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Miscellaneous - 145 JOHNSON STREET 4/30/2018 (2)
145 JOHNSON STREET / 210/097.0-0030-0000.0 I NORTH 0Twn of 6Andover o dover, Mass.LAKE , COCMIC EWICK yet• RATED BOARD OF HEALTH Food/Kitchen .PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT........4,'O'r`� ;,FG ....el�2 i�� ........................ . ............................................................ Foundation has permission to erect........................................ buildings on ../� ........ ? !.✓4!.,faw....L)..E............................. Rough to be occupied as.........................&Ae-6..... ' . :.t�.....Z)-a.e)l .....���P Chimney provided that the person accepting this permit shall in e ry respect conform to he 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. I e--rzj PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations-Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION AHTS Rough ........ . .... ...............:.......................... Service BUIL G INSPECTOR Final r Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street Na SEE REVERSE SIDE Smoke Det. ,� �� Office use Only �# (14t (t:GmmumdUq " ofrim 1.m Permit No: ` 6eIJP tial of ablit Occupancy A Fee Checlad � �,. , BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 3190 (leave blank) 1 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK , All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR,,12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date 4G& or Town of NORTH ANDOVER To the inspector,of Wires: ; The udersigned applies for a permit to perform the electrical work described below. Location (Street & Number) [ AJ H c-OeDC�C Rr,� Owner or Tenant �,�j �''� , Owner's Address N -S 'au ti [� s `Y S Is this permit in conjunction with a building permit: Yes No ❑ (Check Appropriate Box) Purpose of Suilding (jl�`r� f '�lv� 1��1�1Q��C-^ Utility Authorization No. Existing Service 01-00 Amps Voits Overhead `! Undgrnd 71 No. of Meters New Service Amps _J slits Overhead 7 Uncigrno `— � No, of Meters Number of Feeders ana Ampacity W rcLocation and Nature of Proposed Electrical d✓"G �-�— &2 �1 ,Y J w� 10 F-� No. of Lignang Outlets No. of Hot -t---s No. of Transformers Total K„A No. of Lighting Fixtures ( Swimming P= Abover- In- r grna. _ grna. _ I Generators KVA No. of Emergency Lighting, 4, No. of Recectacie Outlets I No. of Oil Burners Battery Units �} <r�n. No. of Switch Outlets I No. of Gas Surners FIRE ALARMS No. at Zones .. No. of Ranges .�, I No. of Air Conc. Tota, No. of Detection and ' fx Ions Initiaung,Devices Heat Total Total ;'S No. of Disposals �^ I No.of Run= Tons KW No. of Sounding Devices ,• No. of Seif Contained No. of Dishwasners �^ I Space/Area Heating KW Detection/Souncing Devices i No. of Dryers r'- I Heating Devices KW Local i ii Municipal —Other Connection No. of « No. or Low Voltage No. of Water Heaters KW I Signs Saihasm Wiring ig No. Hyaro Massage Tubs I No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massacnusetts general Laws » ,, I have a current Liaoi ity Insurance Policy inctuaing Comp!Oiec Operations Coverage or its substantial equivalent. YES NO Z 1 have suomineo valid proof of same to the Office. YES = NO Af you have checxea YES. please indicate the type.of coverage by checking the appropriate cox. INSURANCE = BOND = OTHER = (Please Scecc!y) ` (Expiration Dates ^ Estimatea Value of E!ectncal Work 5i Work to Start Inspection Date Recuestec: Rough Final Signed unser the Penalties of perjury: , FIRM NAMELIC: NO. 40 r ° Licensee Sig.-.azure UC. NO. l � V� V l`F � � BA t. Tel.1. No. A Address No, OWNER'S INSURANCE WAIVER: I am aware that t t_:censee toes not nave trio insurance coverage or its substantial equivalent as re.e quiresby M [ts Gen w ana at signature on :hs permit application waives this requirement. Owns ADent t (Please he ne • . Telephone No. 00 PERMIT FEE S t. igna ure ottivMer or Agents x-o5o8 .. Date........ 7 � M2 HOR7H TOWN OF NORTH ANDOVER 3r ��{ � ''• °C PERMIT FOR WIRING ca • : This certifies that ......\", 1..:... ........�.ta.V L k R...A..............................:..... has permission to perform ..... ........ Edc . .................... wiring in the building of...........4�.�^...!... . ................................................... ........ North Andover,Mass. Fee.... . ..: .... Lic.No. .(fiA .b0.(4'........................................................ ELECTRICALINSPECTOR GES � I("9%/27/9711:49 11:49 15.00 RAID WRITE: Applicant CANARY: Building Dept. PINK:Treasurer Location 14-5 JoN,ys�u 5`T2��/ No. �> y Date w i7 NORTiy TOWN OF NORTH ANDOVER p? •' ` 0 „ Certificate of Occupancy $ _ + Building/Frame Permit Fee $ ,SSACMUSEt Foundation Permit Fee $ 0 Other Permit Fee $ .a Sewer Connection Fee $ Water Connection Fee $ TOTAL $ _ n � 7568 i4 Building Building l�oror e 5 6 8 Div. Public Works PER�i1T NO.-' APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1 MAP KJO. I LOT NO. 2 RECORD OF OWNERSHIP ;DATE BOOK ;PAGE ZONE SUB DIV. LOT NO. - LOCATION ' +5 ��L j A l 5c) 1 C PURPOSE OF BUILDING �/L I X I CY I w(�OD 6 t ,(� OWNER'S NAME lL Lj i �)`C�1 J 14 ` eZp ���� NO. OF STORIES SIZE `-/, OWNER'S ADDRESS j /y`r r' Lj1 +`1pal �.�i�"� BASEMENT OR SLAB ARCHITECT'S NAME l 'T SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME /g� /+� SPAN f DISTANCE TO NEAREST BUILDING P DIMENSIONS OF SILLS DISTANCE FROM STREET 5_0 FF—P-7— POSTS DISTANCE FROM LOT LINES—SIDES _0 +L�,r REAR l '� GIRDERS /O AREA OF LOT �'y!`�/ S F r_ FRONTAGE / HEIGHT OF FOUNDATION Q.�� - THICKNESS IS BUILDING NEW E'IC y� ii1 SIZE OF FOOTING 1 X IS BUILDING ADDITION `[ V MATERIAL 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 BOTH SIDES ST. BLDG. COSTd 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 L �•� D ILED BOARD OF HEALTH SIdNkfLfJtE_0k 001ittR b6i AUTHORIZED AGENT FEE PERMIT GRANTED OW"IFR TEL.N PLANNING BOARD CONTR.TEL.# L9 19 - Crl"ITR l'C. #� � BOARD OF SELECTMEN A '+G6 INC INSPECTOR `l /7�56S L y I BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY STORIES 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 2 13 CONCRETE BL'K. PINE BRICK OR STONE HARDW D PIERS PLASTER _ DRY WALL _ UNFIN. 3 BASEMENT AREA FULL FIN. B'M'T AREA _ '/ 1/7 '/. FIN. ATTIC AREA _ NQ B M 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 HARD"J D _ ASBESTOS SIDING _ COMMCN VERT. SIDING ASPH. TILE _ STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. 8 FIOOR _ BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIOR I--I POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLEHIP BATH (3 FIX.) GAMBREL MANSARD TOILET RM. (2 FIX.) _ FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY __ k 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. 8 COLS. _ HOT W T'R OR VAPOR WOOD RAFTERS AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS IL B'A'T 1TRIC d I NOC 3HE TING own of ori over No. , ;. North Andover, Mass., Odgc M I 1 99 - i BOARD OF HEALTH ! Food/Kitchen PERMIT TO BUILD Septic System a • BUILDING INSPECTOR 1 THIS CERTIFIES THAT........................ ( 0 �7.................................................... Foundation has permission to erect.....t.�ao .L�............ buildings on .............14"s..3. 4Q:;FP Rough 1 t0 be OCCUp18d as..............� .x.�.�1....... 0!ph....�..)05P ....................................................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final U(\J I [ ';`; i ;( f` ; I ( ; y (� I ( '(5 I ` , ` , ELECTRICAL INSPECTOR Rough .................... .... Service BUILDING INSPECTOR ' Final r .-' t 1'i r e z. GAS INSPECTOR C.�i_'treg r���. irr .:, l.�i! i,. ;r.. . . ,. r�( > ------ -- _ Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner PLANNING FINAL CONSERVATION FINAL Street No. Smoke Det. SEWER/WATER FINAL DRIVEWAY ENTRY PERMIT ...•F`. L'. a.r ..`'i°_'b•-�-y ti... .-.='t-...a �.a .... _ :'i.'4-v _'J's'tll\.\ ..c�••:ltii•n'�y-11"�.+!'.,'v:'s vnr 7:-�:•i%'�k. �'4; o.' a)v'K•u•.. f � x o _ f i m y IL _ -i I r o _� j I • Town of North Andover BUILDING DEPARTMENT Homeowner License Exemption (Please print ) DATE JOB LOCATI N Ivi "r)LS V Number Street Address Section of town "HOMEOWNER" Name Home Phone --Work/ Phone PRESENT MAILING ADDRESSf'�t�) City own State Lip code The current exemption for "homeowners" was extended to include owner -occupied dwellings of six units or less and to allow such homeowners to engage an individual for hire who does not possess a license , provided that the owner acts as supervisor . (State Building Code , Section 109 . 1 . 1) DEFINITION OF HOMEOWNER: Person(s ) who owns a parcel of land on which he/she resides or intends to reside , on which there is , or is intended to be, a one to six family dwell- ing , attached or detached structures accessory to such use and/or farm structures . A person who constructs more than one home in a two-year period shall not be considered a homeowner . Such "homeowner" shall submit to the Building Official , on a form acceptable to the Bulding Official , that he/she shall be responsible for all such work performed under the building permit . (Section 109 . 1 . 1 ) The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other applicable codes , by-laws , rules and regulations . The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he e will,"m -ly w' h said procedures and requirements . HO:,;EO�, VIER' S SIGNATURE APPROVAL OF BUILDING OFFICIAL Note : Three family dwellings 35 ,000 cubic feet , or larger , will be required to comply with State Building Code Section 127 . 0, Construction Control . 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 JL i &1 1'f 2'�ccXL<F� Phone _6 9-6 , LOCATION: Assessor's Map Number Parcel Subdivision Lot(s) Street 6 q_,_ 0614 WSCI flit- �_ St. Number ************************Official Use Only************************ RECOMMEN TIONS OF TOWN AGENTS: _ -,_ Date Approved _/ Q - 1 -`� nse ation Adm' istrator Date Rejected Comments Date Approved Town Planner Date Rejected Comments Date Approved Food Inspectors-Health Date Rejected G�2�U Date Approved eptic Inspectors-Health Date Rejected Comments ~_:�)G Public Works - sewer/water connections - driveway permit Fire Department Received by Building Inspector Date N 0 R T 0 A 6 E INSPECTION PLAN ' City/Tovn_Nc='T-4_ANL)b`,1EV-State . NA Bate: `j_Z`1_9Z____-- Scale: I = y0 -------- --- ----- ------ ----- '' Owner:__GROCK EF— --------- Buyer s------ IA__------ Deed Ref. bK- 3oo4 P6.2S4 Plan No. 3-7o$ Drawn per City/Town of____ N A ____ Tax Assessors Map. q } S�Eo �``�A OF Mq JOHN 3't It F. CD McO KIN, 9 N P J 4( LAH�S It 5� I N ' 9 t N 50LLIVAtl AFA = 41� (c25� 5•�• �dt�d) • loy.s� -7Z . y To: _ t4 Do N V�i-------------------------K. - --- - ------------ ----- - I hereby certify that the above Mortgage Inspection Plan was prepared for use in convection with a new Aortiale and is not Intended or represented to be a property line or land survey. It cannot be used for establishing fence, hedge , ualis or building lines. No responsibility is extended herein to the land owner or occupant. The location of the original building(s) as shown herein was in compliance with the local applicable zoning bylaws in effect whom constructed, with respect to horizontal dimensional requirements, or is exempt from violation enforcement action under Nass G.L. Title VIi, Chap. 40A, Sec. 71 unless otherwise shown herein. Subject building(s) lies in a flood zone designated Zones: � and shown on FIRM map Community-Panels-----25005 8_---Colo d Oated:___jQ-1 y _ Job No. DEVELOPMENT CO9 23 2. ---- ---- ------------------------- --- -- - JCD, INCORPORATED, LAND USE Q CONSULTANTS 4 AUTUMN LANE, NETN=t NA OIB44 509-693-9932 S Cll\ © �- � z PER)t1T No. v APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 MAP -NO. LOT NO. �D 2 RECORD OF OWNERSHIP DATE BOOK 'PAGE ZONE I SUB DIV. LOT NO. I 1 LOCATION L P (,�� 410 H N^� PURPOSE OF BUILDING OWNER'S NAME A / �.� l[G(`�C�� � NO. OF STORIES SIZE j OWNER'S ADDRESS`i vV„��t^ �+ BASEMENT OR SLAB ARCHITECT'S NAME ^tel/7i P SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME p / t1 /+ IfQ/-��,� SPAN DISTANCE TO NEAREST/BUILDING 4�•`y+ DIMENSIONS OF SILLS -+ POSTS DISTANCE FROM STREET , DISTANCE FROM LOT LINES-SIDES REAR GIRDERS AREA OF LOT FRONTAGE ENEIGHTUNDATION THICKNESS IS BUILDING NEW ._ - NGX IS BUILDING ADDITION CHIMNEYIS BUILDING ALTERATION 13�C1" R�cVcCJla�rN 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 3 PROPERTY INFORMATION INSTRUCTIONS LAND COST i SEE BOTH SIDES EST. BLDG. COST60.11.;--o Q EST. BLDG. COST PER 06. FT. PAGE 1 FILL OUT SECTIONS I - 3 EST. BLDG. DOST PER ROOM PAGE 2 FILL OUT SECTIONS I - 12 SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE 7; ILE ANp PPROVED BY BUILDING INSPECTOR p/ C DATE FILED O —,�q ---- r— L •ULLaING INSPRCTOR SIGNATURE OF OWNER OR AUTHORIZED AGENT - 3 0� DWNER TEL�_ �_ .. IFEE 1 ![KNIT SRATED \ 10ONTR-TEL1 N( __ — 'OON7A.i1C.� - ��,� Town . of North Andover BUILDING DEPARTMENT Homeowner License Exemption 'Lease print) DATE oZ7/, JOB LOCATION C Number Street Address Section of town J - )MEOWNER" 6 6 2 of C l -3S' Name home Phone rk Phone ,,RESENT MAILING ADDRESS ( ��( 50N '5 City Town State Zip code The current exemption for "homeowners" was extended to include owner occupied- dwellings of six units or less and to allow such homeowners to engage an ! individual for hire who does not possess a license, provided that the owner acts as ' supervisor. (State Building Code, Section 109 . 1 . 1) DEFINITION OF HOMEOWNER: Person(s) who owns a parcel of land on which he/she resides or intends to reside , on which there is , or is intended tq. be, a one to six family dwell- ing )-attached or detached structures accessory t.o such use and/or farm :structures . A person whoconstructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form' acceptable to the Bulding Official , that he/she shall be responsible for all such work performed under the building permit . (Section 109. 1 . 1) The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and .other applicable codes , by-laws , rules and - regulations . Phe undersigned "homeowner" certifies that he/she understands the Town of ,orth Andover Building Departme^t minimum inspection procedures and ,�quirements and that he/she will comply wi h said procedures and equirements . iOMEOWNER' S SIGNATURE ',PPROVAL OF BUILDING OFFICIAL ,Dote : Three family dwellings 35 ,000 cubic feet , or larger , will be required to comply with State Building Code Section 127 .0, Construction :�ntrol . _ _ pc�•3�,y U r10R Ty Jf T0VM Of _ - over No. 430 9ANWICK, _cocLti1� dover, Mass., 19 97 LAKE �9S �qq-w D P BOARD OF HEALTH Food/Kitchen PERMIT T Septic System BUILDING INSPECTOR THISCERTIFIES THAT............ -..... t..�...........G. „ac 1�.e... .................................................................................. Foundation has permission to erect.....R.:f!WO t...Y$��Auildings on ........ ........... c / 3 �C� .!:�..5�.......v............................... Rough to be occupied as.......... t.rn..� c 1............��..ec.7 't�� Chimney .......................................................................................................... . provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION TARTS ELECTRICAL INSPECTOR Rough ........................... ........... ......................../..... ..... Service B LDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough No Lathing or Dry Wall To Be Done Final Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner Street No. R--tq t �* 00 6-9{ Smoke Det. c-k a- l t a - sews (Print of Type) FVR PERMIT TO DO QASFITTINQ NORTH ANDOVER 3Je Maas. Date I � � tg� Building Qle �GJ^ Location_ r)6l S&,( S+ Permit #— Y Owner's Name _ New p Renovation p Replacement Plana Submitted:. Yea Q No p TIE* C fA n ac h z tl J M W O v !- Z 0 M '4 a• a = O /- W t d M F- at M O a zW NN !� V r t i h A M 30 y r ! X < M se r rdG I � tt 'w i s F� J 1- i I 'i e S �, o u° a° a sue—asMT. RAREMANT IRT FLOOR ' !ND FLOOR I SADFLOOA TF 4TH FLOOR STH FLOOR I � RTH FLOOR 7tH FLOOR t RTH FLOOR Installing Company Name art ell Check one: Certificate Address Q Corp. d Partnership .� p Firm/Co. Business Telephone (0�� =3"j'?� -_ Name of Ucensed Plumber or Gas Fitter INSURANCE COVERAGE: I have a current liability Insurance policy or Its substantial equivalent. ' Yes one If you have checked "ea, please Indicate the No p type coverage by checking the Rppropriate box. A liability, Insurance policy bit Other type of Indemnity D god p OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage require]byy Chapter 142 of the Mass, General Laws, and that my signature on this permit application waNea this requireme Check one: %nature of Owner or Owner's Agelit Owner p Agent O 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 m knowledge and that all plumbing work and Installations performed under the Perm Issued for Ihla Y pertinent provisions of the Massachusetts State a:s Uode and Chapter 142' the Al� application will be In compliance with all Tko0ausmn f Ucense: Trib ber gna ure o w n um er or as oIor ller CIh,/lown asterLicense Numberurneyman K T 1`10'VED(OFFICE USE ONLY) y r �! Date X . ...... . ..... A NORTH TOWN OF NORTH ANDOVER pf � ". '6.. to PERMIT FOR GAS INSTALLATION t • M a i � • s o + SSACHUSEt M O This certifies that . . . . �!r. ;I X 0 S, , , , . . , .,~ o, has permission for gas installation !4-. (. . . . . . . . . . . O 0 in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at North Andover, Mass. Fee. . . :. .: . Lic. No.. . . . . . . . . . . . . . GASINSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer MASSACHUSETTS UNIFORM APPLICATION:FOR•PERMIT-T000'Pi.UMBiNO (Type or Print) te NORTH ANDOVER ,Mass.!" } ."Date: •l d L ' Building Location Permit � .. Owners Name IA 1 CVLpcfcg w " New Renovation Replacement RJ Plans Submitted 0 ` FIXTURES ' � . I z h» x x a ' lA hn O Z > N Z N Q ¢ a = h Z p O Z a h •* O ... W I !- W al Q1 S Q h V W N Q p d z cc a. t7 Q < tL W N Fa'. W d [� < J to ¢ tZ -1 p tC 'q y"'t. a i tW V d Y a 2 x. Y a O ~ Y _Y �[ W st: !C W d t- > 1- O N N O N F- z o O 0 _. W f O d d Z _. d d O d .t .a d cc <t: oG < O < H k > 3 Y -J All ao o a ..r 3P x F H tL v o o < 3 a m Q SUB—BSIOT. •. i Y BASEMENT i 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR �•,. STH FLOOR + �� 6TH FLOOR ; 7TH FLOOR STH FLOOR I (Print or Type) f r Check one: Certificate :i�., Installing Company Name C.k Y0- Start, {- ?I 6� 0 Corp. Address J n( � pr.j rL,Q rtuyS rv; 4q Ll4 10 Partner. L j Firm/Co. Business Telephone L37Z j Name of Licensed Plumber: 6�LIA w j Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy ® Other type of indemnity Bond a Insurance Waiver: 1 , the undersigned, have been made aware that the licensee of 't- this application does not have any one of the above three insurance coverages. Signature of owner/agent of property Owner Agent'-,.0 I hereby certify that all of die details and information I have submitted(or en(ered)in atkive application ate Ifue and ehtnte to die best of my -- - knowledge aad that all Plumbing work and installations performed under Permit issued for this application will be in compliance with all petligept pro,.s visions of the Massachusetts State Plumbing Code and chapter 142 of the General Laws. By Title . Signature of Licensed Plumber City/Town: T e of Plumbing License APPROVED ZOFFICE USE ONLY) License Number El Master Journeyman • Date P2 3504 / pOR7M �0 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . .c.-. . .�./�. . . �.1 . . . . . . . . . . . . . . . ... . . . . . . has permission to perform . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . k�!!. . .'!?e,.,- .�f.- !t. . . . . . . . . . . . at. . k.� . . . . . . . . North Andover, Mass. 1 Fee. .''. }I . .Lie. No... . . �. . . . . . . . . . PLUMBING ITOR 10/10/97 11:03 35,00 PAID WHITE: Applicant CANARY: Building Dept. PINK:Treasurer MASSACHUSETTS UNIFORM APPLICATION-•FOR PERMIT;-TO.D (Type or Print) . . NORTH ANDOVER ,Mass". ; Dater Building Location 45 I41,(Son( 5 fi _ Permit i. Owners Name i b' v New D Renovation Replacement Plans Sybmitted ' F I TURES z Z W N W O) O z N Z Q Q (- Z 0 Z o) IL YI of t.. U W to � d >K t tJi ac in °' vx, w a, a t- N z o a w o a a o• a. "l I0- Fa- W a o) o °1 a c: ..i x o a in 1Ji. a W z 0 54 M O !- Q W IL !L W < _ r a z _x _z a > r o N t z o p w W f' o 0 x < 4 S N N 4 d 0 a .� J a a QC aG O < t� 3 sua—,BSMT. i BASEMENT 1ST FLOOR 2, Z I 2ND FLOOR 3RD FLOOR j 4TH FLOOR STH FLOOR 6TH—FLOOR 7TK FLOOR 8TH FLOOR (Print or Type) Check one: Certificate Installing Company Name CJ--A W Fn�(tit Corp. - Address 3 Oil(; yercS(�, Lr4 Partner. L--j-t-t Lk (4, Firm/Co. Business Telephoned Name of Licensed Plumber: LJY4 VU(6t2W�( Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: i Liability insurance policy ® Other type of indemnity Q Bond L Insurance Waiver: I, the undersigned, have been made aware- that the licensee of { this application does not have any one of the above three insurance coverages. Signature of ownerlagent of property Owner AgeneN o , ",;;i; l hereby ecrti(y that all or the delails and infofnsalion I have subusiticd(or cnlmd)in aM•vc application life time aa4tale to dre best of wy I �• - knowledge aad that all plumbing work and installations Iocffnfnicd undcf rcfuiit 1%sued(of this application will be in cassplianas with all restigoot P60P.4 vowas of the Mamcliusetts State Plumbing Code and Chaptcr 142 of the Genual taws. , By Title - Signature o 'censed Plumber II City/Town- SiType of Plumbing License J 1 I -.___.__ ..__ __.. _.. License Number Master Q Journeymaq Date,/10 iW 3518 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING g ? 9 SSAcMus� (P This certifies that . . . . m 3 . . . . . . . . . . . . . . . . . has permission to perform ..� u!.f -- Vt plumbing in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . >at. � � . . . . . . . , North Andover, Mass. Fee,t I . . . . .Lic. No.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR a WHITE: Applicant CANARY: Building Dept. PINK:Treasurer Office Use Only 9:r The Commonwealth of MassachusettsPermit No. Department of Public Safety Occupancy & Fee Checked_ T&4 BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12U0 3/90 iteavc blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed In accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR E ALL INFORMATION) Date d__ City or Town of To the Inspector of Wires: The undersigned applies for a permit to perform the electrical Work described below. Location (Street & Number) Owner or Tenant O Z 4 6 C Ijy C / Owner's Address W67 S Is this permit in conjunction with a building permit: Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization NOJ a„3 _ 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 � � U1V/JC—er Gi�QCJ1V P S/' i C 9 No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Above In— No. Swimming Pool grnd. ❑ grnd. ❑ Generators KVA No, of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond, Total No. of Detection and tons Initiating Devices Heat Total Total No. of Disposals No. of Pumps 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 ❑Other Connection No. of Water Heaters KW No, of No. of 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 Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES❑ NO 0 _I have submitted valid proof of same to this office. YES❑ NO If you have checked YES,,-please indicate the type of coverage by checking the appropriate box. INSURANCE [A BOND ❑ OTHER ❑ (Please Specify) Estimated Value of Electrical Work $ Expiration Date Work to Start Inspection Date Requested: Rough Final Signed under the penalties of perjury: FIRM NAME LIG NO. Licensee 11(2d1���?—l� JM^J9110signature C. NO. Q,3�p Address—/.;47 _ � ,/4' 6r— �/W=&CC IVA Bus. Tel. No. Alt. Tel. No. ,:f-08' 014NERIS 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 1 i M Do Not Write In Here D N For Electrical Inspector Only M r m n Street and No. _i DName ........................................................... Z Electrician .................................................... PermitNo. .................................................... Comments .................................................... lb Date.................................. 22 7 TH TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING 10 �,SSACMUSEt al This certifies that .. .................. ............. .......... ............................. has permission to perform ....... ...... . . ............................&.................................. wiring in the building of............ ...................... .............................................. at..........I.................................................(.................... .North Andover,Mass. Fee...................... Lic.No ......... ............................................................... ELECTRICAL INSPECTOR 05/26/95 15:34 r 35.00' PAID WHITE! Applicant CANARY! Building Dept. PINK:Treasurer GOLD: File 1' Q BUILDING PE.'--a. OF NORTH w- ED 646•YO TOWN OF NORTH ANDOVER o 5_,,OPPLICATION FOR PLAN EXAMINATION Permit No#:`� Date Received 06 zP116 �.y w°Rwreo�ep�,(5 SSACHUS� Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION N-5 - 5V t-N 5>VtV 1 Print PROPERTY OWNER WILL,t Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑} UUatershed Dastrtct Water/ewer DESCRIPTION OF WORK TO BE PERFORMED: 12� a v�Z 00 V-XIF4�N A-L'- 45T7-)-12 a ucr t,<ufit� !}ted L c\� s,l�-r t✓ Identification- Please Type or Print Clearly OWNER: Name: Wt t,L-1 6T- 1 61. ctg-acy� Phone: 69:6- >R 7 7 Address: S Contractor Name: Phone: Email WN Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $_* to , 0 G O . O G FEE: $ l Check No.: Receipt No.: `t NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Plans Submitted ❑ Plans Waived LI" " Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL e. Public Sewer Tanning/MassageBody Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM LANNING & DEVELOPMENT Reviewed On � Signature I COMMENTS �11 L C�,nQa'GII UI dI�Q lOtAVA JJ)5�' c� bONSERVATION Reviewed on Signature U �J' COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Wafter& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: ART rnp Du - 4 1,F1�REDEP ��� EN,tT3 -`Te mp,�ster ons�t F tYs�, ro ca " F o Osgood Street bocated at'X1241[ t E Main;tSfre t - Fre�De;partentsg�r� ture%dated �tC®MMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANCER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA-- (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits Building Permit Application Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks Building Permit Application Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Mass check Energy Compliance Report (If Applicable) Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Building Permit Application Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 Location No. 1 1,? 110 Date • • TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ r_ Foundation Permit Fee $ Other Permit Fee TOTAL $ �Q Check# Building Inspector V r , NORTI� w: f A- .A . .' ve' .** 0 hA ver, Mass, 6046 ®0 COC MICNt WICN U BOARD OF HEALTH i Food/Kitchen PERMIT T L D Septic System THIS CERTIFIES THAT .. BUILDING INSPECTOR has permission to erect ............ buildings on .145.....T. NAfOi .� Foundation l . Rough to be occupied as�Ip,^& f�l4q�R ! ..... .. .. ��"'�./ .� .� ......... Chimney provided that the person accep ing this permit shall in a ery respect conform to the terms of the application Final on file in 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONS TI N S Rough < ice .. .. .. .......... .. Final BUILDING INSP OR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Dis�,,ay in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. i Smoke Det. i i Scope of Work. Remove old bulkhead from back of house and install new bulkhead on side of house. Set back is 20 feet. House is 33.7 feet from property line. Unit (Type-E) will stick out 95.5 inches. That leaves about 5.7 feet to spare. Remove old bulkhead: • Drill holes in existing opening walls and floor for rebar. • Pour a new basement wall. • Demolish old stair unit to 16 inches below grade. • Drill drain holes in bottom of old unit. • Fill with gravel. • Construct a roof over unit below grade, insulate and water proof. • Fill with dirt and then gravel for last 6 inches to grade. • Repair siding on house. Install new bulkhead: • Dig hole. • Cut hole in foundation wall. • Inspect and repair any existing drain around foundation footing in the disturbed area. • Drill mounting holes in foundation wall. • Apply sealant to vertical face of new unit and install. • Pour concrete around unit to revent saggingover time. p • Back fill. • Landscape. • Install new door in foundation wall. • Install new door on top of unit. • Repair siding on house. DA(SET) 5 83\ vo, ?90S93F SOA' l �� °Ass• `�`�' S AFF LOT AREA �'� s8ti� 45s004 S.F. pN D.H. (FND.) C.B./D.H. (FND.) e� �^p � Q4 �M h All, a ry C.B./D.H. N N (FND.) C.B./D.H. co (FND.) E�1 SHfo .7g H'EA H R-'550.19*_. •- U.P.#3726 61.00. R"-- o SV Tro N3D39'14.. PIPE(FND.) P:\13\13-48\ \DWG PLOT.DWG ?QAD PLOT PLAN p�SNOF4140 y #145 JOHNSON STREET dover �� PDR G�NORTH ANDOVER, MASS. Goo�wiNPrepared for \an on su i tan is ;N o No.48133 i WILLIAM & JULIE CROCKER inc. 9 , SCALE: 1"=40' DATE: 11--5-13 1 East River Place, Methuen, Mass. q( LAN _ 7 t � •. ,tea..? r'. fir' s � a Oro a R&M o v Asa -^�� .«���• . ,Yr v r� st wp Involt AZT 6%know 2,00 y •s"" —w` > :�' :gym. .. .u;. - �.,rrn �a r - _�,.-mow v�-»,�---:. r ,•v ,� n fWq 4731 44 a n i r 4 44 s Y O . In, F ' 1 q r � , ta� aim v g own ms MET 10, r rin '_.-+.—e-.:.�r'a.' ..a�r`�e..•".c�.' �.,.a .�-�'� .,F....,az ' ..®°`.'i...,_�, Fs° �� V �py�k 6, T TYPE—S TYPE—A _ TYPE—B TYPE—C 19 52" 30" 22"T { 74" 1 66" T 6C 68" III 43" IDTH 51�" WI 51!4" WIDTH 55'/z" WIDTH 55'f�" ! FINISHED BASEMENT FLOOR 2" ABOVE BASE OF CASTING TYPE—D TYPE—E } TYPE—F _ 22" I 30"— }f 22"� ____ y8.� i 22" t -"2^ —/WIDTH58" !_ 7WIDTH58" 86" 93" 101" 84" WIDTH 55'/x" FINISHED BASEMENT FLOOR 2" ABOVE BASE OF CASTING ' 18" �MIN� i = 72" 40" .A,B,C,D = 96" � MAX ��E.F = 120" 12" j FOUNDATION. COATING 84" 60" REQUIREMENTS FOR WARRANTY: 1. KEEP FOUNDATION SEALER A MINIMUMF 1 EXCAVATION REQUIRED 0 2 FROM OPENING. 2. POUR A MINIMUM OF A 11 1�" STEP IN BULKHEAD OPENING AS SHOWN. 3. KEEP FOUNDATION OPENING A MINIMUM OF 18" FROM FOUNDATION CORNER. 4. ROOF DRAINAGE MUST BE DIVERTED AWAY FROM BULKHEAD OPENING. HOW TO ORDER: 5, PROPERLY INSTALLED PERIMETkR DRAINAGE TO DAYLIGHT REQUIRED. DETERMINE DIMENSION FROM TOP OF FOOTING TO PROPOSED FINISHED 5. BACK FILL MUST BE CLEAN GRAVEL WELL COMPACTED. GRADE. REFER TO TYPES AVAILABLE AND SELECT SIZE TO ASSURE TOP 7. TOP OF CONCRETE CASTING MUST BE A MINUMUM OF 2" ABOVE GRADE. OF STAIRWELL WILL BE 2" TO 6" GRADE AROUND BULKHEAD MUST SLOPE AWAY FROM FOUNDATION. ABOVE FINISHED GRADE. New Eog/ands Premier Precosler &ISHEA 800-696-7432 (SHEA) BULKHEAD INSTALLATION CL7NCRET 8 PRODUCTS wvwsheoconcrete.com RECOMMENDATIONS 773 Salem Street 87 Haverhill Road 160 Old Turnpike Rood Page: A4.2 P.O. Box 520 P.O. Box 807 Nottingham, NH 03290 rr'w fi Wilmington, MA 01887 Amesbury, MA 01913 bhinstal.dw 12/01/2009 Specifications subject to change without notice A NOTES: 1. CONCRETE: 4,000 PSI MINIMUM AFTER 28 DAYS. 2. HEAVY DOUBLE LEAF STEEL DOORS. 3. OPTIONAL DOOR LOCK AVAILABLE. i HC FN r 39 t1 HA HB 93 4 81,E 4 1 o- I W— L END VIEW SECTION VIEW BASEMENT FLOOR HEIGHT W L HA HB HC WEIGHT ITEM TYPE (WIDTH) (LENGTH) (TOTAL)(PRECAST) (DOOR) LBS NO. S 51 45" 95" 43" 52" 2,400 BH—S A 51 60" 90" 60" 30" 3,600 BH—A B 551h" 66" 90" 68" 22" 4,800 BH—B C 55%" 74" 95'x" 76 19'x" 5,500 BH—C D 55%" 86" 106 84" 22" 6,200 BH—D E 58" 95%" 115" 93" 22" 7,800 BH—E F 58" 104" 123" 101" 22" 9,000 BH—F Jar " SHEA /l/ew Eng/ands Premier Precaster ibi 800-696-7432 (SHEA) BULKHEAD �2-- CONCRETE PRODUCTS www.sheaconcrete.com 773 Salem Street 87 Haverhill Road 160 Old Turnpike Road Page: A4.1 '`` P_0. Box 520 P.O. Box 807 Nottingham, NH 03290 Wilmington, MA 01887 Amesbury, MA 01913 ulkhead.dw 12/07/2006 npcn Specifications subiect to chance without notice i r TOWN OF NORTH ANDOVER o.�,s_ _ _�•°� OFFICE OF _ IBU LDING DEPARTMENT ;�= t 1600 Osgood Street,Building 20, Suite 2035 North Andover,Massachusetts 01845 Gerald A. Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PER—MIT APPLICATION Please print DATE: JOB LOCATION: `F 5 N S ON 'S l Number Street Address Map/Lot HOMED ? �VI�TER 1,y1�t, �,g-�'�I Gt2aGr.CFn2 `� � 68-6 3a72 TK( C13-2 138-A Name Home Phone Work Phone PRESENT MAILING ADDRESS � crLt�� City Town State Zip Code The current " exemption for homeowners was extended to includeowner occupied dwellings we'liin s of one or two family P g Y dwellings and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be, a one-or two-family dwelling,attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner.(780 CMR Section 110.R5.1.2) The undersigned"homeowner"assumes responsibility for compliance with State Building Code and other applicable codes,by-laws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNERS SIGNATURE __�L e� APPROVAL OF BUILDING OFFICIAL Revised 8.2015 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 i The Commonwealth of•Massachusetts Department oflndustrialAceldents 1 Congress Street,Suite 100 T Boston,MA.02114-2 017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE PILED WITH THE PERMiTTMIG AUTHORITY. Applicant Information Please Print Legibly NaMe(Business/Organization/Iridividual): l�``1 C-' l F'j f� H, c-olzo c,-v,-r—,-VZ .A-d&ess: [ i V[j t-� S 01'-j 5 J_V�FBF City/State/Zip: 14-1y 0 cyY� M 0 t 7r,5_ Phone#: OL 72r 6 3-6 3 9,7 7 Are you an employer?Check&e appropriate box: Type of project(required): 1.❑I am.a.employer with t employees(full and/or part-time).* 7, ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 3.F1I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. F1 Demolition 4.5d I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 E]Building addition ensure that all contractors either have workers'compensation insurance or are sole 11..❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ 13.❑Roof repairs These sub-contractors have employees and have workers'comp,insurance. 6. We are a co oration and its officers have exercised their ri t of ' tion er MGL e. 14.❑Other ❑ rP p P 152,§1(4),and Nye have na employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who sub iiit 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 state whether or not those entities have employees. If the sub-coritracors have employees,they must provide their workers'comp.policy number. ]'am an employer that is pi'ovidiiig workers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins,Lic.#: Expiration Date: �? >�� fir-- 0 fi-nlvc)t F,r mA Job Site Address: J -�1 1 S c .I City/State/Zip: j �,5 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 o. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DTA.for insurance coverage verification. I do hereby ify under the ai s d penalties ofperjury that the informationprovided above is true and correct. Si afore: z Date: —,&A L OZC' Phone#: Official use only. Do not write in this area,to be completed by city or town offzciaL. City or Town: Permit/License# Issuing Authority(circle one): ; 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 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 contraAt o 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 enferprise,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 b6 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=contractors)name(s),address(es)and-phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you'are required to obtain a workers' compensation policy,please call the Department•at the number listed below. Self-insured companies should'enter their self insurance license number on the appropriate line. - City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.# 617-727-4900 ext.7406 or 1-877-NUSSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia i North Andover MIMAP May 2, 2016 Q .Q-QQ9S I � Q97.0- OZ9 ~r v d st 5h— 19 , - � K 7 P= a 6� t os7 n-QQ � b e 09= 0033 0 MVPC Be Interstates Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83, —I SR Meters Data Sources:The data for this map was produced by Merrimack — NORTIY Valley Planning Commission(MVPC)using data provided by the Town of Roads QE tt.90 �•1� North Andover.Additional data provided by the Executive Office of i r Easements r s� �� Environmental Affaim/MassGIS.The information depicted on this map is Parcels 3 L for planning purposes only.It may not be adequate for legal boundary WW F to definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER 10 " MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY 4 ' Y OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT • ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF .(r o4-no r� {j THIS INFORMATION ,SSACMIfs� 1"=52 ft � �