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HomeMy WebLinkAboutMiscellaneous - 166 WATER STREET 4/30/2018® N N O C', 0 - m - O rn �p rn gD oD �; "� g� 6 c mo m O O 11603 Date ... ....... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING .'his certifies that.....................A.............. .................... ..... .................................................. has perrmssion to perform ..... ................. plumbing it the buildings of... ....................................... ..........North Andover, Mass. at:.:... ...... .................. Fee..Y(. ... :77:� . ...... Lic. No. ......................... .................................................... PLUMBING INSPECTOR Check #, 123 SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent,which meets the requirements of MGL Ch. 142. YES UT NO Mf IF YOU CHECKED YES, PLEASE INDICATE THE TY OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY D BOND D OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNERF-11 AGENT IR SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this applic are R4? and a41a to the be of and that all plumbing work and installations performed under the permit issued for this application I be i com lanceertin ro(Massachusetts State Plumbing Code and Chapter 142 of the General Laws. � PLUMBER'S NAME (/ )t/,pLICENSE # [Z `Z,. �J SIGNATURE (VIP © JP DI CORPORATION 0_f #PARTNERSHIP ®# ; LLCaf COMPANY NAME d ADDRESS CITYSTATE ZIP�� FAX CELL1 EMAIL TEL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK POWNER TYPE OR PRINT CLEARLY CITY r MA DATE — PERMIT # hbb� JOBSITE ADDRESSOWNER'S NAME__ ADDRESS TEL FAX OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Q RESIDENTIAL NEW: 0 RENOVATION: ® REPLACEMENT: Q PLANS SUBMITTED: YES Q NODI FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OILISAND SYSTEM J _mm (._.__ (_.� _- � [ _ _ _J; -f DEDICATED GREASE SYSTEM _-__ [ DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER _f DRINKING FOUNTAIN FOOD DISPOSER _ f ._.__.-. �: _ -_- --._ f f ____..1 FLOOR/AREA DRAIN _----- J _-J INTERCEPTOR (INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN ( _._. J _._.f —� _.� __ _.� ._-__J__- SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent,which meets the requirements of MGL Ch. 142. YES UT NO Mf IF YOU CHECKED YES, PLEASE INDICATE THE TY OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY D BOND D OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNERF-11 AGENT IR SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this applic are R4? and a41a to the be of and that all plumbing work and installations performed under the permit issued for this application I be i com lanceertin ro(Massachusetts State Plumbing Code and Chapter 142 of the General Laws. � PLUMBER'S NAME (/ )t/,pLICENSE # [Z `Z,. �J SIGNATURE (VIP © JP DI CORPORATION 0_f #PARTNERSHIP ®# ; LLCaf COMPANY NAME d ADDRESS CITYSTATE ZIP�� FAX CELL1 EMAIL TEL o El z �El w LU The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): Address: City/State/Zip: AW Phone #: J ���5^`s9yy Are you an employer? Check the appropriate box: Type of project (required): 1.? flam a employer with _employees (full and/or part-time).* 7. ❑ New construction 2. ❑ I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity. [No workers' comp. insurance required.] 9. F1 Demolition 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 10 Building addition ❑4.❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole 11. ❑ Electrical repairs or additions proprietors with no employees. 12: []Plumbing repairs or additions 5. I am a general contractor and I have hired the sub -contractors listed on the attached sheet. ❑ These sub -contractors have employees and have workers' comp. insurance.= 13. ❑Roof repairs 6. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other 152, § 1(4), and we have no. employees. [No workers' comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit: flus 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. J Insurance Company Name:y /1A -t; . Policy # or Self -ins. Liic. #: Expiration Dates l Job Site Address: �h l'��Y f'�— City/State/Zip:A ..� IQ5- Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage vertu . I do her y certify unde the pains ajrd pgnldties of provided above is true and correct. 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 Phone #: f. 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 ofhire, 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 te applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should'enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia Date ..... �..1. ....... b ................. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ....... ,....1 6 v N C i ...................�..c:............................................ ...l... ..,.... ..,. has permission for gas installation ..I .C�.:��. :. '1 .......................................... in the buildings of ...... ...................... at ...... 1.t�o... r...... ............................. North Andover, Mass. Fee.�c�........ Lic. No..".�..I.I.9.......................................................................... GASINSPECTOR Check #I ?;o2----�5 0428 M,Ij.� Ib %-` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I MA DATE PERMIT # JOBSITE ADDRESS OWNER'S NAME) OWNER ADDRESS TE= .�FAXL� TYPE OR OCCUPANCY TYPE COMMERCIAL Fj EDUCATIONAL D RESIDENTIAL PRINT CLEARLY NEW: [� RENOVATION: D REPLACEMENT: ® PLANS SUBMITTED: YES NOD APPLIANCES -1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER - CONVERSION BURNER COOK STOVE DIRECT VENT HEATER ..-. �- DRYERTza FIREPLACE FRYOLATOR FURNACE _ l I! -.--- --- _— - GENERATOR�1_ GRILLE, - INFRARED HEATER .--- LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER_- WATER HEATER OTHER�_ - - - - - - - -- - - - INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch.142 YES J - NO [j IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 52--' OTHER TYPE INDEMNITY El BOND EJ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER0I AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application a true an accurate the best of my k le ge and that all plumbing work and installations performed under the permit issued for this application will be ' complianc with all ertinent f t Massachusetts State Plumbing Code. and Chapter 142 of the General Laws. PLUM BER-GASF ITTER NAME[Z-;j>lt� - LICENSE # SIGNATURE MP1GF El JP JGF LPGI © CORPORATION Jj# L= PARTNERSHIP D#L--�--�9 LLC DI#= COMPANY NAME: �/ �,✓ - �' ADDRESS CITY ,r¢ _ _ � STATE ZIP TEL FAX CELL -�_,_ __ _.�_ EMAIL m wEl W Ix tii LU LL A a Claim # Advantage Claim Services 522 Chickering Road #B North Andover, MA 01845 Adjuster Assigned: Glenn Guarente Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws, Ch. 139, Sec. 3B To: Building Commissioner cv Board of Health or Inspector of Buildings Board of Selectmen Town Hall Town Hall North Andover, MA 01845 North Andover, MA Re: Insured: 166-168 Water St. Condo Property.address: 166 Water St. North Andover, MA 01845 Policy #: 2304781 Loss of: 2014/09/06 File or Claim No. AD 1548 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.—Ch.-139—Sec.-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. Glenn Guarente Title: Adjuster On this date, I caused copies of this notice to be sent to the persons named at the addresses indicated above by first class mail. 09-17-14 Signature and date �`to ` �f►`' (.�'.� 'tic Location { r' No. _ Date 140*,rN TOWN OF NORTH ANDOVER _ _ O F w 9 s Certificate of Occupancy $ s.+cMus Eta Building/Frame Permit Fee $' f' Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # l 17200�-�-- ✓ Building Inspector A TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVAT OR DEMOLISII A ONE OR TWO FAMILY DWELLING ,rr.. VSs,. ,: . , , a.w.iv -t_,E: • „a .. _ .� �-<,,: , BUILDING PERMIT NUMBER: L DATE ISSUED: SIGNATURE: Building Commissioner/IEEREtor of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: SECTION 2- PROPERTY OWNERSHIP/AUTHORIZEDAGENT 1.2 Assessors Map and Parcel v q Map Number Number: qorll- Parcel Number -C-14 m1.3 Zoning IInfoiation: Zoning District Pr osed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft (Pri Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 2.2 Owner of Record: 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zone ❑ 1.8 Municipal Sewerage Disposal System: ❑ On Site Disposal System z M 90 0 mn ic as M r aa. z 0 SECTION 2- PROPERTY OWNERSHIP/AUTHORIZEDAGENT Historic District: Yes No 2.1 Owner of Record i A.", - (Pri Address fo ervice-: tgnature Telephone 2.2 Owner of Record: Name Print `s Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: License Number Address Expiration Date Signature Telephone 3.,2 Registered Home Improvement Contractor Not Applicable ❑ Wmpany Name Registration Number Address Expiration Date Signature Telephone z M 90 0 mn ic as M r aa. z 0 w �a SECTION 4 - WORKERS COMPENSATION (AG.L. C 152 § 25c(6) 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 .......❑ No. ...... 0 SECTION 5 Description of Proposed Work check au applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Descriptich oWroposed Work; J/f� AV SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item 1. Building Estimated Cost (Dollar) to be Completed bV permit applicant_; QJ4IgL A (a) Building Permit Fee Multiplier USE QI1TLy ,,: 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing 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 PERMIT 1, as Owner/Authorized Agent of subject property Hereby authoriz to act on otw=lorized by this building permit applicatioon/ My bgh 1 � 1 1=V4, � V, 6 Xignature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, 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/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1ST 2ND 3 SPAN DIMENSIONS OF SELLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIlVINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print I ffI am a homeowner performing all work myself. aI am a sole proprietor and have no one working in any capacity 0 I am an employer providing workers' compensation for my employees working on this job. Company name: Address City Phone #: Insurance Co. Policy # Company name: Address City Phone #: Insurance Co. Policy # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to $1,500.00 andlor one years' imprisonment.as_well as_civil.,penaltiesin tfzefnfm-of a_STOP WORK_ ORDER..and.a fine_of_(.$10.0.00)_a-day against -me. understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the sins and Wallies of pe ' ry that the information provided above is true and correct. SignatureDate ''�� Print name Phone.# Official use only do not write in this area to be completed by city or town official City or Town Permit/Licensing El Building Dept ❑Check if immediate response is required E] Licensing Board p Selectman's Office Contact person: Phone #: ❑ Health Department Other .. DISPOSAL rVI P.O. Box 32, Danville, NH 03819 I 603-772-7758 CUSTOME NAME _ � . ORDER TAKEN t R DAT T E 'x -, .-. CUSTONIERpRESS C�1F P}10fNE IF tDATS CALLED IN liable for any damages to pavement, Container # CALLER'S NAMEi ,i�elivery resulting from trucks servicing containers placed at the ❑ Dump & Return customer's request. JOB NANiE1 ���, � II t JOB PHONE # DELIVERY DATE CUSTOMER'S SIGNATURE/"\ ! 1 f" 6 vv�l CUSTOMER'SPRINTELMAME JOB ADDRESS DRIVER�ox PEFi1bD RENTAL RATE { QTY CONTAItIEFt'DESCRIFTION flF TIME PER wEEiZ, •' NEEDED "' �° / DISPOSAL FEES PNCE PER TONT. RATE FEE HAUL CHG & OTHER CHARGES <✓"'. �.��``*"°••" THIS CONTAINER HAS A WEEKLY RENTAL CHARGE TO BE COM LETEd BY DRIIkER R DAT T E 'x Customer acknowledges that Allstar Disposal will not be liable for any damages to pavement, Container # curbing, lawns, or other property ,i�elivery resulting from trucks servicing containers placed at the ❑ Dump & Return customer's request. ❑ Remove No Hazardous Materials Accepted. CUSTOMER'S SIGNATURE/"\ ! 1 f" 6 vv�l CUSTOMER'SPRINTELMAME RENTAL AGREEMENT O z 91 ON W � ® ''m c =M o w oy w„ c 'Ora CLc b O cb C/) L v cn U M.+ tb G O w O w -C U Cd C x � � �' m O 04 G w cEd W m 0 w v cn cc r=. x UW O u: G x z C m cn o E cn • hO ''m c =M w oy w„ c 'Ora CLc cc 03 = o o � m vCD :.. IN . o o. yr y O m CDv ®cM E v� g n y y w o d m y ® D O! c O e 32 �O dC t o V®h z- m Oe m m CL. - -.Vi cs COD Nd C W m MDO �. 'E c a , v 'w 2 O 06 vm ®� ®_$ � O H OCD t CL - CO �lp t MI. - NO V) ''cow V CDL- coCL �m C O V O CL CA C3 CODc cc Cos . ' • P Location No. Date �oRTM TOWN OF NORTH ANDOVER 0. t 9 i • : : , Certificate of Occupancy $ s CHUSE<�'' Building/Frame Permit Fee $ Foundation Permit Fee j $ Other Permit Fee Shed $ J0, 00 TOTAL $ q n , D( Check # !a ;-b 0 15935 Building Inspector SIGNATURE: - V//llt Building Commissioner/InEwor orBuildings Date SECTION 1- SITE INFORMATION 1.1 Prop y Address:% 'a Ao/ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 1.2 Assessors Map and Parcel Lo 1 Map Number Number: --,42 q f Parcel Number 1.3 Zoning Information: Zoning District Proposed Use d� " Address or Service: 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard 2.2 Owner of Record: Name Print Rear Yard Required Provide Required Provided Required Provided SECTION 3 - CONSTRUCTION SERVICES 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zone ❑ 1.8 Municipal Sewerage Disposal System: ❑ On Site Disposal System ❑ z M 90 0 on ic M r z^^ Y) SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record �69 �.4i✓ /�4 �j� am (Print) _ d� " Address or Service: "elf/� rSignature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature, Telephone z M 90 0 on ic M r z^^ Y) I 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 .......❑ 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: SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL x� USV01A'Y Y � ..........:. 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (e) X (b) �~ 4 Mechanical HVAC' 5 Fire Protection 5 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN -OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT �1 V,,2,'2 �� ��� as Owner/Authorized Agent of subject property Hereby authorize 4ew'z'o ,S%rr%�!%�J � /� � to act on My behalf, in all inters ve to work authorized by this uilduig pernut applicatio Signat'ire of Owner V 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 TINMERS 1 2ND 3 SPAN DRAENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE FORM U - LOT RELEASE FORM C K) D'Z y 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 or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT R �N� T QVJJ �S PHONE l -Co9I -66,61 LOCATION: Assessor's Map Number 1 PARCEL SUBDIVISI STREET Ileo LOT (S) ST. NUMBER xxxxx***x**********************OFFICIAL USE ONLY*********************************** I I RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMIN COMMENTS TOWN PLANNER COMMENTS R DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED__ FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR -HEALTH DATE APPROVED DATE REJECTED COMMENT PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTO Revised 9\97 jm TE T"I 1'11 Via 11V I. 111LAII AQJVUln l lav 1V 1UUJUJ1;IUIU lUU 1/ VU1 MORTGAGE INSPECTION PLAN NORTHERN ASSOCIATES, INC. N. MAIN STREET ANDOVER MA 01810 TEL: (508) 474-4410 FAX., (508) 474-5067 i' MORTGAGOR: RYAN N. & SUSAN M.STARNES .LOCATION: 166-168 WATER STREET CITY,STATE: N.ANDOVER ,MA DATE: 11/9/96 December 10, 1996 Ryan N. Starnes and Susan M. Starnes, hereby knowledge receipt and acceptance of this Mortga snection Plan; elated 11/9/96, on this date. i yan N. Starneq ,„san M. Starnes I\ -71Z n/ J , LOT 5 } 7,2757,S.F, DECK HS.# 166-168 2 STY.WD, 'v/ATER CERTIFIED TO: FLAGSTAR SANK TOTE: This mortgage inspection was prepared cpecificall.y for mortgage purposes only and .s not to be relied upon as a land or property .inc survey. Bu*11ing location and offsets shown are apoaif'ioally for acning dataroination )nly and not to.be used to establish property .ines. The land shown hereon is based on eferenced information noted and may be subject :o further takings, and easements. Northern %ssociates, Incl accepts no responsibility for iamages resulting from said reliance by anyone 3ther than trio said mortgagee and its assigns i onnection with its proposed mortgege financing C.P. 75.0' STREE DEED REF. PLAN REF. 6591 SCALE: 1 = 20' JOB #: 96/4598 0 01 This mortgage inspection was prepared in accordance with the Technical Standards for Mortgage Loan Inspections'as adopted by the Massachusetts Board of Registration of Professional Enginoora and Land Surveyors 250 CHR 605. I further. state that' in my professional opinion that the structures shown conform with thelocal zoning horizontal dimensional setback requirements at the time of construction or are exempt under provisions of M.G.L. CH. 40-A Sec. 7. Rl.Property/House is not in a Flood Hazard. 2.Proporty/House is in a Flood Hazard Area. 03.Information is insufficient to determine Flood Hazard. Flood Hazard determined from�te�Federal Blood O z Ll z w o m "tjo w° Cl) a cn U U z04 z 0 w° °�° aT, U w O H w G. w O w U w W -� z rL c� m u. p w a w�' ii w d w x w v w' z cn o v v) z CF") 0 z 0 C/) Cl) z w 0 U G M CA coy .(D L CL co O co V CO) 0 0 CO2 C O V 0 CD !D � 3� Lft co O0. a' cma C � C O O Z CD CL CO) C c o CD C V O ` C N O O ' w O d� CL C A p m C �L O O � D uj: N E Q IL N 0 0 m� CM I co -- E cc 0 CN N N cm c m 3 m N A mOV4.� L C C E m� • m c�. cm m y m IT L L O X O O> i0., LIO Z C t -c .:coo c Z m CL „O„ y m L r... LC C oc H E dL C Z v CD V C.3CDc g i n o m '� -O O CO2 O _ F— L 4- Qpm z CF") 0 z 0 C/) Cl) z w 0 U G M CA coy .(D L CL co O co V CO) 0 0 CO2 C O V 0 CD !D � 3� Lft co O0. a' cma C � C O O Z CD CL CO) C •'� PLICATION FOR PERMIT TO DO GASFITTINGPAISSAC`US O Mint w Type) NORTH ANDOVER, , Masss. Dated �� Building d4 _ �—� Permit # Locatlon Owner's 4 New p Renovation p Replacement tY' Plans Submitted: Yes p No p Installing CompanyNom" Address i. Business Telephone Name of Licensed Plumber or Gas Fittera-i22 rc '��✓ % Check one: �] Corp. Ci Partnership p Flrm/Co. a INSURANCE COVERAGE: ; Check one 1 have a current liability Insurance policy or its substantial equivalent. Yes p No If you have checked yes, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy p Other type of Indemnity p Bond p Certificate OWNER'S INSURANCE wAivEn: 1 am aware that the licensee d��ot hays the Insurance coverage required by Chapter' 142 of the Mass, a ral Laws, and that my signature on thia permit appllcation waives this requirement. r , Check one: OwnersR----Agent p I fWaby certify that eq of the details and Information I have submitted (or entered) In above applleallon are true and accurate to the best of my knowbedgo and that all plumbing work and Installations performed under the permit Issued for this appilcatio will be In compliance with all pertinent provisions o1 the Massachusetts Stale Das Code and Chapter 142 of the of Laws, ¢� gy, T of Ucense: /&�-- Plumber na ure o c n um er or as r THIS Qssptter gtylTovm er License Number Journoyman --� APPFIKYVED (OFFICE USE ONLY) MOMMI �HA����mom10010010-on onN a NNIUMMMIN onionNo mom Room I noAN M101000010on Installing CompanyNom" Address i. Business Telephone Name of Licensed Plumber or Gas Fittera-i22 rc '��✓ % Check one: �] Corp. Ci Partnership p Flrm/Co. a INSURANCE COVERAGE: ; Check one 1 have a current liability Insurance policy or its substantial equivalent. Yes p No If you have checked yes, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy p Other type of Indemnity p Bond p Certificate OWNER'S INSURANCE wAivEn: 1 am aware that the licensee d��ot hays the Insurance coverage required by Chapter' 142 of the Mass, a ral Laws, and that my signature on thia permit appllcation waives this requirement. r , Check one: OwnersR----Agent p I fWaby certify that eq of the details and Information I have submitted (or entered) In above applleallon are true and accurate to the best of my knowbedgo and that all plumbing work and Installations performed under the permit Issued for this appilcatio will be In compliance with all pertinent provisions o1 the Massachusetts Stale Das Code and Chapter 142 of the of Laws, ¢� gy, T of Ucense: /&�-- Plumber na ure o c n um er or as r THIS Qssptter gtylTovm er License Number Journoyman --� APPFIKYVED (OFFICE USE ONLY)