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Miscellaneous - 16 ACUSHNET STREET 4/30/2018
J 16 ACUSHNET ST U-1 // 210/024.0-0060-0001.0 j f 1 ' �4 North Andover BctaM of Assessors Public Access Page 1 of 1 �oRTk Forth Andover Board of Assessors roperty Record Card Click Seal To Retum Parcel ID:210/024.0-0060-0001.0 FY:2013 Community:North Andover SKETCH PHOTO Search for Parcels No Sketch o Picture Search for Sales Available g�!l f a b le 1 f Summary Residence Detached Structure Location: 16 ACUSHNET STREET Condo Owner Name: KIRALY,GABRIELLA C/O JAMES MOOTREY Commercial Owner Address: 16 ACUSHNET STREET City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood:0 Land Area: 0.00 acres Use Code: 102-CONDOMINIUM Total Finished Area: 1938 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 242,800 255,600 Building Value: 242,800 255,600 Land Value: 0 0 Market Land Value: 0 Chapter Land Value: � I LATEST SALE Sale Price: 260,000 Sale Date: 09/27/2005 Arms Length Sale Code: Y-YES-VALID Grantor: DONOVAN,DAVID Cert Doc: Book: 9786 Page: 262 f I http://csc-ma.us/PROPAPP/display.do?linkld=2251139&town=NandoverPubAcc 3/19/2013 Condo Property Record Card PARCEL—]D:210/024.0-0060-0001.0 MAP:024.0 BLOCK:0060 LOT:0001.0 PARCEL ADDRESS:16 ACUS HNET STREET FY:2013 PARCEL INFORMATION Use-Code: 102 Sale Price: 260,000 Book: 9786 Road Type: T Inspect Date Tax Class TSale Date: 09/27/05 Page: 262 Rd Condition: P Meas Date. Owner: Tot Fin Area: —1-93-8'.. ...Sale Type_ B '__CeiUDoc: ____ Traffic. R M Entrance KIRALY,GABRIELLA Tot Land Area: 0.00 Sale Valid: Y Water: Collect Id C/O JAMES MOOTREY - - - Grantor: DONOVAN,DAVID � - `Sewers ' ' Inspect-Rees: Address: _ 16 ACUSHNET STREET Exempt-B/L% / Resid-B/L% 100/100 Comm-B/LP/o Indust-B/L% / Open Sp-B/L% / NORTH ANDOVER MA 01845 CONDO INFORMATION VALUATION INFORMATION t Style; f `dot R rats; 5" Fri Liv Area; 1936 3srrt Fre : i3: Current Total: 242,800 Bldg: 242,800 Land: 0 MktLnd: 0 Apt Un-it##: I Full Bed: 2 Unf Liar Area: Fan Bs nit SF: Prior Total: 255,600 Bldg: 255,600 Land: 0 MktLnd: 0 t wit Desi. bh/Part ed. t 6dot%SR.! Fn Ssfnt Ord: � Res nit Typ . fait Baths: 1 'Bldg caltrs: Parking Class. C CA Ubt,T fl if Sanas: 'Prkin Rstr: N , Comp Name:' ACU 1=t ua[ity: M No O✓rhd Dr; Parking Open: CONDOMINIUM Co pl,co e,''. l itch4 Type, Parking Cc vid Cor p.Class: Kitchen n dual' Atypical, ackin Oar: Condo 1'y0e,, 82 W61f.Halght. Ff€Yr Built: 1980 . Pct Cofti fnt, 50.000!0 4 ,,a ue' Method;: Flooring; "ear Built: 1886 Pct Int IQd 80,{1000 I Saeloor <f iflirags; Fade: A, lr t Ad} .ctr: Nurn loors:' .0 Fare Alarm' -. ,6,4tion: A Val Acl Pct7 P larsnEzlrs: Pct Cornplet : Vat 't mt; HeatType, HW View Quality: Hdat cbatr& t AC 6antrot. Unit Loc A j: Frep( ce0 Market Ac `> Stacks fl don'do Val, H rhs, �86uhd Val 4 ISO Struc: /ii c tr Val: SKETCH PHOTO No t`3ketch N o IF-1 i'c - A Wit ail I We% lifA a Tv 11 , Parcel ID:210/024.0-0060-0001.0 as of 3/19/13 Page 1 of 1 Date.....ffnly TOWN OF NORTH ANDOVER PERMIT FOR WIRING A US ies that .... . ....... This certifies ............. . has permission to perform wiring in the building of......... ...................... /2............................................. at.... .........?,1................ .North Andover,Mass. Fee.P.q......... Lic.No. . ..........I.. . . .. .......... ..... .. . CTRIC�L INSPECTOR Chec'k # 10445 \ C.ontinrorewQalZh o�cc77ae�ciu�eae Official Use Only .U�arfinen!o�,tire�arvic� Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] eaveblank 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 ININK OR TYPE ALL INFORMATI019 Date: I I City or Town of: NO«'�'1 kJ O tl4er To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Nger) C1 e Owner or Tenant � p� Telephone No. a r?e" Owner's Address ' Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building pwe 1111 Q Utility Authorization Norvi c�v4 �j {1kn- -oy.`&4 Existing Service `Z 00 Amps IIN>/ agVolts Overhead[O Undgrd❑ No.of Meters o2 New Service C/✓AA�L Amps IV / Volts Overhead❑ Undgrd❑ No.of Meters k= , Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: lace SP WA Mki 2" vc QMe coA (lr-fbrs Com lotion o the ollowin table Tay be waived by the Inspector of Wires. ' No.of Recessed Luminaires Q No.of Ceil.-Susp.(Paddle)Fans f Total Transformers a KVA in i No.of Luminaire Outlets No.of Hot Tubs D Generators Q KVA O t No.of LuminairesSwimming Pool Above El - Elo.o Emergency g Igurnd Batte Units No.of Receptacle Outlets No.of Oil Burners ® FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners Q o.o on an O � Initiating Devices No.of Ranges No.of Air Cond. otal Tons No:of Alerting Devices Q No.of Waste Disposers eat p Number ons o.oSelf-Contame 0 Totals: Detecttion/Alertin Devices No.of Dishwashers C9 Space/Area Heating KWO Local❑ CM=k i'on ❑ Other No.of Dryers O Heating Appliances(' KW 8ecunty lems: No.of Devices or uivalent No.of Water KW o.o o.o Data Wiring: Heaters Q Signs Ballasts No.of Devices or tguivalent No.Hydromassage Bathtubs Q No.of Motors O Total HP© Telecom No.oD ve icesunicons or E uivWinnAent(5 OTHER: 0 Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Vlecqical Work: d (When required by municipal policy.) Work to StartInspections to be requested in accordance with NEC Rule 10,and upon completion. INSURANCE CO GE: 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 cm�ragc is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [YM BOND ❑ OTHER ❑ (Specify:) I certify;under the pains andpenaftiq of perjury,that the information on this app&cation is true and compkie- FIRM NAME: rretoik Lie aS r e l eC--�-ri C la LIC.NO.: I Sb*9- Licensee: Fray)k if. L1 Oa. Signature !�Z. � . LIC.NO.: 3 S 3 8 SE (If applicable,enter"awmxt"in the license nwntWr bn Bus.TeL No.aq7A —4 70—l c,b o Address: 3by%n S+-. , /I( V l-, 01 61 d Alt Tel.No.:�/'�_4�n foo *Per M.G.L.c. 147,s.57-61,security w rk requrres Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE:$ S'fa rw� DawiCtX1 Date. AORTN TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION SS.4 US Et This certifies that . . . . . . has permission for,gas installation 4�4.� . . . . . . . . . . . . in the buildings of at .,,4 North Andover, Mass Fee.( b. . . . Lic. No.. ./. . '21q . . . . . . . . . . . . . . . . . . . . . . . . . GAS INSPECTOR Check 7323 MASSACHUSE'ITiS UNMRMAPPLICATO NFORPERM[TTO DO GAS FITTING . (Type or print) Date � C,/�� p ` Q NORTH ANDOVER,MASSACHUSETTS Building Locations _�t7 / C W S A sZ,95- / Y-7-, Permit# Amount$ —Al 0 �l) � i (/ G� i"7 Y/ !1 Ll IA,-,Owner's Name G A g r',t� t VA• t New❑ Renovation Q Replacement Plans Submitted ❑ d a U W W p U O p O Z rn a t7 U d A z 0 0 � � d CW7 F Z F d W Q W H U yy t� H �� U c4 > .0 0 H O S1JB-BASEM ENT BASEMENT 1ST. FLO O R 2N D. F L O O R 3RD . FLOOR 4TH. FLO 0 R 5TH. FLO 0 R 6TH. FLOOR 7TH. FLOOR `i 8.T•H, FLO O R (Print or type) ®/.� /M /> Check one ifi�te stalling Company Name 9 /� 3� Ld orp. Address �, Partner. C' rZv� F&,r- w14 Cj usmess Telephone — Firm/Co. Name of Licensed Plumber or Gas Fitter l INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Y es ' No' If you have checked des,please in ate 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 Owner0 Agent 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 my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts StteGttChater142 of the General Laws. By. - S a of Licensed Plumber Or Gas Fitter Title dumber ,�/1 Civrown 1_I ""�Fitter WenSe n ffr<a—ster APPROVED(OFFICE USE ONM El Journeyman i The Commonwealth of Massachusetts Department of Industrial Accidents Office ofInvestigations 600 Washington Street Boston, AL4 02111 www-mas&gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le6ibly Name(Business/Organizalion/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑l am a employer with 4. ❑ I am a generalcontractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2,❑ I am a sole proprietor or partner- listed on the attached sheet t 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. [No workers' comp.insurance 5. 9. ❑Building addition p ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I L Plumbing repairs or additions myself.[No workers'comp, C. 152,§1(4),and we have no 12.❑Roof repairs �y insurance required]t employees. [No workers' COMP,insurance required.) 13.❑Other `=may applicPnt that clrec box#I mut also fill out the section below shoe,;ng tY wo_r-.�•combens�on Policy infor-...y,;on. f 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 workm'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: 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 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 DIA for insurance coverage verification. I do hereby cerkfy under the pains and penalties of perjury that the information provided above is true and correct Signature: Date Phone#: 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 pf--non 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 certificates)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 stove to sign and date the affidavit. The affidavit should be returned to the cit' or town.ivat the hcauGL for the i ick ,A,i ei e ' t the ent y app pE�itor l: ..s .s b :ng qu sfwa,me .n..Depar�.... of Indm-rial Acciden s. Should you have any questions regardirig 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. 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 ofMassachusetts Department of Industrial Accidents Office of Inve-stigat oas 600 Washington Street - Boston,MA 02111 Tel. #617-727-4900-ext 4006 or 1-8 77MAS.SAFE Fax#617-727-7749 Revised 5-26-OS wurw,mass.-govfdia Date ' . . . ... f NORTH "''D;.-'+ TOWN OF NORTH ANDOVER ° p PERMIT FOR PLUMBING ,SSACMus - This certifies that /.�U. . ! `` �. . . . . . . . . . . . . G / �l1 has permission to perform . . AG°el. . . . . . . . . . . . . . . . . . plumbing in the buildings of .4!6 4ew.�. . 4,2 . at Afir. . . . .S.... . . . . . . . ., North Andover, Mass. Feej.O . . . .Lic. No.I,T.;�I) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check 8390 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLU-AMI ]'G (Type or print) NORTH ANDOVER,MASSACHUSETTS a� • Date_ Building Location 16 tjo &SA W2/ owners Name Amount Typb of Occupancy New Renovation ® Replacement dans Submitted Yes No n FIXTURES Z CrrrH O H F i P4 A , U Ir u1 I A R W FC '� S[B-R4V1C 4 i $�4+NFNl' M ELOCR 2M M" MFLa . 4MROM I �IANIfJQ2 i 67SRD(R 7IHN-OCR S1HNIt[XR Certificate (Printor type) Check one: 15—,716) Installing Company Name /!Zy « Q Corp.' Address 1 D' Q Q� Partner. o Y�n� L,rv� o YL` 0 1 Business Telephone FinnlCo. Name ofUceused Plumber: D J-2-1 ��- Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of in Bond ❑ L__A 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 rgnature K, Owner Agent I hereby certify that all ofthe 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 and installations perfo d under Pemut Iss�forapplication will be in compliance with all pertinent provisions ofthe Massachusetts StaC e hap General Laws. By: ngnans um T lumbing License • i Title S 7 / p icitynovin Lrcense iNUMber Master Journeyman E APPROVED(OFFICE USE ONLY The Commonwe¢ZiFh ofMassachusetts 1 ' Department of£ndustriid Accidents Office of LiVeSt�e ans 600 wasizington street Bostarz, MA 62111 n Iicant Information w►v�v.mczs,�gov/dia . Workers' Compensation Irzsut ance Af dallt:guUders/Contractors/Elect ricians/Plumbers ' Please trim Le•_ibly Name(Business/Organizatio&Individual); Address: • ' City/State/Zip: Phone#: ---------------- •Are you an employer?Check the appropriate box: am a employer with 4. ❑I am a a Fiepairs project(required): employees(full and/orpart time).*' have hired contractor and I the sub-contractorsur construction 2•❑ I am a sole proprietor or partner_ Jilted on the attached sheet Remodeling ship and have no employees These subcontractors have ' worldng for me in any capacity, workers' c molition [No workers'eom . �mP•insurance• P insurance 5. ❑ we are a corporation and its Building addition required-] officers hake exercised their ctrical repairs or additions 3- 11.1 am a homeowner doing all work ritr t of 11 Lays el£ eynption per MGL mbing repairs or additions [No workers'comp. c. 152,§J(4) and we have no insurance required.] t employees. f repairs - co P•msurancr,mquired_] . er �t zjo alai e`f i^e ecce cellon 'Form eowne=who submitiffis affidavit indicating j' �'ercas'comY s�cu^ �c �'eY= dog^a1I•a +Contreetors'�h.:t ehenk th---bor nrq a--ch ed sn additional sheet show flee ohm hn ee ��eoaaaetors iii t guvLtt't a new name of&ae amdavit mdi:ating such. X am an employer that is providing workers'conzpensarion insurance for my employees Belowsub contcactoas and their workers'is the pof{�ndjob site informatwn Insurance Company Name: Policy#or Self-ins.Lic,#: Ek--piration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensafion policy declaration,page(sho�ng the policy number-and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to theimposition of criminal penalfies of a fine up to$1,500.00 and/or one-year imprisonment,as well as ci of ap to 5250:00 a day against the violator. Be-advised that a copy of vfi es in the form of a STOP WORK ORDER and a fine Investigations of the DIA for insurance coverage verification. of statement may be forwarded to the Office of Z do hereby certify under thepains andpeizalties ofperjury th4rtthe infor, onprovided above is true arsd correct Simaature: Date7. Phone#: - -- - Official use only. Do not write in this area, to be eom feted p by city or town official City or Town: PermitlLicense# Isstl�Authority(circle one): X-Board of Health EuiIriittb Department 3. City/Tatvn Clerk 4.Electrical Inspector 5.PIumbina G.Other a Inspector Contact 1oer-sona: Phone'#; Information an- d. Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to Phis statin,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employeris defined as"an individual,partacfship,•associattion,corporation or othef Iegal entity,or any two or more of the foregoing engaged in a joint enterprise,and including tLe legal representatives of a deceased employer,or the receiver or trustee of an individuaL partnership,association o,<other legal entity,employing employees. However the owner of a dwelling house having not more than three aparfm cuts 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 appurben n thereto shall not because of such.employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or IP cal licensing'agency shall withhold-the issuance or renewal of alicense or permit to operate a business or to>✓onstr-uct 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.perfonnance of public work um-61 acceptable evidence of compliance with the ins r-dwe requirements of this chapter have been presented to the contracting authority." Applicants Please fill•out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Linuted Liability Companies(LLC)or Limited Liability Partnerships(LLP)-vi no employees other than the members or partners,,are not required to carry workers'comp ensation 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 confirmaiion of insurance coverage. -Also be stare to sign and date the affiidavit. The affidavit should be ret-ued to the city or cmm that the ap.uGauon u'u the pernnit•Qr Ric=--e is being request4"uat fihe Dan ariTM--qt or i Industrial Accidents. Should you have Piny questions re ardi �she Have U,'u=yru are�Tured to obtain a wor,. ' compensation policy,please call the Department at the number listed below. Self-insured companies should Enter their self-insurance license number on the appropriate lime. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provideda space at the bottom of the affidavit for you to M out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to HE 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 permuts or licenses. A new affidavit must be filled out each . . year.Where a home owner or citizen is obtainer a license or permit not related to any business.or commercial venture (Le.a dog license or permit to burn leaves etc.)said person is NOT required to complete this of 6vit The Ofuce ofInvestigations wopld hke to thank you in advance for your coopmzation and should you have any questions, please do not hesitate to give us a call The Deparnnent'-s address,telephone an&Xax_u=ber._-. The Commonwealth of Mamrb-uset-ts Depari-ment of Fndustrial Accidents OfEce of Inregdg'atiions ' 6.00 Washington Street Boston,MA 02111 2'eL J�617-72.74900 ext 4-06 or 1-9"7-h-LASSAFE Revised 5-26-05 Par#6.17-727-7749 • � u�mass._aovfdia g, 1 T N O NR AN� �R : PLCAN F PE� �� � acraa r2YIt x" Awftl"d:d l ' l o g� z IMPO TAN :`A Iican 5 comp te iaiI" ,� ` thi )age PROPERTY` ER M NO.: LL _.I',j r NIi I1S i ILII l:a' - T PUUSE"OFBUTL INO ;::- TO ,I M' C . ' ;S_❑.___ � ; 't PE 0F'IMPR 'EMEND' PR POSE USE -- Resi.dential ;. Non- Residential _ ❑New Building ❑Qne family ❑ Addition VTwo or more family ❑ Industrial ` LJ Alteration No. of units:kl� epair, replacement ❑ Assessory Bldg ❑Commercial ` ❑ Demolition —L7-Moving(relocation) ---❑Other ---- --- -p -Others:- ❑ Foundationonl - - DESCRIPTION OF WORK TO BE PREFORMED _ entiS atiOn Please Type or Print learly) OWNER: Name: y j�%e',4L, /I 1 _._. Phone: Address:'-� �,.�.,�. r��,.�� r r- y CONTRACTOR Name:_ - �ilol .9.1V � . --- .�� Phone• �,�'�—����- ------ _e1ft'0;i0_;_z1J www" 14 ME- Supervisor's Construction License: ` `� --- _ , A �E _Date ���/ �=/ate . Home Improvement License: /3 / �` _.__ Exp.-•Ddte'.f4 �D ARCHITECT/ENGINEER" "— -- Name:-Phone: Address: � - . . ,__ - :%'-`= �• � -�"?___ Reg. No. FEE SCHEDULE:BULDING' EMIT.•$10.00 PER$1000.00 OF THE TOTAL ESTIMATED.COST. g�jSED ON$125.00 PER S.F. Total Project Cost_:$ IT 006,__ x10 -FEE: Check Check No.: ��y� Receipt.No.I '7 (� 1Li'{J 1 J,Ja.ITi [ i•�..�r,JJ t.), Page 1 Location �(� �uf�e T J/— No. 6 Date 1-d lj �z 01 NORTh TOWN OF NORTH ANDOVER �? •. • 0- 49 1 Certificate of Occupancy $ a ; ; S�CHU t� Building/Frame Permit Fee $ b� Foundation Permit Fee Other Permit Fee $ TOTAL $ Check # CZ0 19876 Building Inspector ZnTaSAL Swimming Pools Tanning/MassagelBody Art ❑ ❑ Food Packaging/Sales ❑ Tobacco Sales ❑ ❑❑ Permanent Dumpster on Site Electric Meter location to project ---NOTE: Persons contracting with unregistered contractors do not have access to the guaran fund m Signature of Contractor Signature of Agent/Owner y ❑ . Plans Submitted ,'• Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans THE.,OLLOWING SECTIONS F R•OFFICE USE ONLYIZ INTERDEPARTMENTAL SIGN'OFF-U FORM DATE•REJECTED DATE APPROVED PLANNING &-DEVELOPMENT "❑ f EWater Shed SpecialgPermits Site Plan Special Permit =_ _ -0 Other' -COMMENTS' - --�-----may_ - - --DATE -#REJECTED DATE APPROVED e �. .` i g ' �,. ONSERVATION- �' s=`� . Ll y V; COMMENTS �, _ �.-~ s: ..• 1 e J i ?f DATE.REJECTED d DATE APPROVED H.EALT-I-I- �*L, -�- -- -❑ y -w _ F 1 i + COMNTS t�= n , � Zoning Board of Appeals`.Variance,Petition Zoning Decision/recei ipt sul rtl d Eyes ' ' t ?,:i l Sn',{' i Planning Board.Decision: Comments _1 Comments Conservation Decision: Way�teyyt�rn&kSeswer•�cPoannfectionts�ignature&date Temp Dumpster on sit yes_no: ) Fire Department signature/date s . +• I r + , Building Perm t Approved and Issued by: �� ! Page 2 of 4 NORTH own of over No. 0over, Mass., COCHICHEWICK 0RATED P'? Cl WARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THATW........ . .. . .......... Foundation 41 NNW has permission to ore ..................................... buildings on.16...... .........IA.. INOF�. . .........W.N. Rough to be occupied as.......0,10,16 .0j..A%. W.0...TWO'. . LJO.... .................. Chimney '"tihi'ls"permit shall in every respect conf m—s—o'ftho appl' ion on file in provided that the person acce* Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN THS re re I c -_atio "ES D, U TR e UNLESS CONS 0 S ELECTRICAL INSPECTOR Rough Service BUILDING INSPECTOR Final 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 No. SEE REVERSE SIDE Smoke net. Pae# of Prop ont g pages I Norman L Biad Construction 40 Femview Ave. #10,N. Andover Tel: (978)687-6263 Lie#016141 -MA Reg# 131950 Prop ubm ed To, a 11 ,ij,,, Job Name4 2 Job# Addres Job Location �G Y' 6 OL'a Date Date of Plans Phone N L� r��,, O / Fax# Architect We f ereby submit specifications and estimates for: . _________._..._. _._:71 _. fro. _.l Z-4 r / . rhti _, - _ ... Zr), a 7FWe 'opose hereby to furnish material and labor—c mplete in accordance with the above specifications for the sum of: Dollars with I rayments to be made as follows: Any all:ration or deviation from above specifications involving extra costs will be Respectfully execut d only upon written order,and will become an extra charge over and submitted above -ie estimate.All agreements contingent upon strikes.accidents,or delays beyonc our control. Note—this proposal may be withdrawn by us if not accepted within days. 01cceptance of Vropogal The at ove prices.specifications and conditions are satisfactory and are Signature. hereby accepted.You are authorized to do the work as specified. LLDate'Df -its will be made as outlined above Acceptance Signature NC,319 i - I I ✓�ie�oorrmw�awea�z a�✓�aaaac�ucav,Cta BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 016141 Birthdate: 03/15/1947 Expires:03/15/2008 Tr.no: 20180 Restricted: 00 NORMAN L BLAD 40 FERNVIEW AVE#10 �.. N ANDOVER, MA 01845 Commissioner � ' I i ,p� ✓�ze Lra7vnza�n�aea�Z a�✓j/lcraaac`ucaelta �\ Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 131950 Expiration: 10/13/2008 Type: individual NORMAN L.BLAD NORMAN BLAD 40 FERNVIEW AVE #10 ,,per N.ANDOVER,MA 01845 Deputy Administrator ACO D CERTIFICATE OF LIABILITY INSURANCE DATEMIDD 109/11/2006 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Internet Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 522 Chickering Road HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. North Andover,MA 01845 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: NORFOLK&DEDHAM NORMAN BLAD INSURER B: 40 FERNVIEW AVE#10 INSURERC: NO.ANDOVER, MA 01845 INSURER D: INSURER E: COVERAGES 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 POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. U Ll LTR INSRD TYPE OF INSURANCE POLICY NUMBER FULI DAT ( IDD FECTIVE DATE(MMIDD/YY) LIMITS A GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILITY 20155 PDAMAGE T REMISES Ea occurD ce $ 100,000 ®CLAIMS MADE ✓M OCCUR MED EXP(Any one person) S 5,000 09/14/2006 09/14/2007 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY nPROJECTM LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) I ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ ✓ HIREDAUTOS BODILY INJURY $ ✓ NON-OWNED AUTOS (Per accident PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ SII ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE RETENTION $ $ WORKERS COMPENSATION AND - EMPLOYERS'LIABILITY TORY LIMITS ER ANY PROPRIETORMARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? Ifyes,describe under E.L DISEASE-EA EMPLOYEE $ SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMITI S OTHER r i CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. ./ AUTHORIZED REPRESENTATIVE ACORD 25(2001108) ©ACORD RPORATION 1988 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' d 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Aleg, f Address: y4 �CN�vy�`� 4✓� /� City/StateJZip��/ y/�m1/Lh, 1,4104'KPhone.#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I mployees(full and/or part-time).* have hired the sub-contractors 6. El New construction 2. I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working for me in any capacity. employees and have workers' 9 Buildingaddition [No workers'comp.insurance comp.insurance.$ ❑ required.] 5. ❑ We are a corporation and its 10.E]Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.[1 Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12.[Roof repairs insurance required.]t c. 152,§1(4),and we have no employees.[No workers' 13.❑ Other 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 new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: 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 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 DIA for insurance coverage verification. I do hereby certify n er the pains and penalties per' ry th t the information provided above is true and correct. Signature: Date: Phone#: 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#: I 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-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial 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. 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.#617-727-4400 ext.406 or 1-877-MASSAFE Fax#617-727-7744 Revised 11-22-06 w...mass.govfdia I Building Setback( (tont Yard Side-Yard Rear Yard Required Provided Required Provides Required Provided / ,/ ' DIMENSION Number of Stories: Total square feet of floor area,based on Exterior dimensions. Total land area,sq.ft,: > NOTES and DATA—(For department use) I Y d a F. At, J {f-• 1 � � . r – �rt-. _.n _ .-.. �FTL:r• -E^ .. _ t :� •*r.J-, .. 1 L_ .. 4". 3'11 M a t Doc:INSPECTIONAL SERVICES DEPARTM_ENLBPFORMOS jj — CreatedJMC.Jam2006 JI 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 Li 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 Addition Or Decks ,❑ Building Permit Application F --�— u---Surveyed Plot-Plan- ❑ Workers Comp Affidavit ---�--❑--Photo Copy of H:I:C:And-GS.L. Licenses - — --� --- - -- ❑ Copy Of Contract h`t I ,❑~Floor/Crossection/Elevation Plan Of Proposed Work-With-Sprinkler-PlanAnd-Hydraulc Calculations-(If Applicable) P_Mass-check-Energy•Compliance Report (If Applicable)----- - ----� TI [--,-New-Construction-(Single-and Two-Family)- _ -- - - -- -- — --- ❑'Building Permit Application`s ❑ Certified Proposed Plot Plan o Photo of H:I:C:And'C:S:L:I icenses T' - — - - — --- ❑- Workers Comp Affidavit ❑ Two—Sets-6f Building Plans,(Oife-46 Be-Returned) to Include'Sprinkler Plan And F- . Hydr_aul-i-c.Calc.ulations_(I£Applicable.�... _ ----❑:Coppoof Contraet a -Mass check Energy Compliance.Report ln,all cases if a'va.riance or special permit was requi"r`ed the Town'Clerks office must stamp-the=decision from the Board of App ea Is,that.the.appeal period-is over.The applicant.mustthen•get this recorded at the Registry.of Deeds. One copy and y .•proof of recording must be submitted with the building application t ' Doc:INSPECTIONAL:SERVICES DEP.ARTN1ENTMFORN103 i 4 Page 4of4