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Miscellaneous - 152 WAVERLY ROAD 4/30/2018
N 12/5/2017 OE NORTH ,ry 10-�'s e, •• OP . , r, ,SswcHuse� Community Software Consortium �T Nosh Andover Board of Assessors Back to Results I Search for Parcels I Search for Sales I View,'Print Record Card I 16-1 — 6-1— I* Li) , „ hJ a View Summary Property Total Value: Ca rd CRAMPY, BARRY Building Value: Residence Map View CHAMPY, CAROLYN View Land Abutters Segments Properties Chapter Land Value: City: Detached State: Structure Neighborhood: Sales Land Area: History Use Code: Value Total Finished Area: History Tax Class: Condo Pct -Exempt -Land: CGrtir-drei- Parcel ID: 2101014.0-0051-0000.0 FY: 2017 Community: North Andover Location: 152 WAVERLY ROAD Previous Year Total Value: Owner Name: CRAMPY, BARRY Building Value: 181,100 Owner Name2: CHAMPY, CAROLYN 161,700 161,700 Owner Address: 152 WAVERLY ROAD Chapter Land Value: City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 5 Land Area: 0.17 acres Use Code: 104 -TWO -FAM -RES Total Finished Area: 3095 sqft Tax Class: T Pct -Exempt -Land: 0 Pct -Exempt -Bldg: 0 Sewer. Road Type: T Water. Road Condition: P Assessments Current Year Previous Year Total Value: 342,800 392,800 Building Value: 181,100 231,100 Land Value: 161,700 161,700 Market Land Value: 161,700 Chapter Land Value: Latest Sale Sale Price: 250,000 Sale Date: 1210212005 Arms Length Sale Code: G -NO -PARTIAL Grantor. CAMPIONE, DOROTHY Cert Doc: Book: 9921 Page: 332 W pe auvJ � Z 152 Photo (Click on Photo to Enlarge Sketch (Click on Sketch to Enlarg) h c3e v ' VVA- Copyright © 2015 Community Software Consortium. All Rights Reserved http://epas.esc-ma.us/PublicAccess/Pages/ParcelSummary.aspx?MenulD=3&LinklD=189508&Commcode=210 1/1 Date ..... W! .......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING fi 6-� �kql-jpq 4-4 This certifies that ..................................... has permission to perform .............................................. I ........................................ wiring in the building of ... ..... ".. at .1 --)4— Y -,J CA, e rP-- -1 ................................ ............... t ................. ................................ I North Andover, Mass. Fee... 1-2-5 .............. Lic. No. ....................... ........................................................... LECTRICAL INSPECTOR -1'k 7 Check # 12972-/ 6 P 2-o oq iz-1 I S- It < s Co►nr►lonruoa�i�+ o/ li/ae�aas%ua¢tfa Official Use Only G P S Permit No. 2 I _ o ar rx o aro aruico9 Occupancy and tee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1107] (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:- l City or Town of: N0t-A-k, mf To the Inspector of Wires: By this application the undersigned gives notice is or her intention to perform the electrical work described below. Location (Street & Number) `50Q_ W&_Vt t^'l,r )jfnJ Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes W No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters N New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity i Location and Nature of Proposed Electrical Work: Install Solar Electric- Photovoltaic (PV) system Danels rated kW (ED STC Grid Tied. In conjunction with a Buildina Permit C'onanletion of the followiue table inai, be waived by the hisnector of ryires_ No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total ansfortpers ItVA No. ofLuminairc Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above n- Swimming Poo! rnd. rnd. 11 o. o Emergency Lighting Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones -� No. of Switches No. of Gas 3urners o• o. Detection an Initiatin Devices No. of Ranges No. of Air Cond. Toone No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: nm cr I 'Cans 1C a. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating TMI Local ❑ Connection El Other No. of Dryers Heating Appliances KWecurrty yystems: No. of Devices or FAuivalent No. of Water KW Heaters 0.0 No. of S• ns Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP r firing: TelecommunicationsafDevices No. of Devices or Equivalent OTHER: Attach additional detail if destred, or as required by the Inspector of hYires. Estimated Value of Electrical Work: OLC3 600) (When required by municipal policy.) Work to Start: ASAP 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 N BOND ❑ OTHER ❑ (Specify.) I certify, under thepains and penalties ofperjutgp, that the htformaden on this application is true and complete. FIRM NAME: SOLARCITY CORPORATION LIC, NO,:1136MR Licensee: MATTHEW T. MARKHAM Signature LIC. NO.:1136MR (If applicable, enter "axetnpr- in lite license number line.) Bus. Tel. No.: 774-25&8180 Address' 24 ST MARTIN DRIVE (BUILDING 2- UNIT 11) MARLBOROUGH, MA 01752 Alt. Tel. No.: 774.258-&'05 *Per M.G.L. c. 147, s. 57-61, security work requires Department o['Public Safety "S" License: Lie. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee doer not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) Q owner owner's a ant. Owner/Agent Signature Telephone No. PERMIT FEE.' $ (�j o9ol _t 11.l0 VW HWHOBIHO t t Itren z "W1E1 Ht1 NIAVW INNS lz WVtixtlVN 1 MIHIIVW T tNO I LVklGJdOa A1. t 3NV'iA NV I :1 t 88)313 1i31SVW 03H S 193H Sd ISH1311 9Ri'IM0.1103 3HA. s3nssf SNV Y 31413 113 �..OM . i • - • �}y,�� ��*y-�-�MIiF�G.4 SiWiJ}i 1!1 Li i'^ari-+i it �lMMItN/"t H.. +a .. -..7! II►7yJ Y ili V V!F �L Ii"I.R. P Y.?7Y1i�:JY4Y�16J+J' J1n1au3ts inoilii`M pate► trDgT CsaTa.wasaa�Tu�l M ?9LM V'JU'll9nOUOB qyq Uvw C!! vdCitl:atf'I!!021bl S 911 z v it `uolsou pwo luawalddnS LI C)Zxkt .; :tl+j%tAl ixa OL 1S alms - tslfald ` ied 01 :odAa LLytl53 :uotleJlsi611a », uotialn3iM gcautsng {Tun uivjIV lawnsuoj jo aaWo (} :oi ujntal punoj ji •aiep uotiartdxa aqi alglati bOLOV'6 NOD IN3W33AONdWi 3WOH lln JSn 11 11S( IUI 10 11 Tt.% 1101 UJ ii�a1 10 a'.UaJI' utniR nla iNattie� %.1 U . o"in%ark o j3t , •` I t t .1 j l i i l, i � :E tl fi' i .!�!`, )i .6:lEf .j .... ..y--d%l j, �f�ta+...,,.ww.+1 rY! . r p.lu;) iso•1 luaw,Coldtu,& lumaualj ssaal)pV •a;ftwgj 1oj uosvoj allutV-pina u.tniai pur ssalpp%. alnpd(l A WZ/8/£ :uo1lejIdx.i pjeo luaw,aIddng :adAi MM :uolteASllia» 11flHl.)NFKt I�h 4 1'i I4..0. ZOW VO `OA.!_VA NVS AVM MAIAHV31:) 990£ VIVH)IHVVV IIVVV NOI.LVHO&JOO ,ki[O HVIOS uc.)1lP..tlsi��O-d 1013BIJu00 luaWlAo.ts Luj )wol j 9 E l LU s)osngoesso jN `uolsog , OL 1 S altltS - pzp1d 1-11-ld 01 ' uotlUjn91M s,,anisn� { 1t1' .'t1i � tl .121Iat1tiil()1 o a�iI.TC> 7,r�rrtxtrrr�r��c11 , I 0 The Commonwealth oflflassachusetts Era Department of IndustfialAccittients Orwe of Inyesdgations I Congress Street, Sante Ido Nosion, i'l A 0,2.1:14-2017 ivw w. rnass.g'oi►1dla Workers' Compensation Insurance Affidavit; Builders/CnntractordFIectricians/Plumbers Ampileant Info aticin Please Print Le ibl N€ ne(SusimWOrganizationlindividual): SolarCity Corp. _ Address: 3055 Clearview Way Cit /5tatelG1 : ban Mateo GA. 94402 Phone M 000-1 05-L4M' Are you an employer? Check the appropriate box: required): Type of project (required)- j.� l.wr P am a employer with 5,000 4. I ani a general contractor and I Q s 0 New construction employees (full anchor part -tune).* 2. [] i arm a sole proprietor or partner.- have hired the sub-cotttractors listed on the attached sheet. 7. ❑ Remodeling ship and have no ernpioyees These sub contractors have S. Demolition working forme in any capacity, employocs, and have workers' 9. Buildingaddition Q [No porkers' comp. insurance required.[ comp. insurance t 5. We are a corporation and its 10.0 Electrical repairs or additions 3. Q I aut a liorneowner doing all work officers have exercised their I LE] Plumbing repairs or additions m ioll No workers' camp. i P Pi&of exvaiWdon lot iAGL I2.0 Roof repairs insurance required.) # c. 152, 1(4), and we have no § employees. [No workers' l3 ✓�Mier Solar/PV comp. insurance required. *Airy applicant that chucks box Ml must also lilt out the section below showing their workers' compensation pafloy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outsittc contracmrs most submit anew affidavit lndirating such. *Contractors that check this box must attached on additional sheet showing the name of the sub.contraaors and state whether or not those antities have employers. If the sub -contractus have employees, they must provide their workers' camp policy number. Yarn as employer that isproviding workers' Compensation insurance for my employees. Below Is the policy arld job site irrjarmatlati. ImurauceCompany Name. Zurich American Insurance Company Policy -$ or Self4rls. L1c. 9: WC0182015-00 Expiration Date: 9/1/2016 1� Job Site Address: l .!?!r City/State/Zip:�a t' na0y l.P raQ; Attach a copy of the workers' compens titin policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required tatdcr Saction 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 andlor one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of tip to S250.00•a day against the violator. Be advised that a copy of this statement rnay'be forwarded. to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ees10y under the palxs and perialfies of perjury that Ilse informaden provided above is trete and correct. Si e: Date.1^ Phone #: Offfdal acre only. Do not write hi fiUs area, lobe cumpleted by elty or town. offlelai. City or Town: Permia.leense Issuing Authority (circle one)' 1. Board of Health 2. Building Department 3. CitylTown Clerit 4. Electrical Inspector S. Plumbing Inspector G. Other Contact Person: Phone fi; ACCM" CERTIFICATE OF LIABILITY INSURANCE DATE{MMlDDnYYY, CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY 0811712015a THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(Ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endomement(s). PRODUCER CONTACT NAME_- MARSH RISK & INSURANCE SERVICES PHON$ -FAX'_' FAX. ... ... .... ..... _..._....__..._.. 345 CALIFORNIA STREET, SUITE 1300 TAN . No, xil:.... _.............. _ ... _......... .. ...... ..i.tA1C..ND1:..................................... CALIFORNIA LICENSE NO. 0437153 E-MAIL :..... SAN FRANCISCO, CA 94104 _ApeR€.....................................-...... .......................... Af it Shannon SwU415-743.8334 INSURER1S] AFFORDING COVERAGE.. ... _ .. .... _..._....+ ... NAIC #.--.... 998301-STND-GAWUE-15.16 INSURER A; Zurich American Insurance Company 116535 INSURED INSURER B : NIA NIA SolarCity Corporation .. _._.. .... ... .... .. ... ...... ......._...... 3055 Clearview WayINSURER C : NIA NIA _. ... .... ....... ....... ......._.. _......._.. _ ._. ......_........ _... San Mateo, CA 94402 WSURER.D : American Zurich tnswence Company A0142 GEN'L AGGREGATE LIMIT APPLIES PER I INSURER E:... 6,000,000 INSURER F: COVERAGES CERTIFICATE NUMBER: SEA -002713836.06 REVISION NUMBER:4 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLaES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ...... ..._......TYPEOFINSURANCE'... ..... ..... ... b6 _.—..._...POLI FOU EXR' ...... .._.. ...._.......__. ..LIMITS ..._........_.. .FOUCYEFfr ............ NUMBER....... LicyTR DDI A X COMMERCIAL GENERAL LIABILITY a iGLO0182016-00 0910112015 ;0910112016 EACH OCCURRENCE $ + 3,000,000 r X I DAMAGE TO 012WEb CLAIMS -MADE I OCCUR i PREMISES LEA oocurrenceZ ,,,,r 8.. _ . ,._ ....... _.3,000,000 X SIR: 8250,000 MEO EXP (Any one person) S ..... _ ...._....._................... __.._............ .... L INJURY S PERSONAL &ADV .D . .........._.............. 3,000,000 ....----......_. GEN'L AGGREGATE LIMIT APPLIES PER I GENERAL AGGREGATE $ 6,000,000 PRO- X POLICY F 1 JECT L ...; LOC { .. _ .. ... .. PRODUCTS • COMPIOP AGG `. $ _. . 6,000,000 i OTHER $ A'AUTOMOBILE LIABILITY tAP0182017-00 !0910112015 09101/2016COMBINED SINGLE LIMIT 5,000,000 K ANY AUTO ': - BODILY INJURY (Per person) ': $ X ;ALL OWNED X SCHEDULED AUTOS)..... AUTOS BODILY INJURY Wer accident): $ i NON -OWNED X AUTOS ..... .... ..__ ........ ............ PROPERTY DAMAGE want}. ... .. :.X•yHIREDAUTOS r.. t(Perac ..... _... _....+5 .. ...... .... .._.......... COMPICOLL DED: $ 35,000 rUMBRELLA LAS OCCUR I EACH OCCURRENCE 'S EXCESS LIAR CLAIMS MADE; AGGREGATE $ DEO RE i0N$ ( $ D WC0182014-00 (AOS) :0910112015 ;09101!2016 X ': PER OTTH- ; ANo eMPLOYERs a ealrY A YIN . yYC0t62015-00 NU1 ECUTIVE, • /N. •- : N /Ay ! .: ( F.._.... STATUTE ........i �. ..... j. _ . ... ...... os1a1/2ot5 09101/2016 , FE L EACH ACCIDENT ± $ ............... 1.000.000 OPFICERIMEMBER EXCLUDED Mandato In NH WC DEDUCTIBLE; $500,000 { mandatory I I E.L DISEASE - EA EMPLOYEE] 5 ._. _._...-_-'_.. ._ .. ._ ...... ._.... 1,000,000 ... ...._ ... . N yes. desenbe under DES RIPTION OF OPERATIONS below E L DISEASE - POLICY LIMIT . 6 1,000.000 I 1 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD.101. Additional Remarks Schedule, may be attached If more space Is required) Evidence of insurance. SolarCity Corporation 3055 Gearview Way San Mateo, CA 99402 SHOULD ANY OF THE ABOVE RESCRiSED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh Risk & Insurance Services Charles Marmolejo �— —I ©1888-2014 ACORD CORPORATION. All rights reserved. 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W: o E: z O'v'a' t i o: t, i 1 c 0 c Z 0 E ti 2 >: : � '. : o oil v uo:, >o i l-: Z o� E: E: E i x o o. -E 2 B o 27. = M. vi c i o:.2 E. z -ai uc'i g2 u: Ya > o —m7 o < g: i X. w> o: 31: X. -1 o: -S 22 2: z: 2 -: . : Elz u:u t � I u z Wj- <:a :n u z: . . .. . ...... .... ar E E 4) 4J uw '@ ui m > >. ra = Z p cx c c c r,4 0 La' 'ZI, t9 S "0 0 O< 0• G �5 0 - r 0 :Q a S 0 q 0 %j.- 4) C, oo V= = > Z o u - �p Q>1 Tr- sp -00 OM s s .cc m -(b u - = pi -0 w -0 r ap V a 0 0 C Q on E E - (U a 6 0 > 0 - ob (U CL m -0 0 s LA to im 0 iz a 0 C) 0 u z 4 MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION Two Center Plaza Boston, Massachusetts 02108-1904 (617) 723-3800 Ma Only (800) 392-6108, FAX (800) 851-8424 NORTH ANDOVER HEALTH DEPT. NORTH ANDOVER TOWN HALL NORTH ANDOVER MA 01845 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws, Ch. 139, Sec.36 RECEIVE�D JAN 0 5 2009 TOWN OF NOR" HEALTH DF"-" .... _. _ .. " Re: Insured: BARRY AND CAROLYN CHAMPY Property Address: 152-154 WAVERLY RD, NORTH ANDOVER, MA 01845 Policy Number: 0874676 Type Loss: Ice Dams Date of Loss: 12/2112008 Claim Number: 258839 !F Claim has been made involving loss, damage or destruction of the above captioned propert, which may either j exceed $1000.00 or cause Massachusetts General Laws, Chapter 143, section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. MPIUA Claims Division A00021 1212712008 MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION Two Center Plaza Boston, Massachusetts 02108-1904 (617) 723-3800 Ma Only (800) 392-6108, FAX (800) 851-8424 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws, Ch. 139, Sec.313 NORTH ANDOVER BUILDING COMMOSSIONER NORTH ANDOVER TOWN HALL NORTH ANDOVER MA 0.1845 Re: Insured: BARRY AND CAROLYN CHAMPY Property Address: 152-154 WAVERLY RD, NORTH ANDOVER, MA 01845 Policy Number: 0874676 Type Loss: Ice Dams Date of Loss: 03/01/2015 Claim Number: 333061 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1000.00 or cause Massachusetts General Laws, Chapter 143, section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. MPIUA Claims Division CMA00021 3/4/2015 Location No. Date IV 40RTil TOWN OF NORTH ANDOVER 400 Certificate of Occupancy $ Building/Frame Permit Fee $ MU Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# x 188U2 /�� 13dilding Inspector 1.1 Property/Address: 1.2 Assessors Map and Parcel Map Number Number: Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area Fronts ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 34) Pubes 0 Pm ate 0 1.5. Flood Zone Information: Zone Outside Flood Zone 0 1.8 Municipal Sewerage Disposal System: ❑ On Site Disposal System ❑ sEc liVPl l - rKVrEK1 Y VWNEKSMlr/AU'1'11VK1MD AGENT Historic District: Yes No 2.1 qmper of Record j<e Y e -z Name (Print) V Address for Service: Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1,1 'censed Construction Su r: Not Applicable ❑ Licensed Construction Supervisor: t G.5y / ( l eo) 6g&)) �S License Number Address 17 / J V WWW / I Expiration Date Signatu Telephone 3.2 R�`stered Home Improvement Co r l Not Applicable ❑ Company e I33 V t"l 5 6 0 rt/ S-3 eP,06� *5S Registration Number Add �l 1 L (O �7 5'6 c G s7s E . Date SECTION 4 - WORKERS COMPENSATION (M:G.L. C 152 § 2506) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes ...... K, No ....... 0 SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other Specify Brief Des 'ption Propose ork: ^ �✓ SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item �/ �-- Estimated Cost (Dollar) to be IO S �%�• Com leted by permit applicant 1. Building ��QFICI;`n1TSE (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbina Building Permit fee (a) X (b) /�� (� 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PER I, , as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Signature of Owner/A Ient Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 ST 2 ND 3RD SPAN DIlvIENSIONS OF SILLS DINIENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHEANEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE U �i °�✓�:avaa`"`. e'wow- B DING REGULATIONS BOARD OF TION SUP ERVISOR _icense: CONSTRUC090414 Number: CS Birthdate: 0112811959 Tr' no. 90414 E%Pires.. 0112812008 Restricted: 00. LARRY i LEBIp` 21 WINGATE M04 MA #7 04 HAVERHILL, �N comm}Sslon67 ld" ay ov'S MAd Sca guVLeV"ENT CONToCTOR BN�N1E\MpFtOVEM 5829 istrati�on' S�14120p6 ae�xP\rat�oh'. \�a��\dUa\ Type' NC RRY �E8 ANG LA � LEB#7p4 \t\GPTE Mp,p1831 NAVERH\\.\ , Adm 11 7O �'-�4 Go x O u w° ' cin 0 H a UD a G w ° U x 0 R w a°' w a UD a°' cn _ O H m C m3 H O CL— y WCOD 7rFig It %, o o O H C O r i a V :nc: Cc D o ` o t ts 1: CL �CoCD z o ts cm O 'm 3 cm H C � �Ccc W � l0 N aB H O = O E N CD H C 7 CO m C: c" C co 0 CDc CD Z 0 Z O O f a� 0 O cr. i O Z di O y cCD C I CC 0.— gm — o a? 'E m c� 0 CD CD = O� O L � � Q 0 ca ow CJ* 15 c CD C-7 h w— � O GO LU U) U) w LLI lz LUw U) Of O C H¢ y C C �1SO .3 o Z _ O H m C m3 H O CL— y WCOD g. 4:5-020 •fHA c +-s A C dL OH O +'•'cr- cm CJ ID W m 42 O D E N CD H C 7 CO m C: c" C co 0 CDc CD Z 0 Z O O f a� 0 O cr. i O Z di O y cCD C I CC 0.— gm — o a? 'E m c� 0 CD CD = O� O L � � Q 0 ca ow CJ* 15 c CD C-7 h w— � O GO LU U) U) w LLI lz LUw U) The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers pplicant Information Please Print Leeibl, Name (Business/ rganization/Individual): Address: �2 (90X S3 e, City/State/Zip: f,3 Fd MrLsS Phone #: T / f 65-7 Are .-7 Are you an employer? Check the appropriate box: I .k 1 am a employer with 4. ❑ 1 am a general contractor and 1 employees (full and/or part-time).* have hired the sub -contractors 2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. + ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ 1 am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. El Electrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other *Any applicant that checks box #I must also till 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. *Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: � Je c 7)( Policy # or Self -ins. Lic. #: —3%S P 3 SSS 602 . p/S—Expiration Date: Job Site Address: // City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of investigations of the DIA for insurance coverage verification. I do hereby certify der the pai nalties of perjury that the information provided above is true and correct. Si nature• Date: Phone �� a 6 / 5 7 5�- Official use only. Do not write in this area, to be completed by city or town official. 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 contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of 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 -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 confinnation 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 till out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to till in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to 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 Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia iic fro 6 �n6 p 056, ,� ; �� '�� � "..p k • i YF,.e y �. "t.- ; k ��irSLANC AND V�a�_. ? p}' fp�prr G, BOX -5389 fl ` �mBC5RAa®9tF�C4Fii, -835 >94+-CELLip5�! , i 9 _ G �1# � :ReB #135829 �y Q *dP�i y ',; t. «i: .,.�. §si�OtVv^€ -�+3m� -�P�i#Y y k q4 -k. *ire'^ y : •' Tvwtoll e, 4 sass _ > e ".o 'g Y=-='' k r. 4u �. a ST tl P s �� ry '�'•M+-;�-1 �,1 . -n a q `:t t � MjAO J x,d :f�,li 07I _ 'g s �� NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordancMfa=as ' of MGL c 40 S 54, a condition of Building Permit at: %63 1 that the debris resulting from this work shall be disposed of in a proper li ensed solid waste disposal facility as defined by NIGL 11,S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 10A. The debris will be disposed of in: k. ation of Facili Signature of Permit Applicant Fire Department Sign off: Dumpster Permit Date TOWN OF NORTH ANDOVER OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 Ile. � Of 4t�ao .a''�• 3? e•o .• ppL O 9 Dorothy & Joseph Campione IS-,; * 154 Waverly Road North Andover, MA 01845 March 7, 2001 Dear Mrs. Campione, Telephone (978) 688-9545 FAX (978) 688-9542 Please be advised that it appearing upon an inspection of the property owned by you at 154 Waverly Road it has been observed that there are several unregistered motor vehicles. Please be advised that this is in violation of the Towns General Bylaw # 175-1 a copy of which is attached. Please contact me so that we may begin the process to rectify these issues in a timely manner. I may be reached between the hours of 8:30 —10:00 AM and 1:00 — 2:00 pm at (978)688-9545 Respectfully, 4 Michael McGuire Local Building Inspector Cc file 154 Waverly Rd imreg my D.Roben Nicdta, Building Commissioner TOWN OF NORTH ANDOVER OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 " + Telephone (978) 688-9545 • °A FAX (978) 688-9542 Thane E. Benson, Ph.D. Attorney AT Law 162 A Waverly Rd. North Andover, MA 10845 March 7, 2001 Dear Mr. Benson, Enclosed you will find copies of the letters that went to the owners of the properties in regards to your complaint of Feb. 21, 2001. I will be watching these sites for compliance in a timely manner. If I may be of further assistance I may be reached between the hours of 8:30 — 10:00 AM and 1:00 — 2:00 PM at (978) 688-9545. Respectfully, Michael McGuire Local Building Inspector Cc file, 154 & 156 Waverly Rd unreg m/v D. Robert Niceua Building Commissioner TOWN OF NORTH ANDOVER OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES 27 Charles Street COMPLAINT FOR INVESTIGATION DATE: �` YUa✓I Z (� 1a'v I FROM: ADDRESS: Telephone (978) 688-9545 FAX (978) 688-9542 Tel #: / g t o 03 Complaint Against: Doi C���;6f�e �� %c�u.l2✓ �� l �b�-�5"() ELECTRICAL: PLUMBING: GAS: BUILDING CONTRACTOR: PROPERTY OWNER: �E EE® 2 1 2001 BUILDING DEPT. OTHER: / V e41 J -e- o �, � ✓ d,l' Q / �r 7'0 �V�a. GOG�t Signed: TOWN OF NORTH ANDOVER OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES 27 Charles Street COMPLAINT FOR INVESTIGATION DATE • &A KI a v l FROM: vtSs>� ADDRESS: J (o "tom /.q Gd,, !e ✓ (r !` dl Complaint Against: j C', ELECTRICAL: PLUMBING: GAS: BUILDING CONTRACTOR: PROPERTY OWNER: Telephone (978) 688-9545 FAX (978) 688-9542 OTHER: m 14 O h r e J -P f ✓ e �.� u le o +-, 4 K� � S o a n C E 0 Signed: ING DEPT. Unregistered vehicles on and about 156-158 Waverley Road, 2/21/01 156-158 (back yard) John Shea, property owner Blue Lincoln Silver Chevrolet Eurosport Silver Toyota Corolla 154 Waverley Road (at rear, on Morris) "Dot" Campione, property owner Blue Ford Escort LX Wagon Purple Pontiac Grand Am Red Corvette Stingray Maroon Chrysler LE X40' sailboat MS 3886 AT (belonging to John Shea) fE8 2 1 20(1 BUILDING DEPT. TOWN OF NORTH ANDOVER OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 Thane E. Benson, Ph.D. Attorney AT Law 162 A Waverly Rd. North Andover, MA 10845 March 7, 2001 Dear Mr. Benson, Telephone (978) 688-9545 FAX (978) 688-9542 Enclosed you will find copies of the letters that went to the owners of the properties in regards to your complaint of Feb. 21, 2001. I will be watching these sites for compliance in a timely manner. If I may be of further assistance I may be reached between the hours of 8:30 —10:00 AM and 1:00 — 2:00 PM at (978) 688-9545. Respectfully, Michael McGuire Local Building Inspector Cc file, 154 & 156 Waverly Rd unreg m/v D. Robert Nicetta Building Commissioner TOWN OF NORTH ANDOVER OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 Telephone (978) 688-9545 FAX (978) 688-9542 ,SSACHUStt Mr. John Shea 158 Waverly Rd. North Andover, MA 01845 March 7, 2001 Dear Mr. Shea, Please let this letter serve as your second and final notice in regards to unregistered motor vehicles being stored on your property, which is in violation of the Town bylaw a copy of which is attached. If this department does not hear from you within 24 hours of receipt of this letter it will forward to the Board of Selectman a copy of the letters that were sent to you for further action as provided for in said bylaw. Respectfully, Michael McGuire Local Building Inspector Cc file 156-158 Waverly Rd unreg my D. Robert Nioma, Building Commis cmer