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HomeMy WebLinkAboutMiscellaneous - 149 LANCASTER ROAD 4/30/2018 / 149 LANCASTER ROAD J 210/104.D-0158-0000.0 ^-- i PO Box 55098 Boston,MA 022055098 617-951-0600 Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectman City Hall City Hall NORTH ANDOVER,MA 01845 NORTH ANDOVER, MA 01845 RE: Insured: STEVE T CRECHE and SHELLEY CRECHE Property Address: 149 LANCASTER RD.,NORTH ANDOVER,MA Policy Number: HMA 0314272 Claim Number: BOS00060373 Date of Loss: 2/9/2015 Company: Safety Property and Casualty Insurance Company Claim has been made involving loss, damage or destruction of the above-captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 3B is appropriate,please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim number. I Lisa Monette Claim Examiner 5/4/2015 Safety Insurance Company Homeowners Claims Unit P. O. Box 55098 Boston, MA 02205-5098 Phone: (857) 233-8618 Fax: (617) 535-5833 Email: lisamonette@safetyinsurance.com i I PO Box 55098 Boston,MA 02205-5098 617-951-0600 115 201'5 Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectman City Hall City Hall NORTH ANDOVER, MA 01845 NORTH ANDOVER, MA 01845 RE: Insured: STEVE T CRECHE and SHELLEY CHECHE Property Address: 149 LANCASTER RD.,NORTH ANDOVER, MA Policy Number: HMA 0314272 Claim Number: BOS00061181 Date of Loss: 3/1/2015 Company: Safety Property and Casualty Insurance Company Claim has been made involving loss, damage or destruction of the above-captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 3B is appropriate,please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim number. Lisa Monette Claim Examiner 5/20/2015 Safety Insurance Company Homeowners Claims Unit P. O. Box 55098 Boston,MA 02205-5098 Phone: (857)233-8618 Fax: (617) 535-5833 Email: lisamonette@safetyinsurance.com PO Box 55098 Boston,MA WA5-5098— - 617-951-0600 Ail Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectman City Y Hall Cit Hall NORTH ANDOVER, MA 01845 NORTH ANDOVER, MA 01845 RE: Insured: STEVE T CRECHE-and SHELLEY CRECHE Property Address: 149 LANCASTER RD.,NORTH ANDOVER, MA Policy Number: HMA 0314272 Claim Number: BOS00061181 Date of Loss: 3/1/2015 Company: Safety Property and Casualty Insurance Company Claim has been made involving loss, damage or destruction of the above-captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 3B is appropriate,please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim number. Lisa Monette Claim Examiner 5/27/2015 Safety Insurance Company Homeowners Claims Unit P. O. Box 55098 Boston,MA 02205-5098 Phone: (857)233-8618 Fax: (617) 535-5833 Email: lisamonette@safetyinsurance.com Safety Insurance Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectman City Hall City Hall NORTH ANDOVER, MA 001845- NORTH ANDOVER, MA 001845- RE: Insured: STEVE T CHECHE and SHELLEY CHECHE Property Address: 149 LANCASTER RD.,NORTH ANDOVER,MA Policy Number: HMA 0314272 Claim Number: BOS00046003 Date of Loss: 10/27/2014 Company: Safety Property and Casualty Insurance Company Claim has been made involving loss, damage or destruction of the above-captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 3B is appropriate,please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim number. Allan Leavitt Claim Examiner 11/3/2014 Safety Insurance Company Homeowners Claims Unit P. O. Box 55098 Boston, MA 02205-5098 Phone: (617) 951-0600 EXT 3213 Fax: (617) 531-8891 Email: AllanLeavitt@SafetyInsurance.com J, g 3 01994 j CERT/RED FOUN0,4 r10 1V PLAN LOCATED /N Nn R Mn .DING DEPARTMENT SCALE/"= 4n I - 6/9 /94 Scott L. Gi/es R.L.S. 50 Deer Meadow Rood No Andover,Moss. A . I O o LOT 4/ 43, 740 S.F. �. or 42 o ti •• ,F°�'�o LOT 40 52' i —_ R= 350.00 L /50,00 Af�OA� CR ROAD rj / CERT/FY THAT OFFSETS SHOWN ARE FOR THE USE THE OFFSETS OF THE SU/L DING/NSPEC TOR ONLY c SHOWN COMPLY AND SUCH USE/S FOR THE s WITH THE ZONING DETERM/NATION OF ZONING Y 3972 SY LAWS OF CONFORMITY OR NON-CONFORMITY NO.A/VDOVER,MA. WHEN CONSTRUCTED. L uu�g WHEN SU/L T. w 6/9/94 CERTIFICATE OF USE & OCCUPANCY Town of North Andover Building Permit Number 232 Date DECEMBER 16, 1994 THIS CERTIFIES THAT THE BUILDING LOCATED ON 149 LANCASTER ROAD - LOT #41 MAY BE OCCUPIED AS SINGLE FAMILY DWELLING W/3 CAR GARAGE IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. CERTIFICATE ISSUED TO A J Maillet & Sons, Inc. Wescott Rd. ADD S X/A Building Inspector r1 & F f-, • North: Andover Town of No. 232 =' �North "Andover, Mass., w AV` 19 " / r r l � l-l V C K '�V 1� I 4 l �JL BOARD OF HEALTH t PERMIT TO BUILD Food/Kitchen l t y�t�u a„� S•e c.�y t✓ ��0�� �0' I BUILDING INSPECTOR I THIS CERTIFIES THAT........... p 0ex g � �i�• Foundation O n io ; has permission to erect.��1.� ildin s on . . ... . ..�� ... . . .��,��.�.�y� Rough SSS �� Ch mne 7l to be occupied asqf.�t,�llL�� • M........ :i ....... ..e�....�� v r thprovided that the person accepting this permit shall ib ever respect conform to the f 4. is office, and to the provisions of the odes and By-Laws relating to the Inspeft f ,�� In ® i rel 9�1 Buildings in the Town of North Andover. �' PLUMBING I SPECTO VIOLATION of the Zoning or Building Regulations Voids this Permit. �- o DATE�.— . FEE PA f'G G 0 PERMIT FOR FRAME/BU i N, (^ �11 �'� � � ►P {;" )"� r' ELECTWCL I P Rough l� At -0-71 DATE:�._.._FEE PAID:...._. ........... ........:.......... .... Service BUIL NG INSPECTOR ' Fin OCCLIlxmc % ASE 1)11 't 1 cq1 th et, :i.l 1 '•1(44ityl GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Ins ctor, F E DEVARTMEN� -� Burner i} � ��� Street PLANNING C I� I N A L CONSERVATI �N F N L ; s e No. .� /1� � Smoke Det. SEWER/WATER 7:qW —FINAL DRIVEWAY EN RY PERMIT 6 �v Location No. Date NOR7N TOWN OF NORTH ANDOVER Ot i �a° a'�h0 (T1 Certificate of Occupancy $ rr Building/Frame Permit Fee $ Foundation Permit Fee $ v s�CHus�. Other Permit Fee $ (2J Sewer Connection Fee $ f¢ �„3 Water Connection Fee $ Q-1 TOTAL $ Building Inspector }x,94 08.45 2,513.GO PA fl �f Div.Public Works ... �� .. . -.._.-�..��.-:5.-�'`w.-�..Jw'i—. r... r ti c'"W--..•�;,�, mss.— .... �.._. Location No. 3a2 Date NORTH TOWN OF NORTH ANDOVER �r of�T. o , +y � p Certificate of Occupancy $ + •0 d Building/Frame Permit Fee $ _ cHustt Foundation Permit Fee Other Permit Fee , *�, $ '—` z.— Sewer Connection Fee Water Connection Fee TOTAL Building Inspector i ` jt� 7344 Div. Public Works Location � � f_,�!'��,;TC✓ !� No. 3�"' Date MORTq TOWN OF NORTH ANDOVER9 �� • 0 ^' p Certificate of Occupancy $ :a a ; Building/Frame Permit Fee $ .� n+ Foundation Permit Fee $ P Ss� usE Other Permit Fee $ ' $ A/o (o5 7 Sewer Connection Fee $ r V1, >fj,j Water Connection Fee $ ' TOTAL 60 o 4".- S, o'� ilding Inspector I 6976 Div.�P blit"Works y � - _f APPLICATION FOR PERMIT TO BUILD — N RTH A PAGE 1 p. lrifi No.' r� O NDOVER, MASS. � q' t / MAP 4-40. LOT NO. ifj 2 RECORD OF OWNERSHIP ;DATE BOOK ;PAGE ZONE SUB DIV. LOT NO. ) E Y p n _LsZQ LOCAT �A NGAST IG RLJT_ PURPOSE OF BUILDING OW NAME /1 M 6 1 L 1-L- - NO. OF STORIES SIZ OWNER'S ADDRESS3 wL-5�7T , li��„ R rl bo UEdQ i �I�I BASEMENT OR SLAB (l/ ARCHITECT'S NAME �" SIZE OF FLOOR TIMBERS 1ST V /'� 2ND � y'/�J 3RD BUILDER'S NAMEQ ,M4ILJ.YTw"SDlYSI .Z(YG� SPAN �1 l°C it DISTANCE TO NEAREST BUILDING I)/y V DIMENSIONS OF SILLLS� --- DISTANCE FROM STREET p(/ POSTS DISTANCE FROM LOT LINES-SIDES V� �] REAR /d� w GIRDERS AREA OF LOT 4`� r7 4 © s..F, cs� FRONTAGE HEIGHT OF FOUNDATION �i ,( THICKNESS 16 IS BUILDING NEWT ..7 l ^, 0- SIZE OF FOOTING o/ 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 l INSTRUCTIONS 3 PROPERTY IfqFORMATION ��-�-�� r' LAND COST SEE BOTH SIDES f E ,f�� (� EST. BLDG. COST �(j ��f�F PAGE 1 FILL OUT SECTIONS 1 - 3 1 :�_j / C! "C/ EST. BLDG. COST PERL/SQ. FT./ PAGE 2 FILL OUT SECTIONS 1 - 12 c::j 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 BOARD OF HEALTH t SIGN RE OF OWNE R AUTH R Z D AGENT FEEQE d Y ?c2 c) OWNER TEL.#175; /.3 V9 PLANNING BOARD PERMIT GRAN � CONTR.TEL.# 19 1,_ CONTR.LIC.#--Q-I tog I BOARD OF SELECTMEN 9 199- . %} � . BUILDING INSPECTOR 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 I 8 INTERIOR FINISH CONCRETE �yl 3 t 2 13 CONCRETE 81.K. —{ PINE BRICK OR STONE HARDW D — — PIERS — PLASTER — — DRY VJAIt UNFIN. 3 BASEMENT AREA FULL FIN. BM'T AREA _ 1/1 1/7 .'/, FIN. ATTIC AREA _ NO B M FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WAILS I 9 FLOORS r CLAPBOARDS B t 2 3 t DROP SIDING CONCRETE ��_ WOOD SHINGLES EARTH ASPHALT SIDING HARDVJ D ! i ASBESTOS SIDING _ COMMON VERT. SIDING ASPH. TILE _ STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. 8 FLOOR BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING S`717 STONE ON FRAME _ .,,,,.,.s 1d��.. ,,,, ����tt SUPERIOR I� POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE 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 8 GRAVEL STALL SHOWER `- ROLL ROOFING MODERN FIXTURES _ TILE FLOOR LI TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. &COLS. STEAM STEEL BMS. & COLS. _ HOT W'T'R OR VAPOR WOOD RAFTERS AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd ELECTRIC 1st 13rd NO HEATING i 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 f/illss out this section***************** Cy' APPLICANT: _C`` 211 6 le,/ -/ J6 4-5, Phone 2,4 "Y / LOCATION: Assessor's Map Number ParcelJ� t Subdivision Lot(s) �/ q Street4 s .. y/ � St. Number ************************Official Use Only************************ Vne DATIONS F TOWN AGENTS: P/, Date Approved tion Administrator Date Rejected Comments V�(( Q Date Approved Town Planner Date Rejected Comments Date Approved Food Inspector alth Date Rejected Date Approved roved C6 Septic Inspector-Health Date Rejected Comments Public Works - sewer/water connections 6_g-9� driv�ewaay- permit Fire Department Date Received by Building Inspector Date....?.. .. ..... . ....... a p OQTM o= TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION �,SSACHUSE4 This certifies that . `= � . .�-�r-r . . . . ._. fir•+ . has permission for gas installation . . . . . . . . in the buildings/of „ ; . at . . , ' . . . . . . . . . , North Andover, Mass. Fee.:_. . . . . . Lic. � .. . . . . . GA�INSPECTOR Check#�� 6905 FOPP�tASSAChfG�SET`��UNIFO�Rlll l�I�LiCAT'l(�l� FOR PERMIT�'® ®O GAS FIT3'il�G Cltgrt d awn �c�orJ Q r Date: 9/3�0 9 Ferr�it€ Building Locatia _ /�� bt1Acc.'=h:r fZ-ac,A _.___ Owners Name:�k-u4-Z/,a Type of Occupancy: Commercial Educational Industrial Institutional Residential New:: Alteration: Renovation; Replacement:> Plans Submitted: Yes No O Y FIXTURES cc UJ FU re Ir Z tiz W ® w W O r ~ z - �- z (40MOw W W W .� O M UJO O > LLIW O �u� z 0 z LU t� ma z z w z -j 0 W Ca ® ® u. f7 0 � z � O >� � � � z 0 SUS SSMT. BASEMENT x 1 FLOOR 2 FLOOR Vu FLOOR 4 FLOOR 6 FLOOR 6 FLOOR 7 FLOOR 8 FLOOR Installing Company Name: Central Cooling&Heating, Inc. Check One Only Certificate� „ of Corporation. 2806C Address:, 9 North Maple Street City/Town: Woburn State: MA Bu'Mness Tel: 781-933-8288 Fax: 781-932-9017 Partnership Nairne of Licensed Plumber/Gas Fitter:,Mike Bernasconi Firm/Company INSURANCE COVERAGE: I have a current Habil` insurance policy or its substantial equivalent which meets the requirements of MOL.Ch,142 Yes ✓ No If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy V` Other type of indemnity Bond OWNER'S INSURANCE WAIVER: l arat avi'are that the licensee does not have the Insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that nay signature on this permit application waives this requirement. Check One Only Signa of Owner or owner's Agent Omer Agent By checking this box L];I hereby certify that all of the details and Information i accurate have submitted(or entered regarding this to the best l t g a lippli t of m'. Knowledge and that all plumbing work and installations performed under a permit issued PP on are true and compliance with all P for this application Perone P tson will Pertinent provision of the Massachusetts state Plum P be in 9 Code Ch tri 1 o the General Laws. LAPPROVED 7JOFFICEUSE ✓ Type of License: Plumber Gas jitter V 19natu a of L cense Pfau-mi as Master Journeyman License @umber: 15137M OmLY LP Installer FINAL INSPECTION BELOW FOR OFFICE USE ONLY PROGRESS INSPECTIONS) FEE: $ PERMIT# APPLICATION FOR PERMIT TO DO GAS FITTNG f NAME&'TYPE OF BUILDING LOCATION OF BUILDING SKETCH PLUMBER GASFT£TER LP INSTALLER LICENSE NUMBER: PERMIT GRANTED F-1 DATE: GAS FITTING INSPECTIOR 4_ t l The COM11notiwectith of Alassachuseas DeParttarent of Industrial Accidents Office afInvestigations Map#_ Lot# 600 WasilittZ,�rfrxFt Street Address: e`F Boston,MA 02111 Permit# J` W157.mas3'.gt3vIdia Workers'.Compensation Insurance Affidavit. Builders/Cont.ractors/Electricians/Plumlbers A ppfical�t Inormation _ I�Iease Pritct Le ibll> Name(Business/OrganizationlTndividual): .- 7-(' �' f� Q F_ Addles: t t ri/f , 9Ig reG City/State/Zip: UJ6 1)u r 1116Pone#: Are you an employer?Check the appropriate box: w 1•® lama employer with 4. [ I am a general contractor and.I Type of project(required): employees(full and/or part-time).* have hired the sub-contractors 6. ®New construction 2.® I ani a sole proprietor or partner- listed on the attached sheet. 7. [�Remode ship and have no employees These sub-contractors have � yees 8. n Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp.insurance.# 9• ®Building addition required,] 5. We are a corporation and its 10.El Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their g 1 l.®Plumbing repairs or additions Myself [No workers'comp. right of exemption per MGL insurance required.]t C. 152,§1(4),and we have no 12 Roof repairs employees.[No workers' 13•®Other Rno! ce r-in C,, o comp.insurance required.] *Any applicant that checks 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 now affidavit indicating such. #Contractors that check this box must attached an'additional sheet showing the name ofthe sub-contractors and state whether or not those entities have employees. if the'sulr-contractors have employees,they must provide their workers'comp.policy number. ani an er pl®yer that is providing`workers'compensation insurance,for my employees Below is the policy and jab site in�ornration. Insurance Company Name:_ Policy#or Self-ins.Lic.M.. d 0 2- j S,6 Expiration Date:- Job Site ate:iobite Address:_ Lc i ( �, _Vc City/Stage/zip:_ /V- 'i;'da rn 7,4— Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as � g required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine u to $1 500 P .QO and/or one-year imprisonment,as well as civil penalties in the farm of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the IIIA for insurance coverage verification. =eerfy ains andprenatties of perjury that the information provided above is true and correct Date: Phone##: Official use only. Do not wrUe in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Mfor alto . and hist ueflons Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an ertmkyee is defined as"...every person in the service of anotber under any contract of hire, express or implied, oral or Nvritten." An entployer,is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged iu Joint enterprise,and including the legalal 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 theounds or building appurtenant urtenant thereto shall not because of such employment be deemed to be an employer. � g pP " y shall withhold the issuance or MGL chapter 152, §25C(6)also states that"every state or local licensing agency e in the commonwealth for an renewal of a license or permit to operate a business or to construct buildings y applicant who has not produced acceptable evidence of compliance with the insurance coverage required." commonwealth nor an of its political subdivisions shall Additionally,MGL chapter 152 25C '1 states `Neither the y P P �§ { ) 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 fall 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. Alsd be sure to sign and date the affidavit. The affidavit should be returned to the city or town tfiat 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 s Please be sure that the affidavit is complete and printed legibly. The Department has provided a pace 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 submitt 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 proofthat a valid affidavit is on file for future permits or licenses. A new affidavit aaaust 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massae* setts Department ent cif Inds vial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.##617-727-4900 ext 406 or 1-877-WSSAFE Fax##617-727-7749 Revised 1122-06 w-ww.rmass.gov/dla Date..3.r!.?.1 .G 7..... . NONT01Pr~ Of �j •° TOWN OF NORTH A�ER O D • - PERMIT FOR PAS U&TALLATION . � '!�,`°+. o✓"•try SSACMUSE This certifies that . . . . : .f. . . . . . . . . . . . . . . . has permission for gas installation . . . ./ . O. f/4. . . . . . . in the buildings of . . . .`. . . . . . . . . . . . . . . . . . . . . . . . . . . at . .,���`1. . 1�?!?!./.? ' ./`. . . . . . . . ., North Andover, Mass. Fee. .7.Q.- . Lic. No. Z.`,.'. . . . ! : . . . . . . . . ASINSPECTO Check# C14 Y 5994 MASSACHUSETTS UNIFORM APPUCATON FOR PERMPT TO DO GAS FrrnNG (Type or print) NORTH ANDOVER,MASSACHUSETTS Date �/�f f `�G Building Locations C �t !�i/1/�/� S/r�/�' Permit# S R Amount$ D— Owner's Name New U Renovation D Replacement D Plans Submitted D F z ° Gzy a w o ° ° g ' F Z F" W �i F V O > SUB-BASEM ENT a O A V '�� U �+ BASEMENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH . FLOOR STH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . FLOOR (Print or type) • C k one: Certificate Installin Com Name o<,r / g pan y Corp. Address_ u`Y S% p� >ls�?pl` lr✓S3' Partner. Business Telephone D Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. yes 0- No13 If you have checked Yes,please indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity Bond Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner D Agent hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work a)pd installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachuse tate Gas Code and Ch pter 142 of the General Laws. By: Signature of Licensed Plumber Or Gas Fitter Title D Plumber l 2 -!�— City/Town Gas Fitter License Number Master APPROVED(OFFICE USE ONLY) Joumeyman I Location t l—1 �S� Z". No. � Date 0t N�aoT: TOWN OF NORTH ANDOVER A Certificate of Occupancy $41 Building/Frame Permit Fee $ ��b •a°''��� Foundation Permit Fee $ SSACMUSE r� Other Permit Fee_,I $ 43 " Sewer Connection Fee $ Water Connection Fee $ TOTAL $ 143 r �+ Building Inspector 7697 Div. Public Works PER511T NO. �J3'Z APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 MAP 4-40. I LOT NO. 2 RECORD OF OWNERSHIP IDATE BOOK PAGE — ZONE SUB DIV. LOT NO. LOCATION r i n 2-AtjC,4Src� PURPOSE OF BUILDING f OWNER'S NAME NO. OF STORIES SIZE '2- OWNER'S ADDRESSC�N'CT•s¢s�T/Ii�•2,f .,2 BASEMENT OR SLAB7. ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME �ySTer1 < 4/r of SPAN -- j DISTANCE TO NEAREST BUILDING /�/Y/ !•7 DIMENSIONS OF SILLS DISTANCE FROM STREET //�/1 I� POSTS DISTANCE FROM LOT LINES-SIDESIt L p yf REAR 17`7GIRDERS AREA OF LOTL,(30 ,/� FRONTAGE e_fd,' HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW < T ///''' SIZE OF FOOTING % IS BUILDING ADDITION / MATERIAL OF CHIMNEY IS BUILDING ALTERATION 8 ,/f IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE Ye"s 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 &lEc w tQa/ti LAND COST SEE BOTH SIDES 1.w�V EST. BLDG. COST PAGE 1 FILL OUT SECTIONS t - 3 EST. BLDG. COST PER SQ. 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 PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED OJ "P *Lk�UILDINa INSPECTOR SIGNAT RE OF OWNER OR AUTHORI ED AGENT afzmm 1�F E E OWNER TEL.# PERMIT GRANTED CONTR.TEL.#I iA 14- 19 [ CONTR.LIC.# L v ®iz H.I.C.# /0 3'0-9(,.4. r � 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 I RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE _ a 1 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 _ 1/1 1/1 '/. FIN. ATTIC AREA _ NO B M FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE �_ WOOD SHINGLES EARTH _ ASPHALT SIDING HARDW D _ ASBESTOS SIDING _ COMIACN VERT. SIDING NS-PH TILE _ STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STIRS. & FLOOR _ BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIORI� POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE I HIP BATH 13 FIX.) _ GAMBQELMANSARD TOILET RM. (2 FIX.) _ FLAT A SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY I WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING I 11 HEATING 4 WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. &COLS. STEAM STEEL BMS. & COLS. _ HOT W T OR VAPOR WOOD RAFTERS _ AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ ELECTRIC 1st 13,d NO HEATING t,\ORTowref c'xr of !;1'-' No. 5 3 2 � dover ` wprt dower, Mass., mBE 1 - 14 19C ' A0' ATED P'PER IT -B P��.i� ~� so BOARD OF HEALTH ILDFTood/Kitchen Septic System Gar>� .k�TZ,rn FRough UILDING INSPECTOR f ' THIS CERTIFIES THAT 14 •• . ................................................................ ..................................... tion p = has permission to erect.?Oo .......................... buildings on ` ... �,�IT.�CigS .....•.`t�. c;,•; �... .................................... t0 be Occupied as Z[44Qo�-lb---3 ,?1......1.4powx....4.�.:4.Z.....Gtr?K !lt......................................... ...... Chimney provFinal ided that the person accepting this permit shall in every respect conform to the terms of the application 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 _.= VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough >.: PERMIT EXPIRE N 6 MONTHS Final 41 O'er- UNLESS CONS'hR ELECTRICAL INSPECTOR U � N .) 1 -� Rough t� - ...... Service . ... . .. V--�6 BLDING PECTOR Final s Occupancy Permit Required to Occupy Building GAS INSPECTOR [Final ough Display in a Conspicuous Place on the Premises — Do Not Remove 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. '_ SEWER WATER FINAL DRIVEWAY ENTRY PERMIT Smoke Det. RE PLAN OF LAND NO. ANDOVER y MA• SCALE:/'-' 4O' DATE 11 ----1 SC'O T T L. G/LES R.P.L.S. NO. A NDOV,E ?,MA, cl �. C � '~ `� �• �` �rat� o f���r_05VS N. IL-9 I !X t' ZPA, Ii PH ' �\(a-�`�J J ''• .fit" �Y�� 4 • .+' ` 1. of AG y'� i �' •�-':" \ ��Z`� '`-' .tip. ��215-9' 3 OAP -- .r f , i FORM U - LA,T 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 se t' V APPLICANT: E7 LL- 01- AM rKA N ✓ Phone!! LOCATION: Assessor' s Map Number Parcel Subdivision t(s) Street /L(9 L4 f'�.? .�� St. Number ************************Official Use Only************************ RECOMMENDATId OF TOWN AGENTS:Z<�Z/,','1-7 /,� ) -- , Date Approved 11 1 �/ conservation Adminis rator Date Rejected Comments 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 Fire Department Received by Building Inspector Date REvrsEo' FLAN OF LAND /110. 'N UA UA. SCALE:/ 40' . DATE l 1- 8-93 -•.93 SC O T T L. GILES R.P.L S. NO. A 1VDDV4H,MA, No � •� ` �• '•-" ` ``.�,-•..:�. �„ �,' •`�a� of�J/-�t...l._IS I``-°.1 tool Fk P(y ell Ir AG VA . - �,•� � \ � ..,may`..� `k� �,•�. 1 (fto�N- .� 1- Imo, �k tai �i �� ;►� �.-i rI' ` ` ` ,�..�--�,,•`t•-mac.c�c?�� �� ��,) '+'�•:;,��t,• . ti��' i f �-�"►..�Jai• �� � .1�,� : ,/���}�_t, to ep '•` il� e tt Ab �• • 1�•'� � 'rte• tlt •t1U . . .. ................ ........ I �l2� ��%����i�����r!�/IZI�!''t�rL�f2 O�t./i���`^""'liEk�fGLU•IP� I I HOME IMPROVEMENT CONTRACTORS REGISTRATION ° Board of Building Regulations and Standardsll One Ashburton Place — Room 1301 Boston , Massachusetts 02108 I L------------ --------------------- HOME IMPROVEMENT CONTRACTOR I Registration 105084 Expiration 07/16/96 Type — PRIVATE CORPORATION II HOME IMPROVEMENT CONTRACTOR = Registration 105084 t Type - PRIVATE CORPORATION Custom Quality Pools Inc . I E%piration 01/16/96 Robert A . Bent 16 Wyman Road I Custom Quality Pools Inc. I Billerica MA 01821 I Robert A. Bent IIG�re��o-g L016 Wyman Road ADMINISTRATOR Billerica MA 01821 I COMMONWEALTH DEPARTMENT OF PUBLIC SAFETY OF ONE ASHBORTON PLACE FAllart to MASSACHUSETTS BOSTON,MA 02108 MAwaa�ber.:t'z K� RtPlt°P�t06 - C04*lift � � ro o+tion LI�r„�Sd SI: �vtne.,ta, l EXPIRATION DATE CONSTR. SUPERVISOF FOR PROTECTION AGAINST 01 /10/1997 EFFECTIVE DATE LIC-NO. THEFT, PUT RIGHT THUMB RESTRICTIONSPRINT IN APPROPRIATE � NONE °'. �"� � 06!30/1994 040192 BOX ON LICENSE. _11. 0.rro ro Y ..,... o ROBERT .A HENT Z 'i_.: i W y�'E N R D BLAST N, OPER T RS Z 16 MUST Its LUDE P� TO ( }` 5S 023-44-1846 m BILLERICA MA 01821 PHO TO(BLASTINGOPRONLY) FE - CC MAY 12 igqq - . 00.0 0 NOT VALID UNTIL SIGNED BY LICENSEE AND OFFICIALLY '•� G HEIGHT: STAMPED-OR-SIGNATURE OF THE COMMISSIONER t ,1 t-, y ',,,• at %T" v ae '•-'r�rccm-.u.es; ;1'JIR.'dp DOB: L -_ - •: ma=r:. c� Br, 01 /IU/1953 SIGN NAME IN FULL AU t)GIaATUf�EZiIVE '1%�^•%r �,•�' THIS DOCUMENT MUST BE SIGNATURE OF LICENSEE ^�`�r-...•-^`^""""`"` CARRIED ON THE PERSON OF .O THE HOLDER WHEN EN- B PRINT GAGEDINTHISOCCUPATION. if NER r � } _ - - "_L '.--e...•..e-f = ..... ..•__`• —_ l ". .•..wt :•.... ... •.moo __---_ -'1 1_e_ - 1,• ♦e..=G...•...• eswo•�-A— - —.-- •_— - __ - • I L •J•.•. 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Ra.V•f l•✓rT• •I-••n •T4 !t.•.I►A1[;1; i 1 At.r.a•.-r..IT _ YAN O•A., ►•VC U. C. a c•A\ T �fA•OARp p•••A••.0 - /t atotwT•y.-... I 1 tool r0•r. . CU:>TOI± QUALITY POOLS ' 16 ly!Wl ROAD 311-LFCIC!1t MASS. , 01821 ten; SKI>Pt£R. FJLLSPOLIT OCTAIL. list ALto ocrAc.co PtoT IIAJ+ onq.+Iwc] 1 A, -� ! 7 _