATIVE PURPOSES ONLY. FORT WAYNE POOLS®,INC.,510 SUMPTER DRt
(
ADDITIONAL NOTES FWP makes only those representations which are stated in its written STERLING® FT WAYNE,IN 46804 USA (219)432-8731
i to 900 amt al corners. These dig dimensions comply with the National Spa and Pool unmz A y other represen at ons,statements,or contracts made ��LS
p Institute suggested minimum standards for residential pools. by the eater contracN,to the customer regarding any materials DRAWING N1.1-11M
• If diving boards or slides are to be used with these pools please Produced by FWP are attributable to the dealer/contractor only. The
consult the manufacturers instructions and the National 5 &Pool dealer or contractor who sells or installs your pool is on independent o F T.1 n i c x s s T 0 U A U T r STR-006
Spa contractor and is not an agent or employee of FWP The construction
m bearing capacity of ndin P.S.F. 3.Excavation shall be 2'larger than pool all around. Institute's minimum standards prior b installing diving boards or methods illustrated here are suggestions and apply only to normal DATE TITI.
=least 6"above surrounding Fill voids under bate of panels and lamp well. slides on the se pools. For information concerning N PI minimum ground conditions.There may be additional precautions and/or MAY 16'y 32'
4.Backfill with non-expansive material. standards,write: National S &Pool Institute,2111 Eisenhower methods of construction.The responsibility is the contractor's. 1995 I�Js f,
Avenue,Alexandria,VA 22314•703/838-0083 RECTANGLE 2 RADAIS
COPYRIGHT 1903,FORT WAYNE POOl30,INC.
OORT
Town of over
L
No. 2,3 3
* Zdover, Mass., 9 .199,
0 LAKE ^ T
9A.COCNICN EWICK
V
.9� �qA T.E
BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT................................ 1...(...(..... ................. .. . ..!`1'1.. .........................................................
fbo I Foundation
has permission to erect..................1' kgs on...../..26. D-Lb. .......F,4- ..lyl..........' .. Rou h
S� /U c N 1J O Chimney
to be occupied as.....................................���.......�........................�.�'...�..L(...................��....... ....................... y
provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final
this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of
Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS
ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION STAR9Uf1IN Rough
............................ Service
... . ..... .... . ......... ........
G INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Display in a Conspicuous Place on the Premises — Do Not Remove F nagh
No Lathing'or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector.
Burner
Street No.
Smoke Det.
3 APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MUSS. PAGE 1
p. 3� I LOT NO. O d SQ 2 RECORD OF OWNERSHIP JOATE BOOK PAGE
T
SUB DIV. LOT NO. F D
'ION PURPOSE OF BUILDING
S NAM[ 3;t f P Au,, Adams S NO. OF STORIES SIZE `7
S ADDRESS 13& `jT--t—o, - of ^v. p, BASEMENT OR SLAB
ECT'S NAME 'V LlSIZE OF FLOOR TIMBERS IST 2ND / 3RD /J
R'S NAM[ A SPAN _ � 39 V( /\ lI 1.a.,l�J
CE TO NEAREST BUILDING �� I DIMENSIONS OF SILLS
CE FROM STREET / S� fi POSTS
CE FROM LOT LINES— SIDES 1O V REAR /_ 'I" GIRDERS
F LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS
.DING W SIZE OF FOOTING x
.DING ADDITION MATER:AL OF CHIMNEY
.DING ALTERATION IS BUILDING ON SOLID OR FILLED LAND
UILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER
OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER
IS BUILDING CONNECTED TO NATURAL GAS LINE
3 PROPERTY INFORMATION
INSTRUCTIONS
LAND COST
>TH SIDES EST. BLDG. COST /ASS
I FILL OUT SECTIONS I - 3 EST. BLDG. COST PER SQ. FT.
EST. BLDG. COST PER ROOM
2 FILL OUT SECTIONS I - I2 _
SEPTIC PERMIT NO.
RIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY
HED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
19 FILED
BUILDING INSPECTOR
TORE OF OWNER OR AUTHORIZED AGENT G
i OWNERTEL/ 12-13
T GRANTED CONTR.TEL
Iti CONTR.LIC.t 01 0330
H.I.C.1 ` a
j
3 APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1
ILOT NO. c o y(� 2 RECORD OF OWNERSHIP (DATE (BOOK iPAGE
SUB DIV. LOT NOT. �-
'ON PURPOSE OF BUILDING
I NAME 13,i I f P ov-, /lae,,,S NO. OF STORIES SIZE
I ADDRESS / i O(� �4rf�M nd �, 1• A p, BASEMENT OR SLAB
CT'f NAME 10��1 I� 'y L,hy^, SIZE OF FLOOR TIMBERS IST 2ND / 3RD `_
"f NAME A 1'_•. L.`r 7(S SPAN --- 3 [ A if �n ^Ya.� kV 1,
E TO NEAREST BUILDING �� DIMENSIONS OF SILLS
:E FROM STREET /So -r POSTS
:E FROM LOT LINES— SIDES G� REAR /_ C t GIRDERS
LOT o FRONTAGEv HEIGHT OF FOUNDATION THICKNESS
)ING W SIZE OF FOOTING X
)ING ADDITION MATER:AL OF CHIMNEY
)ING ALTERATION IS BUILDING ON SOLID OR FILLED LAND
IILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER
DF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER
IS BUILDING CONNECTED TO NATURAL GAS LINE
INSTRUCTIONS 3 PROPERTY INFORMATION
LAND COST
fH SIDES EST. BLDG. COST
FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT.
V EST. BLDG. COST PER ROOM
FILL OUT SECTIONS 1 - 12
SEPTIC PERMIT NO.
IC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY -
IED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
ILEO l (/
BUILDING INSPECTOR
URE OF OWNER OR AUTHORIZED AGENT
�- OWNERTEL/ IZ73
GRANTED CONTR.TEL/
v iB CONTR.IIC.t 010330
H.I.C.f1 D Y
i
Date.. ..a"�...'I.`./.....
t NoarM,
3?�•'r�`� "�o� TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that .............. ........ . ......... ..................
has permission to performer .. X ... .�...t ...................................................
wiring in the building of...... :....... -"-e ..--................................
. � .... ... N//��o//..�'((rth wAndover Mass.
.. .y. ............. 1�.....�-•-
Fee.- �... ....... Lic.No.............. .... <<- ...... ..
. . ..........
Check #
f/�--._ELECCRICAL INSPECTOR
�J v
5151
Official Use Only
Permit No.
OFE COWWO90MEALW Off'5W"AG7WSEAS
Department of Public Safety Occupancy&Fee Checker:"
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00
r
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR F00
(Please Print In ink or type all information) j Date ? v
To the Inspector of Wirer.
Town of North Andover
The undersigned applies for a permit to perform the electrical rk deschDeed below.
Location(Street&Number o
Owner or Tenant e
Owner's Address
Is this permit in conjunctions with a buildi g permit Y 0 No (Check Appropriate Box)
Purpose of BuildingrJ 1 l Utility Authorization No.
EAsting Service Amps its Overhead 0 Undgmd U No.of Meters
New Service Amps Voits Overhead 0 Undgmd 0 No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work
Total
No.of Lighting Outlets No.of Hot fuse No.of Transformers KVA
yy Above 0 In 0
No.of Lighting Fixtures Swimming Pool gmd 0 gmd 0 Generators KVA
No.of Emergency Lighting
No.of Receptacles Outlets No.of Oil Burners Battery Units
No.of Switch Outlets No of Gas Burners FIRE ALARMS No.of.Zone
Total No.of Detection and
No.of Ranges No of Air Cond Tons Initiating Devices
Heat Total Total
No.of Di sal No. Pumps Tons KW No.of Sounding Devices
No./of Self Contained
No.of Dishwashers S ce/Area Heating KW Detection/Sounding Devices
0 Municipal 0 Other
No.of Dryers Heatinq Devices KW Local Connection
No.of No.of Low Voltage
No.of Water Heaters KW Signs Bailases Wiring
No.Hydro,Massage Tuds No.of Motors Total HP
OTHER:
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
1 have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES C% NO C
have submitted valid proof of same to the Office YES C` NO C` ve YES piease indicat the of verage by checking the appropriate box
INSURANCE 0 BOND 0 OTHER C, (Please Specify) ��� U� . �S �� J /I
Estimated Value of Electrical Work$ ( prrati n Date)
Work to Start Inspectio Dat esquested Rough Final
Signed underthe Penalties of peryu y
FIRM NAME � C��i LIC.NO. 3-3
Licensee /,j Signature f LIC.NO. /
s.Tel No. �O 2
Addres04/d&wml�
Tel.No.
OWNER'S INSURANCE WAIVER: I am awahat the Licenses es not have the insurance coverage or its substantial equivalent as required by Massachusetts
General Laws.And that my signature on is permit application waives this requirement. Owner Agent (Please Check one)
Telephone No. PERMIT FEE $ O2�
(Signature of Owner or Agent)
z a The Commonwealth of Massachusetts
Department of Industrial Accidents
I d Office of Investigations
.1 W
F
Boston, Mass. 02111
5�1b Workers'Compensation Insurance Affidavit
Name Please Print
Name:
Location:
Cily Phone #
I am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
I am an employer providing workers'compensation for my employees working on this job.
Company name:
Address
Ci : Phone#:
Insurance Co. Polite#
Companyname:
Address
Ci!y: Phone#:
Insurance Co Policy#
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to$1,500.00
and/or one years'imprisonment-as-well-as-civil,perialties in the.form da-STOP WORK_ORDER.and_a fine-of_($1A.0.D0)aiday against-me. I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature Date
Print name Phone#
Official use only do not write in this area to be completed by city or town official'
City or Town Permit/Licensino
❑ Building Dept
❑Check if immediate response is required ❑ Licensing Board
❑ Selectman's OfficE
Contact person: Phone#.. ❑ Health Departmen
❑ Other
IT NO. A If= APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE
MAP +40. 0,35 LOT NO. 0 L 2 RECORD OF OWNERSHIP JDATE BOOK *.PAGE
ZONE r I SUB DIV. LOT NO.
I
LOCATION ` Ok 1 PURPOSE OF BUILDING
OWNER'S NAME !""]►. I A .t�s l�(� NO. OF STORIES
OWNER'S ADDRESS 1 M p BASEMENT OR SLAB
ARCHITECT'S NAME C SIZE OF FLOOR TIMBERS IST 2ND 3RD
BUILDER'S NAME 6"r, SPAN
DISTANCE TO NEAREST BUILDING �UUI V1. DIMENSIONS OF SILLS o�
DISTANCE FROM STREET 1-3 u i " POSTS �1
DISTANCE FROM LOT LINES-SIDES ( REAR 1 "'f " " GIRDERS _mob
AREA OF LOT A FRONTAGE\ c3-1 HEIGHT OF FOUNDATION L4 THICKNESS 1
IS BUILDING NEW No SIZE OF FOOTING x
19 BUILDING ADDITION �/ MATERIAL OF CHIMNEY ��..•
IS BUILDING ALTERATION i N,` IS BUILDING ON SOLID OR FILLED LANDSo L7
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER ['
S
BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER f
IS BUILDING CONNECTED TO NATURAL GAS LINE
INSTRUCTIONS 3 PROPERTY INFORMATION
LAND COST
SEE BOTH SIDES
EST. BLDG. COST
� ICJ00 .:
PAGE 1 FILL OUT SECTIONS 1 - 8
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
I
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
I
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
DATEILED
BUILDING INSPECTOR
SIGNATURE OF OWNER OR AUTHORIZED A NT
I
FEE OWNER TEL.AI �g ��-�3
PERMIT GRANTED CONTR.TELA' 5-3 3
19
CONTR.LIC.# �S 3 O
H.I.C.# �J')
Gam"
r
BUILDING RECORD
1 OCCUPANCY 12
SINGLE FAMILY S ORIES 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 _ 3 I 2 I3
CONCRETE BL'K. PINE _ _
BRICK OR STONE HARDW"D
PIERS PLASTER
_ DRY VJALI —//►h'
3 BASEMENT I AREA FULL FUII FIN.. B'B'M'T' AREA _
!/. r/I % FIN. ATTIC AREA _ -
NO B M'T FIRE PLACES _
HEAD ROOM MODERN KITCHEN
4 WALLS 9 FLOORS
CLAPBOARDS B 1 2
DROP SIDING CONCRETE �_
WOOD SHINGLES EARTH _ 1_
ASPHALT SIDING HARD��'D
ASBESTOS SIDING COM1dCN _
VERT. SIDING ASPH.TILE
STUCCO ON MASONRY _
STUCCO ON FRAME
SONRY ATTIC STRS. & FLOOR _
BRICK ON FRAME
CONC.OR CINDER BLK.
STONE ON MASONRY WIRING
STONE ON FRAME
SUPERIORPOOR _
ADEQUATE NONE
5 ROOF 10 PLUMBING
GABLE 14.1 HIP BATH 13 FIX.►
GAMBREL MANSARD TOILET RM. 12 FIX.)
FLAT SHED WATER CLOSET
ASPHALT SHINGLES LAVATORY
WOOD SHINGES KITCHEN SINK
$LATE NO PLUMBING
TAR & GRAVEL STALL SHOWER
ROLL ROOFING MODERN FIXTURES
TILE FLOOR
TILE DADO
6 FRAMING 11 HEATING
WOOD JOIST PIPELESS FURNACE
FORCED HOT AIR FURN.
TIMBER BMS. &COLS. STEAM
STEEL M. &COLS. HOT W'T'R OR VAPOR
WOOD RAFTERS _ AIR CONDITIONING
RADIANT H'T'G
UNIT HEATERS
7 NO. OF ROOMS AS
OIL
B'M'T 2nd _ ELECTRIC
lft 13rd NO HEATING
OR
t
Town of _ Andover
No. � m
3
* /9 19`/
o _ �, dover, Mass.,
NICHE WICK a�1•
I '9 Cq r.�PP�v
�IrED
I S BOARD OF HEALTH
i
` PERMIT T D Food/Kitchen
i
Septic System
f BUILDING INSPECTOR
THIS CERTIFIES THAT...........................................E/....U............. .D. '}.. ..5.....................................................
Foundation
has permission to erect.........AQ L1D/V.. buildings on .........I3..ro 0.4LD 5A.RM. `wy Rough
to be occupied as..........................................................:��.azb m... C Chimney
provided that the person accepting this permit shall in every respect confor 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
ELECTRICAL INSPECTOR
UNLESS CONSTROCTION ST
1
Rough
............................. ...
B G INSPECTOR Service'
• Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Display in -a Conspicuous Place on.the Premises — Do•Not Remove Rough
Final
it No tathino or Dry Wall To BeDone
FIRE
Until Inspected and :Approved by the Building Inspector. DEPARTMENT'
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�1 ORTC(A(' r, 105FLCTIOd PLOT PLAN
LOCATED IN : 00, A0VOVERi, MA, DEGp BK.ii3z PG, n
BUYCR APA M:5 00.
PAT r- MARC 0 11, 1987
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SUBJECT TO r-AtF- Fdj, OF REGORv.
To: 6O-01"EF�ATIVE B?/JKof o
C deOgPand its title ineureral I hereby certify that I
have s=eamed the preaisee and that all buildings are located on the ground as shown, and that
they do ( UII ) conform to the a0ning by lave rhea constructed.
property is Or looted in the flood hazard area. I also certify that this
iR71E1 This certification is based on the survey snrkera of others, and does not represent
an actual survey. For mortgage purposes only.
0!
S
NORTHERN ASSOCIATES, INC.
11 BALLARO WAY,LAWRENCE.IAA 01843 TM.9757118 Y'179�t 0
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IFORM 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:
APPLICANT: <z ,.,.5 Phone b 33
LOCATION: Assessor's Map Number Parcel
Subdivision 01 � -( A✓Lw, Lot(s)
Street 0 (64 :L_La-, `�� St. Number 13 �
************************Official Use Only************************
MMENDATION$. OF TOWN AGENTS:
Date Approved " f
Conservation Adihnistrator Date Refected
Comments Q. 4-P JA 1°"
Date Approved
Town Planner Date Rejected
Comments
Date Approved
Food Inspector-Health Date Rejected
Date Approved
Septic Inspector-Health Date Rejected
Comments
Public Works - sewer/water connections
- driveway permit
� a
r Fire Department
Received by Building Inspector Date
r
310 CMR 10.99
Farm 2
OU'Re No. RDA
(To oe orovded by DEP)
City town North Andover
Commonwealth
' OW of Massachusetts Aoc)hCant Pam Adams
_ 6/20/97
Date Aecueet Tied
136 Old Farm Road
NEGATIVE Determination of Applicability
Massachusetts Wetlands Protection Act, G.L. c. 131 , §40
From NORTH ANDOVER CONSERVATION CC^ItiISSION Issuing Authority
To
Pam Adams Same
(Name of person making request) (Name of property owner), y,
136 Old Farm Road Same
Accress No. Andover, MA 01845 Address
This determination is issued and delivered as follows:
by hanc ceiivery to person making reauest on - (date!
by certifies mall. return receipt requested on 7/3/97 P205 946 490 (date)
Pur,5uant to the authority of G.L. C. 131 . 64C. 'he North Andover Conservation Commiss rn
has consieerec your request for a Determination cf Aeciicaoility and its succorting documentation, and has
mace the following eeterminauon (check wnicnever!s acciicable):
136 Old Farm Road
Location: Street Address
Map 35 Parcel 46
Lot Number:
1. The area described below, wnich inciuces all/oart of the area described in your recuest, is an
Area Subject to Protection Uneer the Act. Therefore. any removing, filling, dreeoino or
altenne of that area requires the fiiir: of a Notice of Intent.
2. = The worK cescrlce^_ below, which Inc,'.ces all:cart of the worK described in veur recuest. is within
an Area Suciect to Protection Uticer 'he .mac'and will remove. 91. dreege or alter 'hat area. There-
fore. sac work recuires the filing of a NcLce of Intent.
Effective '1/10189
3• The work described below, which includes ail:part of the work described In your recuest, is within
the Buffer Zone as defined in the reaulatfons. and will alter an Area Sublect to Protection Under
the Act. Therefore. said work reouires the filing of a Notice of Intent
This Determination is negative:
1 • n The area described in your request is not an Area Subject to Protection Unoer the Act
2. The work described in your reauest is within an Area Subject to Protection Uneer the Act. but will
not remove. fill• dredge, or alter that area. Therefore, said work noes not recufre the filing of a
Notice of Intent.
3, The work described in your recuest is within the Buffer Zone. as defined in the reculations. but will
not alter an Area Subject to Protection Unoer the Act. Therefore. sato worn aces not reeuire ine
filing of a Notice of Intent. Schedule pre-construction inspection with Conservation
Department upon installatio of ero ion control.
4. _ The area described In vour recuest Is ubject to�rotecticn Unoer the Ac'. but since the work
oescrtbed therein meets the reeuirements for the toiiowmc exemotion.as soeciifed In ine Act and
the regulations, no Notice of Intent is reauirec
Issued by NORTH NDOVER Conservation Commission
Signatures)
3 t
This -termination must be signed by a majoniy of the Conservation Commission.
On this 2nd cav of July ° 97 be'--re me
personaiiy apoearec
Scott Masse to me known to be the
�
person described in. ano who executed. the !creccing insirument, anc acKnovvlecce� t"ai he•she executes
the same as his�ner free act and need
December 11, 2003
Nctary Public My commission exotres
This Determination cogs not relieve the ac Dncant irc",G:, ,c'vinc war'.ai'Clner to='-`a' state c,lona'statutes .. cman_es
Dy-taws or regufauons This Determination shall De vai:c to,inree years form the Gate of issuance
The aADlican;.ine ow'nel.any Derson aggrieved Dy this De!e--nination. any owner c:lane aouninc the ianc upon wnic^the crocGSsec went,.
ks to De cone.or env ten resioents of the city or town in vni=r.such ianc is iocatec.are nereGy ncufiec o'their nc fc revues:ine Decartmer:
of Environmental Profecuon to issue a Suoerseeino Determination of ADDlicaoilnp,orovieinc the recuest is mace ov cerviec man or nano
oeirvery to the Deoartmen:,with the aDOrconaie filino fee end Fee Transrninai Form as orov oed in 310 CI-AR 10M i within ten Gays from
I"date of t5suance of this Determination.A cody of ine recuest snaii at the same time De bent Dy.cerldieo mail or nano denvery to the
Conservation Commission and the anOhcant.
1 L-2l~
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Ctol
LOCAtCD IIJ IJO. AODO\/ER,
1.� pt;Li? BK.Ig32 PG. 51
Pi.o.11 IJ o. �9i7
6uY CR AnA11, 6K. P4
DAT I'1ARL►� 11, X98
Y
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PERMIT NO. APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1
MAP d40. LOT NO. 2 RECORD OF OWNERSHIP jDATE BOOK ;PAGE
ZONE I SUB DIV. LOT NO.
LOCATION / Cco Q PURPOSE OF BUILDING Hpv A ZOP,-
OWNER'S NAME , NO. OF STORIES SIZE
OWNER'S ADDRESS �.. BASEMENT OR SLAB
ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD
BUILDER'S NAME `�'oyl„z SPAN
DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS
DISTANCE FROM STREET •• POSTS
DISTANCE FROM LOT LINES-SIDES REAR GIRDERS
AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW �CJ SIZE OF FOOTING X
IS BUILDING ADDITION MATER:AL OF CHIMNEY
IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE yei IS BUILDING CONNECTED TO TOWN WATER
BOARD OF APPEALS ACTION. IF ANY JT` IS BUILDING CONNECTF TO TOWN SEWER
IS BUILDING CONNECT TO NATURAL GAS LINE
INSTRUCTIONS 3 PROPERTY INFORMATION
LAND COST
SEE BOTH SIDES EST. BLDG. C08T �` 0400
PAGE 1 FILL OUT SECTIONS 1 - 3
EST. BLDG. COST PER 8Q. FT.
EST. BLDG. COST PER ROOM
PAGE 2 FILL OUT SECTIONS 1 - 12
SEPTIC PERMIT NO.
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS I
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
DATE Fl.
Eq r.
BOARD OF HEALTH
WNER OR AUTHORIZED AGENT
FEE r'
PLANNING BOARD
PERM IST,-ZR.ALITED
19
BOARD OF SELECTMEN
BUILDING INSPECTOR
BUILDING RECORD
1 OCCUPANCY 12
SINGLE FAMILYs;ORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM
MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES, GA-
APARTMENTS I RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN.
CONSTRUCTION
2 FOUNDATION _ 8 INTERIOR FINISH
CONCRETE _ B 1 2 I3
CONCRETE BL K. PINE
BRICK OR STONE HARDW D
PIERS PLASTER
_ DRY WALL _
UNFIN.
3 BASEMENT
AREA FULL FIN. B'M'T' AREA _
1/4 1/1 '/, FIN. ATTIC AREA _
N_O BM'T FIRE PLACES _
HEAD ROOM MODERN KITCHEN
4 WALLS I 9 FLOORS
CLAPBOARDS B 1 2 3
DROP SIDING CONCRETE _
WOOD SHINGLES EARTH _
ASPHALT SIDING HARDW'D _
ASBESTOS SIDING _ COMMON
VERT. SIDING ASPH.TILE _
STUCCO ON MASONRY _
STUCCO ON FRAME
BRICK UNMASONRY ATTIC STIRS. & FLOOR _
BRICK ON FRAME
CONC. OR CINDER BLK.
STONE ON MASONRY WIRING
STONE ON FRAME _
SUPERIOR
POO
ADEQUAATE I-1 NONE
rj ROOF 10 PLUMBING
GABLE I HIP BATH (3 FIX.) _
GAMBREL MANSARD TOILET RM. 12 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. &COILS. _ STEAM
STEEL BMS. & COLS. _ HOT W'T'R OR VAPOR
WOOD RAFTERS _ AIR CONDITIONING
RADIANT H'T'G
UNIT HEATERS
GAS
7 NO. OF ROOMS Oil
B'M'T 2nd _ ELECTRIC
1st 13rd NO HEATING
Date....3
-l4w.
:"oot
TOWN OF NORTH ANDOVER
0
PERMIT FOR WIRING
,SSACMUSES
This certifies that ...
....................
bd5
has permission to perform .....
wiring in the building of.......
.............. ... ................ ............................
,at....../....30 G)Alifle No Andover,
......................,
Fee-0.............. Lic.No,4/60
EECTRICAL MpEcrOR
Check #
5100
1' Official Use Only \,
Permit No. !O
D�od?�arEi!tc Sa�cty Occupancy&Fee Checke#O
BOARD OF FIRE PREVENTION REGULATIO `527 CMR 12:00
APPLICATION FOR PERMIT TO P FORM ELECTRICAL WORK
All work to be performed in accordance with the M chusetts Electrical Code 5527 CMR 12:00
(Please Print in ink or type all information) Date Mo rCX 1Q 04
To the Inspector of'A res:
Town of North Andover
The undersigned applies for a permit to perform the electrical work described below.
Location(Street&Number �LJ J ;=5/ r 111 F0 cz ID
Owner or Tenant l �� dj2 rl-t 55-
Owner's Address S/�-/►1 E
Is this permit in conjunction with a building permit Yes 0 No (Check Appropriate Box)
Purpose of Building-/ den P Utility Authorization No.
Existing Service Amps Volts Overhead 0 Undgmd 0 No.of Meters
Nqw Service Amps Voits Overhead 0 Undgmd 0 No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work
Total
No.of Lighting Outlets No.of Hot fuse No.of Transformers KVA
Above 0 In 0
No.of Lighting Fixtures Swimmina Pool gmd 0 gmd 0 Generators KVA
No.of Emergency Lighting
No.of Receptacles Outlets No.of Oil Burners Battery Units
No.of Switch Outlets No of Gas Burners FIRE ALARMS No.of Zone
Total No.of Detection and
_No.iff Ranges No of Air Cond Tons Initiating Devices
Heat Total Total
No.of Diposal No. Pumps Tons KW No.of Sounding Devices
NoJ of Self Contained
No.bf Dishwashers Space/Area Heating KW Detection/Sounding Devices
0 Municipal 0 Other
No.of Dryers Heating Devices KW Local Connection
No.of No.of Low Voltage
No.of Water Heaters KW Signs Bailases W',O*
No.Hydro Massage Tuds No.of Motors Total HP
OTHER:
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
(9�
Liability Insurance Policy includin -pleted Operations Coverage or its substantial equival YES- NO
valid proof of same to the O fi NO s If you have checked YES please indicate the type of coverage by check ng the appropriate box.
BOND v OTHER . (Please Specify)
10!/ (Expiration Date)
Estimated Valu of FI�ct� l Work$
Work to Start c� Inspection Date Resquested Rough Final
Signed under the Pe atttes per' ry: / /
FIRM NAME n - O �1 `I �?G CA S /f i+1 P C /1 S LIC.NO.41i7,5150
Licensee /r/-f ll P/" ` IV/04/ Signature t LIC.NO.__l✓a�✓/�/
1 � { Bus.Tel No. 7VI '6 2
Address
/ /rl/1 td/l'>" ��0✓�l' /'Vj� Alt Tel.No._ 7 fl `/y 7 P Ir 9
OWNER'S INSURANCE WAIVER: 1 am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts
General Laws.And that my signature on this permit application waives this requirement. Owner Agent (Please Check one)
Telephone No. PERMIT FEE $ .
(Signature of Owner or Agent)
AiftLl The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers'Compensation Insurance Affidavit
Please Print
Name:
Location:
City Phone
F1
am a homeowner performing all work myself.
F-1I am a sole proprietor and have no one working in any capacity
I am an employer providing.workers' compensation for my employees working on this job.
Company name: 4,
Address t
City Phone#:
Insurance Co Policy#
Company name:
Address
r
City Phone#:
Insurance Co Policy#
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00
and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of($100.00)a day against me. I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do herby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature Date
Print name Phone#
Official use only do not write in this area to be completed by city or town official' ❑ Building Dept
[]Check if immediate response is required Building Dept ❑ Licensing Board
❑ Selectman's Office
Contact person: Phone#.• ❑ Health Department
❑ Other
FORM WORKMAN'S COMPENSATION