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//! 210/106.6-0003-0000.0
4
_ Location
No.
Ja
r U date $T
NORTH TOWN OF NORTH ANDOVER
Of �ao ,a,ti
f P
' Certificate of Occupancy $
,Ss4CNU5Et Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
390
Check # 1,2
15
C 6 9 V Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
z l.,
BUILDING PERMIT NUMBER: DATE ISSUED:
r X
SIGNATURE: C
C9-��
Building Commissioner for of Buildings Date
SECTION 1-SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map and Parcel Number:
S-A LEM 9 77 /065 3
Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Areas Frontage(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. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑
SECTION 2-PROPERTY OWNERSHIPIAUTHORMED AGENT M
2.1 Owner of Record
V I AW 7R.&I S�4Nl
Name(Print) Address for Service: �M
Signature Telephone p
2.2 Owner of Record:
Name Print Address for Service:
z
M
Signature Tele one
SECTION 3-CONSTRUCTION SERVICES 1 90
3.1 Licensed Construction Supervisor: Not Applicable ❑
C)4S ,a -e SPG,
Licensed Construction Supervisor:
License Number
A® O S ITT-W Ste: Af�. ,QJ►' � J / �
014
/al :L-a�Ls� is g .3 3 5oZ 0 Expiration Date
Signature Telephone
t
3.2 Registered Home Improvement Contractor p a��YNot Applicable 0
company Nam T) C ��/7 $ 1 b A) AC� . '�' S L)6, / h �
Registration Number
.2� o S u.TTafJ ST , 1 6 "Dd UEk, Nd�4
nlJ9�g— L g 3 3 7 0 Q Expiration Date
Signature Tele hone
SECTION 4-WORKERS COMPENSATION(M.G.L C 152 § 25c(6) t
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.
Si ned affidavit Attached Yes.......❑ No.......❑
SECTION 5 Description of Proposed Work check all applicable)
New Construction ❑ Existing Building Repair(s) ❑ Alterations(s) ❑ Addition ❑
Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify
Brief Description of Proposed Work:
a IR 9`' /3.F= na�
i
SECTION 6-ESTIMATED CONSTRUCTION COSTS
Item_ Estimated Cost(Dollar)to be IQ CM- MSE ON�
�, rt�� Yr..h,.,xa3;ea"E. a Yaa
Completed b permit applicant ate _ � r gra 3r � ..
1. Building
v� (a) Building Permit Fee
J
Multiplier
2 Electrical (b) Estimated Total.Cost of
Construction
3 Plumbing Building Permit fee(a) X tbl
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 PERMIT
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.
Si natu.rre of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT 1DECLARATION
`
I, �� V f,D C A-5 rl d C—n lV F as Owner uthorized g 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
_ C
Print N e
Si ature of Owner/A ent Date
NO. OF STORIES SIZE
i
BASEMENT OR SLAB s
SIZE OF FLOOR TIMBERS 1 2
IM3
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
1 SIGHT OF FOUNDATION THICKNESS _
SITE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUU DING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
- Lry l tr:rlt I iPl_,i IKHPI( t PAGE 01
ACM�. CERTIFICATE OF LIABILITY INSURANCE 06/04/2001
° THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
PR000ClR
HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
INIPERNST INSURANCZ AGZNCY ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
522 CSICEZRING ROAD INSURERS AFFORDING COVERAGE
NORTH A=O zlt, 14N 01845 —
INSURED INSURER A: ARMLLA
DAVID CA.STRICONB INSURER 8: Ap=LLA MT$CTION
RO08'ING AND SIDINQ INC. INSURER C; Z"TER2i CASVALTT
200 SUTTON STRzZT, SUITS 226 INSURER D:
NORTH ANDOVER 14A 01845– INSURER E:
COVERAGES
TH16 POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
INSURANCEMAY PERTAIN.THE SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.SUBJECT TO ALL THE TERMS,EXCLUSION$AND CONDITIONS OF SUCH
POLICIES AGGREGATE LIMITS
INSR POLICY NUMBER POLICY PECTIN! POLICY EXPIRATI LIMITS
TYPE OF INSURANCE
GENERAL LIABILITY EACH OCCURRENCE d 1 1000,000
A COMMERCIALOEN611ALLwBILITY 8500012710 06/06/2000 06/06/2001 FIREDAMAOE or*fire) It 50 000
CLAIMS MADE M OCCUR MED EXP An vrn neon) d 5 000
06/06/2001 Ob/06/2002 PERSONAL d ADV INJURY S 1,000 000
GENERAL AGGREGATE d 1,0004000
OF-NIL AGOREOATE LIMIT APPLIES PER: PRODUCTS-COMP/OF AOG t 1,000,000
FMIPOLICY InP O• In LOC
AUTOMOBILE WA ILITY COMBINED SINGLE LIMIT
ANY AUTO (Es vowde M) d
S
ALL OWNED AUTOS 44506400001 08/01/2000 08/01/2001 SCOILY INJURY
SCHEDULED AUTOS (Por person) $
250,000
HIRED AUTOS I BODILY INJURY
NON-OWNEDAUT08 (Perewdw%) 6 500,000
1
PROPERTY DAMAGE d 100,000
j (Por sopdert)
GARAGE UABIUTY AUTO ONLY-EA ACCIDENT d
❑ ANY AUTO OTHER THAN EA ACC 3
AUTO ONLY: AGG IS
LIABILITY ABILITY EACH OCCURRENCE is
OCCUR FM CLAIMS MADE AGGREGATE d
d
DEOUCTIBLE
'd
RETENTION d d
WORKERS COMPENSATION AND .
EMPLOYERS'LIABILITY Fp
C WC99 A24009 09/29/2000 09/29/2001 E.L.EACH ACCIDENT d 1001000
E.L.DISEASE-EA EMPLOYEF d 500,000
E.L.DISEASE-POLICY IIMIT 1 100,000
OmER
DESCIVPTION Of OPERATIONSILOCAnCNSNEHICLES/EXCWSIONS ADDED BY ENDORBEMENTIBPECIAL PROVISIONS
ADDITIONAL INSURED: LSM REALTY TRUST
CERTIFICATE HOLDER I F171 ADDITIONAL INSURPO;INSURER LETTER: CANCELLATION
SHOULD ANY OF THE ABOV!DESCR)A!D POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THERROF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 010 DAYS WRITTEN
NOTICE TO THE CERTIPICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO$O SHALL
IMPOSE NO OBUOATION OR UABIUTY OF ANY KIND UPON THE INSURER,ITS AOENTE OR
REPRESENTATY
AVTMOMZW ME 8 ve "PERRY tPER Y
D CORPORATION 1988
V
Town of North Andover
iTt'ED F�9 4O
Building Department
27 Charles Street * _
North Andover,Massachusetts 01845 0ti
(978) 688-9545 Fax(978) 688-9542 �4ofl �
.$ 'TED 0 ��
S�ACHU`��
DEBRIS DISPOSAL FORM
In accordance with the provisions of MGL c 40 s 54, and a condition of
Buildingpermit # the debris resulting from the work shall be disposed
P g P
of in a properly licensed solid waste the
facility as defined by MGL c11, sl 50a.
The debris will be disposed of in/at:
Facility location
,T1-A q,J cj�:44r�-
Signature of Applicant
Date
NOTE: A demolition permit from the Town of North Andover must be obtained for this
project through the Office of the Building Inspector.
NORTH
Town of over
....... ............. .... .
1 .4
No.
dover, Mass., Z40
0F#ATED C:)
BOARD OF HEALTH
Food/Kitchen
PERMIT T Septic System
THIS CERTIFIES THAT A..,P BUILDING INSPECTOR
............. ......................................................................................................................... Foundation
has permission to OW...... ............ buildings on ....A-5746s,
....... ... . ..... 9 ............................4-S-A) 10i....... ................. Rough
%OL e'St b / ,S U nLe..,r.. Chimney
to be occupied as.................................................. A?
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. /0681.3 40 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
........... 4�v....(' Service
Final
Occupancy Permit Required to Occupy BuiBUILDING INSPECTOR
lding 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 No.
SEE REVERSE SIDE Smoke Det.
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