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HomeMy WebLinkAboutMiscellaneous - 170 OLYMPIC LANE 4/30/2018 (2) 170 OLYMPIC LANE ~� 210/106.6-0126-0000.0 I \ i i i DateU 11468 } r1ORTh TOWN OF NORTH ANDOVER o PERMIT FOR PLUMBING low `sSACHUS� This certifies that....... ..c .......................... ... has permission to perform.?. (�j,. ....... plumbing in thebuildings of - ..... ) , O (.,c..... ......................................................... at....»C7 ............................... North Andover, Mass. Fee5%.................Lic. No 2,(101 3..... ( - r► ` PLUMBING INSPECTOR Check 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY/TOWN /I��rn MA DATE �`f� PERMIT#A.14 r' JOBSITE ADDRESS 17b 1 y m i OWNER'S NAME /yl i��Sc W o l r i' k' POWNER ADDRESS 7o 6 l q m iq rC r' n TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL( - PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES ❑ NO FIXTURES Z FLOOR- BSM 1 1 2 3 4 5 6 7 1 8 1 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE l DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES t WATER PIPING 1 OTHER ,} INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESW' NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 3/ 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME ref* �cCIt LICENSE# �.�,��i SIGNATURE MP 0' JP❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# i COMPANYNAME 6CM[ek MMbih � /lZ-hjl/hg ADDRESS /y 5 CITY W 1(h STATE S ZIP a/3B TEL X70 FAX CELL 'rop-8�3 1>111s- EMAIL t � �. f i �I �, . i -� is F {k`rt' 1 r, f // `/%/�� / / �� a� �� � i Date..l�....1.b. 1 ..................... AORTN TOWN OF NORTH ANDOVER ~ p PERMIT FOR GAS INSTALLATION CNUS�� This Certifies that ... J ep JY1 C,1 , ............................................................................................................ -P has permission for gas installafon ...... ...:.....'..::.......-......................................... i�Lin the.buildings o .... ................................................ . ................................................ l v+- "I L...... . ............, North Andover, Mass. at...:.:..... ...:......................t....... .................... Fee:.... . Lic. No.2-.kOJI.-5........" GASINSPECTOR Check#, M ---'" MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK i CITY A'Drth ! nkrlltr 1V� ( MA DATE fJ/� PERMIT# D7,qq G- _ JOBSITE ADDRESS DO 0 IIMn r 6 /n OWNER'S NAME ft ke- W66 i G• OWNERADDRESS 170 Qbyv�T i I h TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ®' PLANS SUBMITTED: YES❑ NO APPLIANCES 1 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 BOOSTER CONVERSION BURNER COOKSTOVE DIRECT VENT HEATER ` DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I havP.,a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES,'NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW I LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑ 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: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co plian with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ' 7V PLUMBER-GASFITTER NAME ���6(� � '°��►f� LICENSE# SIGNATURE MP 9 MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC❑ COMPANY NAMEcI1'J1CalUm&m ADDRESS °' 1'K a CITY `h STATE 1 ZIP TEL 9;'0 �b FAX CELL EMAIL trY►yi/ bI The Commonwealth of Massq chusetts Department of IndustrialAceldents I Congress Street, Suite 100 Boston,MA.021142017 www.mass.gov/dia ,�. Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): �yy1/C Address: 70 City/State/Zip: Phone#: 7 Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. 0 New construction 2.Kam a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.F1I am a homeowner doing all work myself,.[No workers'comp.insurance required.]t 10 E]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.F1 Electrical repairs or additions proprietors with no employees. 12, 'lumbing repairs or additions 5.F]I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.# 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.FJ 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. 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 state whether or not those entities have employees. If the sub-contractors have employees,&t must provide their workers'comp.policy number. I am an employer that is p/•oviding workers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: 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 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 DIA for insurance coverage verification. I do hereby cert i.f and the pains andpenalties of per jury that the information provided above is true and correct. Signature: 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 Phone#: Contact Person: 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 liire, express or implied,oral or written." it 1 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 cavy 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 wvwv.mass.gov/dia 0 -AOMMONWEALTH OF MA$SACHUSEIfTS e . o .i=Em O Maw ` 5 y 00A • !C� f$/�Ti:2 T'(o! �y lJq �t '.�1, R EI •�f�l.�r{�ik``,/'I A P'l- U;�'r+•� „'17 Q�j .f-M S►BEET uj +q r + Z 9 � J Al i ti � I I I ' i' f 1 Cunningham Lindsey U.S.,Inc. CU�nlrl �am P.O.Box 703689 Va Dallas,TX 75370-3689 L1dse Telephone(888)738-8714 Facsimile(214)488-6766 CLCAT@CL-NA.COM ***********************AUTO**3-DIGIT 018 799 T3 P1 95000058989 Building Commissioner or Inspector of Buildings 120 MAIN STREET { NORTH ANDOVER,MA 01845 Form of Notice of Casualty Loss to Building row Under MASS. GEN. LAWS Ch. 139, Sec 3B Claim Number: 263615105 Policy Number: 263615105 co Company Name: MERRIMACK MUTUAL FIRE INS 0) Cause of Loss: ICE DAM o Date of Loss: 2/20/2015 o Insured: MICHAEL WOLNIK Property Location: 170 OLYMPIC LN Claim has been made involving loss, damage, or destruction of the above captioned property, which may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6, to be applicable. If any notice under Massachusetts General Law, Chapter 139, Section 313 is appropriate, please direct it to the attention of the writer. Kindly include a reference to the captioned insured, location, date of loss and claim number. Section 36. No insurer shall pay any claims (1) covering the loss, damage, or destructions to,a building or other structure, amounting to the one thousand dollars or more, or (2) covering any loss,damage or destruction of any amount, which causes the condition of a building or other structure to render section six of chapter one hundred and forty-three,applicable, without having at least ten days previously given written notice to the building commissioner or inspector of buildings appointed pursuant to the state building code, to the fire department or arson squad of the city or town and to the board of health or board of selectmen of the city or town in which the same is located. If at any time prior to the payment the said city or town notifies the insurer by certified mail of its intent to initiate proceedings designed to perfect a lien pursuant to section three A, or to section nine of chapter one hundred and forty-three, or section one hundred and twenty-seven B of chapter one hundred and eleven, the said payment shall not be made while the said proceedings are pending; provided, however, that said proceedings are initiated within thirty days of receipt of such notification. Any lien perfected pursuant to section three A, or to section nine of chapter one hundred and forty-three or section one hundred and twenty-seven B of chapter one hundred and eleven, shall extend to and may be enforced by the city or town against any casualty insurance policy or policies covering any loss, damage, or destruction pursuant to which the proceedings to perfect the lien were initiated. No insurer shall be liable to any insured owner, mortgagee, assignee, city or town, or other interested party for amounts disbursed to a city or town under the provisions of this section, or for amounts not disbursed to a city or town under the provisions of this section. On this date, I caused copies of this Notice to be sent to the persons named above at the addresses indicated above by First Class Mail. Cunningham Lindsey Catastrophe Department cicat@cl-na.com 800-867-3885 Date.... ....................... NonrM 0 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION HU 14 This certifies that 44....... ..................................................... has permission for gas installation .//,..., .. .......44KV�........................ inthe buildings of................................................................................................................... at...... ...... &P. ).c..... V................. No h Andover, Mass. FeeLic. No. ..... ................................ GAS NSPEC R Check# 41/ Lrg 9131 i . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE PERMIT# - JOBSITEADDRESS 1OWNER'S NAME P OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL p EDUCATIONAL ® RESIDENTIAL®� PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES® NO 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 _.__J _-1 —J DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN I 1 f _..1 . INTERCEPTOR(INTERIOR) A__...-f -AL-1__-_r, .._____ I l KITCHEN SINK f f _ _I I t .__..__ I __.._._! � ._ .__ 1. -j _-__- LAVATORY ROOF DRAIN. I _...__.J [ _-. _I _.J ..__._ f ._..-j ---JI 1 _.._.._.f _ _J _f _-j SHOWER STALL SERVICE/MOP SINK _ f _f I _--__[ _.- 1 l ( i _._._i= �� TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER -1== I __ ► .._.__-..J I _-..._ .� __...__� _..___._1 ...._._.,.I ____! .__.. __J _.......� ...._..._.f .._ I .-._.._.f _._...__I I f INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 2--NO Q IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY D BOND 0 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: OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in comp' ce with all Perti t provision of the !Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME - LICENSE# 9020 SIGNATURE MP 0 JP fill" CORPORATION 0#PARTNERSHIP LLC COMPANY NAME e� /-� ADDRESS �� ,v CITY � s�STATE / ZIP �� U s 11 TEL �jp.�•-�CP FAX CELL oo EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTIW YOTES Yes No S02 THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ 60, FEE: $ PERMIT# PLAN REVIEW NOTES L The Commonwealth of Massachusetts - Department of IndustrialAccidints Office of Investigations 600 Washington Street Boston,MA 02111 'www.mass gov/dia . 1-1 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLibly Name(Business/Organization/Individual): 1,4 ('Ie �- Address: r City/State/Zip: LYl� Phone#: 6 a,)� _7 c2 q moo?c7 Are you an employer?Check the appropriate box: Type of project(required): r, I.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction "oyees(full and/or part-time).* have hired the sub-contractors 2.YOl am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. E]Building addition [No workers'comp.insurance 5. El We are a corporation and its required.] officers have exercised their 10.F1 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.E]Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.[]Roof repairs insurance required.]t 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 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:. 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 requiredunder 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. Ido hereby certtfyu er the pains ar 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#: it 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 orartners are not required to ca ' p q 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 y v any questions regarding the law or if you are required to obtain a workers' .r 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 Deparbnent has provided a space at the bottom of the affidavit forou to fill out in the event the Office of Investigations has to c Y g ontactg ou regarding theapplicant. Y g 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 bum 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 oxt 406 or 1-877�,MASS.AFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dla I 10413 13 0 TOWN OF NORTH ANDOVER o ,.•• ,,..tio „ PERMIT FOR PLUMBING 4 s`4gCMUs� µ This certifies that........v ".........Gr.... Yk+...... '............................................. has permission to perform.. 'r, ! .. ....................................... plumbingin the buildings of............................................................................................. at....47 ......(31q.wp.. ........ ......................, o h Andover, Mass. Fee�!C.U...Lic. No. �'l .. .... ..:.................................:....................... PLUMBING INSPECTOR Check# -` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY . MA DATE _. PERMIT# JOBSITEADDRESSOWNER'SNAME k,`SA 4�cs�r�/f�OL II GOWNER ADDRESS j TE ,,F _6O FAX T TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW:[ RENOVATION:E] REPLACEMENT: PLANS SUBMITTED: YES 0 NO M APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER -L:::i L-.. 1Z . I _ 1 _ _ ..:: BOOSTER CONVERSION BURNER - COOK STOVE DIRECT VENT HEATERS DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR .;�!_�� I ._ ! � - -- -1 _. . -I - - - ��— GRILLE INFRARED HEATER �[__ J LABORATORY COCKS MAKEUP AIR UNIT _ OVEN I-- - -- - - POOL HEATER ROOM/SPACE HEATER _ T - _ ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER - WATER HEATER I OTHER . I �- -- INSURANCE COVERAGE a I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES`levo, 0 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ® BOND F 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: OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent pro ' ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE#Eiijil SIGNATURE MP El MGF Ej JP [�-'JGF 0 LPGI 0 CORPORATION®# PARTNERSHIP EN LLC[j# ADDRESS f�lf- COMPANY NAME: ,il � /�J'- � _ CITY STATE[ ' ZIP TEL - FAX CELL 4 o AIL I ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No a�s� THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES i w f The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations quo 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le0bly Name(Business/Organization/Individual):_ 4 I- � J pal Address: � `6— /,✓ .97 City/State/Zip: S f�,� f_ .,/ (/ Phone#: 6 6 7 V a 9,— 9oz� 0 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 6. ❑New construction fiployees(full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet. �• ❑Remodeling ship and'haveno employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions y 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t 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. 7 Homeowners who submit this affidavit indicating they tie doing all work and then hire outside contractors must submit a new affidavit indicating such. tOontractors 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:. 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 requireclunder 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 cern nder tlae pain d penalties ofperjury that the information provided above is true and correct. Si atur 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#: ` II 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 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 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. AIso 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: Tho Commonwealth of Mossachvsetis Department of Industrial Accidents Office of Investigatitoans 600 Washington Street Boston MA02111 Tel,#617-727-4900 oxt 406 or 1-877rMASS.AFE Revised 5-26-05 Fax#617-727-7749 www.rnass.govfdia. ,y Date.... .......... 10657 pF Npnrh,� TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING * g$�causE This certifies that..fel ►,..... ...�'r.�1 t ..................................................................... has permission to perform . ��/�1. ....................................................... plumbing in the buildings of....................:. at... .7,1).../1�. . L�... ..................:.......... .......... North Andover, Mass. r �� .� ���n Fee,°. :.S?� Lic. No. /, 4��?r�.. . ... ......... ... .:...... .. ,...p , ...................................................... PLUMBING INSPECTOR Check 0 V 7 I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITYMA DATE � ' I PERMIT# - JOBSITE ADDRESS ?p r�/_�rr�...t.:.�._. ����- OWNER'S NAME OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL © RESIDENTIAL PRINT CLEARLY NEW: Ell RENOVATION:© REPLACEMENT: PLANS SUBMITTED: YES® N0�]_i FIXTURES 7 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/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM f - __ E _ ( __ f ...1 -. -( I --I ---1 ---. ( -----� f --- R DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN I ..___-{ _--__. 1 ._._._f � ---__.._( -! •---__-.l .._.___._� _..___. __ ._..I __....._1 (: __._-..! FOOD DISPOSER - l -----( ..._---.-.�. ____v-( _.._-I I ._-._... ._w_.__I .__.___.I ._._ I FLOOR/AREADRAIN { _____._1 _____1 ____.- -.-_- _....__� ______1 -___..._...� __._.___3 7-__4 _-..-----J=== INTERCEPTOR KITCHEN SINK -- LAVATORY _( ___ _..... ROOF DRAIN SHOWER STALL SERVICE/MOP SINK __1 __.._I _...___f ._.._-1= I TOILET __._- .0 --( ___._. ---l-,---l-, _._.._- .--._..._1 _.. .URINAL ---- .._.._1 .__..._...I !i WASHING MACHINE CONNECTION _.._ I s __.__4 _ _...I .___._ _-_. __-_.__ ___ 9 __. Al . -.__I __ -� -.-.=--_.G ...-.___ I _.___1. WA TER HEATER ALL TYPES _! - i ..__._J t_—I —( .- I __..___i .____ _.__.__ ( ATER PIPING _I .1 1 _ INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[ 'NO �I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0I BOND 0 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: OWNER 0 AGENT JE]1 SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all P i nt provision of the Massachusetts State Plumbing -Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE# SIGNATURE mP© Jp H CORPORATION __f#PARTNERSHIP D# _ LLC COMPANY NAME - f+ 1 ADDRESS CITY s..._Q( - - .._..__..._.._..._i STATE ZIP 0 3,F /% _11 TEL FAX _- [ CELL . EMAIL i I ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION 11PTES Yes No ' / Aid2 THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth of Massachusetts - Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,MA.02111 U1 www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ 1 am a employer with 4. ❑ I am a general contractor and 1 6. Q New construction employees(full and/or part-time).` have hired the sub-contractors ,�-f listed on the attached sheet.: �• [1 Remodeling 2. am a sole proprietor or and'have no employees These sub-contractors have 8. Q Demolition working for me in any capacity. workers'comp.insurance. g, ❑Building addition and its 5. ❑ We are a corporation a 0 workers' comp. or additions [N �'S' p 10.❑Electrical repairs required.] officers have exercised their 3111 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.Q Roofrepairs insurance .re uiredemployees.[No workers' required.) • 13.❑Other 49 comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. j� T Homeowners who submit this affidavit indicating they aie 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 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:. Policy#or Self-ins.Lie.#: Expiration Pate: 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 o.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. X do laereby certify u er the pain!�q enalties ofperjury that the information provided above is true and correct. - Si afore: bate: 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.PIumbing Inspector 6.Other - f nnforf PPrenn• 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 havingnot 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 If cense 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 our situation and, ifnecessa necessary,supply sub-contractors)name(s), address(es)and phonenumber(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 notrequired to carry workers'compensation insurance. If an LL C 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 i l Location /12a o) /d+ue- No. / ?/ Date D"3—a�. NORTq TOWN OF NORTH ANDOVER Certificate of Occupancy $ cNustt� Building/Frame Permit Fee $ 2 ! O Foundation Permit Fee $ Other Permit Fee $ TOTAL $ C17 10 Check # 15916 'Building Inspector 4 ¢ v , TOWN OF NORTH ANDOVER ,- BUILDING DEPARTMENT APPLICATION TO CONSTRUrr REPAIR RENOVATF OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: rn �� ��-� � w-71 1 SIGNATURE: - Building Commissioner/Inspector of Buildings Date z SECTION I-SITE INFORMATION 0 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 170 01mpic.lane - North Andover, Ma 01845 Map N _Parcel Numbery - - 1.3 Zoning Information: 1.4 Propetty Dimensions: , A5.Q-44---...— Zoning District Proposed Use ILot Areas Frontage ft 1.6 BUILDING SETBACKS It Front Yard Side Yard Rear Yard Required Provide_ red Provided Required Provided 39+/- .+ o 1,7 Water SupplyM.G.L.C.30. 54) 1.5.- Floed Zone Infotn ition: 1.8 Sewerage ystem: Public t Private r7 7,one Outside Flood Zone t Municipal l7 on site Disposal System\ J SECTION 2-PROPERTY OWNERSHENAUTHORIZED AGENT rn 2.1 Owner of Record Mike Wolni¢k-_-_.-- ------- ------ -- -170_.011. pic lane.... Name( tint) Address for Service: 978 686-0690 Signa re —Telephone - 2.2 Owner of Record: Name Print Address for Service: Z r Si afore --- Telephone -------__-.- SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ - - tel:-F ------ Licensed Constructtou Supervisor: License Number Have �. Address ll treat ' Ma. 01969 3-4 eph --9.9II0- ExpiraD n Date?.003 'S Sig lure - elone r 3.2 Registered Home Improvement Contractor Not Applicable -❑ Company-N-w-n-6 124730 rn 862 Haverhill St. Rowley, MA. 01969 Registration Number r- - Address---- - r 8/14/03 Z (978) 834-A�00 - - Expiration Date sitznature Telephone SECTION 4-WORKERS COMPENSATION(M.G.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.......I9 No.......0 SECTION 5 Description of Proed Work check atl a licable New Construction 0 Existing Building ❑ Repair(s) ❑ Alterations(s) ® Addition ❑ r Ammwiy Bldg. I7 Demulitiou fl Other 0 specify Brief Desctiption of Proposed Work.- Remove existing deck. Build new deck and screen house. - /'S�' xaD 5 CAe-0.7-,& pond a 60 ' SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OT ICIA.L USE.ONLY Completed by permit applicant 1. Building $ 21,055.00 (a) Building Permit Fee �r®r- Multiplier rMulti lier 2 Electrical (b) Estimated Total Cast of o2 3 SS' $ 330.00 Construction 3 Plumbing Building Permit fee(e)x (b) _ 4 Mechanical(I1VAC) c �( 5 Fire Protection 6 Total (112,314,5 21 Check Numbcr SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT � t I, Mike WOlnikk as Owner/Authorized Agent of subject property Herebv autltorize Scotty Bnv Construction to act on My b1halt in all natter rel ' e o work prized by this building pennit application Si tats e of 0;vner 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 i Signature of Owner/Agent Date 1 No).OF STORIES S V E BASEMENT OR SLAB SILT:OF FLOOR TMERS 1' 2' 3 SPAN DIMENSIONS OF S11 JS DIMENSIONS OF POSTS DIMENSIONS OF C;IIiDERS 111:161 IT OF FOUNDATION TIIICKNESS SVT OF FOOTING X MATERIAL OF CHIIvINE Y IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONN};C'll D'ro NA'ru",GAS LINK FORM U - LOT RELEASE FORM I,�s l Se,eve— 1lvoc � _0 --> — 77 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 Scott Fiers ( d.b.a. Scotty Boy constr. ) PHONE (9781834-9900 `` LOCATION: Assessor's Map Number 106 PARCEL 0126 SUBDIVISION LOT(S) STREET_ Olympic Lane ST. NUMBER 170 ******************* ***************OFFICIAL USE ONLY******* ►, *********************** RE I41VIENDATIONS OF TOWN AGENTS: CONSERVATION ADMI71RATOR DATE APPROVED DATE REJECTED COMMENTS �!&,� f 6'� TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED Z"t L DATE REJECTED SE IC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS S-elD+ C 1'� {--�DAJ� �i✓P/ Pr.Jt PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9\97 jm 1 w The Commonwealth of Massachusetts d Department of Industrial Accidents F ice of investigations v¢ Boston, Mass. 02111 Workers'Compensation Insurance Affidavit Name Please Print Name: Location: city Phone # oI am a homeowner performing all work myself. 0 I am a sole proprietor and have no one working in any capacity I am an employer providing workers!compensation for my employees working on this job. ComM name: Scotty Boy Constnict'nn Address 862 Hayerhpll str et. abr Rowley MA 01969 Phone t (978) 834-9900 insurance Co. i4;IM . . Mutual Ins _--Policy# 7(1�7�A1 ni gnn1 _ .._T Company name. Address- CRY: Phone#. Insurance Co. _-_ Policv# Failure to secure coverage as required under Section 25A or MGL 152 can lead to the Imposition of crdwN al penalties of,a fine up to$1,500.00 and/or one years'imprisonment_as well.as.civil.penakies in shefoun da-STDP YWRK ORDF-R-wda.fine..of.($100.0Q)A slay againstme. 1 understand that a copy of this statement may be forwarded to the office or Investigations of the DIA for coverage verification. I do hereby certify under the pains and penaltw of perjury that the 1 provided above is true and correct - Signature '� Date 9/17/0 Print name Phone# 978, 834-Q900 Oir I use only do not write in this area to be completed by dty or town official' City or Town Permii/Licensina 0 Building Dept []Check(immediate response is required 0 Licensing Board p Selectman's Office Contact person: Phone# _ 0 Health Department Other Ile Board of 131'ildit Re b bvulatinns and Standards ?, HOME IMPROVEMENT CONT ' RACTOR Registration: 124730 Expiration: 8/14/2003 Type: DBA Scott Boy Co. Scott Fiers 862 Haverhill St. Rowley, MA 01969 Administrator ` •J�fl!' tt'(+J37llt!}It!/4't(/�{I It/• ((I7J.itI!'/1(!�d BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 069762 i_ Birthdate: 07/08/1974 Expires: 07/08/2003 Tr, no: 126 Restricted: 00 SCOTT M FIERS PO BOX 826 BYFIELD, MA 01922 Administrator i ' I! North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed f ' p o m a properly licensed soled waste disposal facility as defined by MGL c11, S150A. The debris will be disposed of in: Waste Management •nderry N.H. Facility ) (Location of Facility) 110, Signature,,015ermit Applicant 9/17/02 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector MORTGAGE INSPECTION BAY STATE SURVEYING ASSOCIATES INC. JOB # 9 40 100 CUMMINGS CENTER, SUITE#316J, BEVERLY,MA., 01915 LOCATION • No5.7..N A 4 L)CoZ4Ef M�4 NOTES: .......,.. •.......•..................�`..........r�.. 1)This is a mortgage inspection survey and not an instrument survey,therefore this plot pian is for � l0 6- ' SCALE : 1" = SO OATS :....,................Z:............. mortgage inspection purposes only.K is NOT to be used to establish boundaries or for the construction REFERENCE : .............oS (a(�'. S of any type of Improvements. "' " """""""'""""""' 2)This survey is based on survey marks of others. ,ESS ...........r.'o......! .T.............. ,)Bushm shrubs,fences and Vee tines do net ................................•......•.......•..... necessarily indicate property tines. 4)Whenever an offset is I'+-or less,an instrument TO: ,7"KE�IQ57 N 14:vJ ,) ZnL4 /4q SUryey is recommended to determine property The location of the building(s)as shown,either Einm and anyP ossible encroachments. complied with the local zoning p g setbacks at the tMre of 3)Offsets shown are approximate,and.are to•be construction oris exempt from violation enforcement action used only for the determination of zoning,Not to under Mass.G.L Title V11 Chapter 40A Section 7 be used to establish property tines. 8)In my professional opinion the building(s)are not located in the special flood hazard zone,as defined by H.U.D.MAP# ZSp D 9 z-9 3 1 N . E c© f i Z i ,, 5 � o a L07" i7o M `50 _ SURVEYOR'S SEAL 15 NOT EMBOSSED. SSED.THE PSN IS A COPY - TWAT cwni n 0 RE ASSUMED TO rl • , j 1 Ix N 1 I � _ jT 10 r i �s 4 i ;I To I i I �X� 1 r s 4 / � 1 MATERIALS DESCRIPTION Deck frame: Pressure treated lumber, 2"x10"joists, 2'x12' stingers, 4"x6" support posts Footings: 10" concrete-4' below grade Decking: 5/4 Correct Deck ( color to be determined) Deck rails: ftberon composite deck rail Fasteners: Stainless Steel and Galvanized Screen house Wall Frame: 2"x4"wall studs,4"x4"posts Roof Frame: 2"x8"rafters,Laminate ridge, 5/8"plywood sheathing Shingles: Architectural Elk Prestige 30 yr. (color to be determined) Exterior Select primed pine Trim: Brosco- Combination storm and screen Screen units: Ceiling, Windsor primed bead board Interior Gable ends, '/2"M.D.O. plywood Trim: Brass door hardware Hardware Velux manual venting skylight Skylights Anderson Frenches ood glider Sliders I We hereby propose to furnish labor and materials—complete in Accordance with the specifications listed on the previous pages,for the Sum of. twenty one thousand fifty-five and zero cents With payments as follows: 1/3 before start of construction: $ 7,000.00 Remaining balance upon completion: $ 14,055.00 All material is to be as specified. All work to be completed in a work like manner according to standard practices. Any alteration or deviation from the specifications listed on the previous pages involving extra costs will be executed only upon a written change order and will become an extra charge above the original estimate price All agreements are contingent upon strikes, accidents or delays beyond our control Authorized Signature: Date: y �� ACCEPTANCE OF PROPOSAL Signature: Date: Estimated start date: EAGA.P. CERTIFICATE OF INSURANCE ISSUE 09/17ATE(MM/DD/YY) /2002 -PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE Byfield Insurance Agency Inc DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE 57 Main Street POLICIES BELOW. Byfield, MA 01922 COMPANIES AFFORDING COVERAGE INSURED Scott M Fiers COMPANY dba Scott Boy Construction LETTER A A.I.M. Mutual Insurance Co P O Box 826 Byfield, MA 01922 COVERAGES 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 RESPECTTO,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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATIO LIMITS LTR DATE(MM/DD/YY) DATE(MM/DD/YY) GENERAL LIABILITY GENERAL AGGREGATE $ COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG. $ LAIMS MADEE:IOCCUR PERSONAL&ADV.INJURY $ OWNER'S&CONTRACTOR'S PROT, EACH OCCURRENCE $ FIRE DAMAGE(Any one fire) $ MED.EXPENSE(Any one person) $ AUTOMOBILE LIABILITY COMBINED SINGLE ANY AUTO LIMIT $ ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ GARAGE LIABILITY PROPERTY DAMAGE $ EXCESS LIABILITY EACH OCCURRENCE $ MBRELLA FORM AGGREGATE $ THER THAN UMBRELLA FORM WORKER'S COMPENSATION STATUTORY LIMITS A AND 7007291012001 11/04/2001 11/04/2002 EACH ACCIDENT $ 100,000 DISEASE--POLICY LIMIT $ SOO 000 EMPLOYERS'LIABILITY DISEASE—EACH EMPLOYEE $ 100,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE TOWri Of North Andover EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 15 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE Attn: Building Department LEFT,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY HIND UP THE COMPANY, ITS AGENTS OR REPRESENTATIVES. 27 Charles Street AUTHORIZED REPRESENTA N. Andover, Ma 01845 NORTH ED Town of Andover No. 19 �Aco':A�q� dower, Mass., 2 pRpP ATED P �5 BOARD OF HEALTH PERMIT T Food/Kitchen Septic System • BUILDING INSPECTOR THIS CERTIFIES THAT.......*M.�.... .`�..........L r,�,N./...Itis ....................................................... oundation has permission to erect........................................ buildings on ...1. ..... .yM.�/%.......".!V 4 Rough to be occupied as..154V r4 .... .... ..��.,. ..®.P11 ...�j.�K........................... Chimney 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. /0 i/ /42 to PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN b MONTHS Final UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR 0000 1;�� * ' . Rough Service 400 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 Det. 4153 Date..../U..2,9...�...Z' NORTH TOWN OF NORTH ANDOVER p PERMIT FOR WIRING C •O��T.O�f�'�1, ACNUS� This certifies that `.X... . .�. . .. .,.—..................fir'�''........................ has permission to perform ... -' 2 ................................................. - .. .................................................... wiring in the building of..�-A.i} at ....... lic. - < r.�..... . ... ........ .North Andover,Mass. Fee..-�...�..... L . a •1�,h3. ....... .... i. . , ���................ CTRICALINSPECTOR Check # ThECOAMOAWEALTH0FMA,S'SACHUSEHSOffice Use only DEPARTMEAT OFPux1cs4FETy BOARDOFFREPREVEMONREGUL4HoNS527CMR12..M Pernu S Occupancy&Fees Checked APPLICA71ONFOR PERMIT TO PERFORM ELECTRICAL WORK 1 ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dat7, Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location(Street&Number) 17 40 n44,4f NE Owner or Tenant m)ke 'v i P;k Owner's Address�SAMe As j4bo Is this permit in conjunction with a building permit: Yesim No E3 (Check Appropriate Box) .Purpose of Building Utility Authorization No. Existing Service �,.. �flmpsVolts Overhead r__1 Under^eundn. No. of ivie'ters New Service Amps Volts Overhead Under 'round g No.of Meters Number of Feeders and Ampacity ---- Location and Nature of Proposed Electrical Work ,IA I;JC er++C�,i No.of Lighting Outlets No.of Hot Tubs , No.of Transformers Total No.of Lighting Fixtures / Swimming Pool Above Below KVA Generators KVA round round No.of Receptacle Outlets No.of Oil Burners IFIRE Emergency Lighting Battery Units No.of SwitchOutlets No.of Gas Burners No.of RangesNo.of Air Cond. Total LARMS No.of Zones No Tons of Disposals No.of Heat TotalDetection and Pum sTons No.of Dishwashers ing DevicesSpace Area HeatingSounding Devices elf ContainedNo.of Dryers tion/Sounding Devices Heating Devices Municipal Other No.of Water Heaters KW M Connections No.of No.of Si ns Bailasis No.Hydro Massage Tubs No.of Motors Total HP o+i2-li"Iccl Ott 50,u cc4 3 GFX PLue;. ®oc 461e-&� Cz�., ���lbxr 14 , s finl==Covtrage.PMM=totheiegtriternat dWb%adntsettsGU)wALaws [havEa'tzlmtLiabllityhntuulc,-�Pokyind&gConple(e 00wdliOnS C0verd9--0ritsA*s1ar1lialegttivalal YES NO [have submatedvalid proof ofsametothe 0 YES ° IfyuuhavedDdodYFS,plea9l thetypeofODWra by iIaddngthe box n , NSURANCE BOND O FEE Specify) EViratim Date, vorktoStatt 6 4 Q E1matedVahteofFlechxalWolk$ gtedund -& fpetjtny Feral rR g?�Ion 9r IV LMWNO. it rsee Sigri ahne ' �! � IicenseNo BusitmTel.No ?I WI�R'S INSURANCE W Alt Tel ANIIt;IamawarethattheLkerw_ nothawtheitnuancecoveageorits&absMtialequivalartasmgmedbyMa%whuseftsGmeralLam dthatmysigrta month SpMnitapphcationwaivt sthisregttiten-oI 'lease check one) Owner 0 Agent Telephone No. PERMIT FEE Igna ure of Uwner or gen y OCT-17-2002 09:25PM FROM-Byfield Insurance 9784620833 T-315 P.003/004 F-164 AICCERTIFICATE CIF LIABILITY INSURANCE DATE io 18 20G2 PRODUCER THIS CERTIFICATE 18 ISSUED AS A MATTER OF INFORMATION IncONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Syfield Insurance Agency HOLDER. THIS CERTIFICATE DOES NOT AMEND EXTEND OR i1 57 main St. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, P,O. Hox 400 INSURERS AFFORDING COVERAGE axet"t-d MR 01922 INSURED INSURER A PREF$RRED MUTUAL INS, CO, SOF RON, JAMES INSURER&,LEQION IN$• CO, INSURER C; 2 Old Town Way INGUBAR P; IN&Wbury MA 01950— INS COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE 13EFN 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 ISBUI_D OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 18 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, IN*R TYPE OF INSURANC! POLICY NUMBER POLICY EFFECTIVE PouOY UpiRATION LIMITS A GENERAL LIABILITY EACH OCCURRENCE6 506,000 X I C MMPRCIAL GENERAL LIABILITY FIRE DAMAGE iAny ane An 6 50,000 CLAIMSMAOE El OCCUR CPP0150536712 11/18/2002 11/18/2003 MEDEXP(Amy enaperaen) 6 5,000 PERSONAL✓d AOV INJURY B 500,000 GENEPALAGGREGATA 6 1,000,000 GEN1AGGREGATELIMIT APPLIES PER! Pft9P.U.QL8- OMP10P 6 1,000,000 POLICYEl J LOC AUTOMOBILELIASILITY / / / / GOMRINIsD SINGLE LIMIT ANY AUTO (EG eaCIdenl) 6 ALL OWNED AUTO$ / I I I BODILY INJURY SCHEDULEDAUT03 (Parperoon) 6 HIREOAUTOS / / / / BODILY INJURY NON-OWNED AUTOS IPar a0aldinD $ PROPERTY DAMAGE IPer weidenV B GARAGE LIABILITY 7 Y• C 6 ANY AUTO / / / / OTHER THAN RANG, 6 AUTO ONLY: AGG 6 EXRESS LIAOILITY OCCUR CLAIMS MADE ACCRErATE S 6 DEDUCTIBLE RETENTION 6 S B WORKIRS WC70934191 03/02/2002 03/02/2003 X EMPLOYE,L EAGHAGCtDENT 6 500,000 E,L,DISEASE-EA EMPLOYEE1 6 500,000 E.LDIBEA8E-POLICY LIMIT 19 500,000 OTHER '6 DESCRIPTION OF OPERATION&LOCATIONSNENCLES!EXCLUSIONS ADDED BY ENDOREEMENTMPECIAL PROVISIONS CERTIFICATE HOLDER AA IN URED;INSURSRLETTr-iR, CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE sXpiRATION DATE THEREOF, THE ISBUINO INSURER VALL ENDEAVOR TO MAIL 10 DAYS YYRrTTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT MIKE WOLINS FAILURE TO DO 80 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE 170 OLYMPIC L'ANE INIURGA,ITE AGENTS OR REPREOENTATVEB. AUTHOR<xfi0 6tEPNfiBENTATIYE ::::] N. ANDOnR MA 01845— CORD 25.8(7187) ®ACORD CORPORATION 1888 ,,A INS026S Ia9iapi ELECTRONIC LASER FORMS,INC.-1800)327-DSAS Pape 1 of 2 I MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) l J Mass. Date Lie W.- r City, Town Permit # Rj {20jt A � i,�AJ Building Ownerts .� AT: Location Name '3 J 3 1 424!M -- 3773— Type of Occupancy: _t2 New ❑ Renovation ❑ Replacement 3 5 39 Date.A. ... ..... i i MORTIj , TOWN OF NORTH ANDOVER 3jpy+4•.t° ,e•bp0 PERMIT FOR GAS INSTALLATION ^ a s I— W s i N S LU Ir- SACHUSEt ,. . This certifies that .'��?! t�•-��: • .. . . .•�� r•r.• . • • • • • • • • • ' • ' ' ' ' has permission for gas installation . . . . • • • • • • • • • • • • • in the buildings of . . . .F. ?.'.. . !t_. . . . . . . . . . . . . . . . . . . . . . . . . . . at ... . . . . . . .. North Andover, Mass. Fee. . . :: . . . Lic. No .,! �)i�'l. f: . . . . . . . . /GAS INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer '8TH"FCOOR—1-1—M — (Print or Type) Check One: Certificate Installing Company Name PIS E-.C"• ❑ Co Address ❑ Partnership Company Business Business TelephoneName of Li nsed Plumber or Gasfitter 1 hereby certify that all of the details and information 1 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 State Gas Code and Chapter 142 of the General Laws. I have informed the owner or his agent that I do not have liability insurance including completed operations coverage. Signature of Owner/Agent 1 have a current liability insurance policy to include completed operations coverage. ? By T PE LICENSE: Signature o Licensed Title Plumber Plumber or Gasfitter City;Town ❑ Gasfitter APPROVED (OFFICE USE ONLY) F1 Master f Journeyman License NurAer FnaM 114.1 HnwAe A WARRCM INr 1QRQ FINAL INSPECTION FEE PROGRESS INSPECTION NO. 199- 199- 199- APPLICATION 99199199APPLICATION FOR PERMIT TO DO GAS FITTING 199 199 NAME AND TYPE OF BUILDING L -NA LOCATION OF BUILDING Street Number GAS FITTER ' PERMIT GRANTED DATE 199 GASINSPECTOR l 1 /I Location / 70 { :' _-t�/,�.��.�,� 4 No. y Date r�3 MORTIy TOWN OF NORTH ANDOVER O � A i • Certificate of Occupancy $ Building/Frame/Frame Permit Fee $ NusE 9 Foundation Permit Fee $ Other Permit Fee $ ` TOTAL ' Check # e�� ( 63 ,Jb . , 1� � Building inspe6tdr • -` TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING '.1' 13 &; O-6IGI&�.ZIS `o ' BUILDING PERMIT NUMBER. � DATE ISSUED: SIGNATURE: Building Commissioner/I for of Buildings Date z SECTION 1-SITE INFORMATION O 1.1 Property.Address: 1. Assessors Map and Parcel Number: 0 0( 'C_ o Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: L4 L/ 3s �-v 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: D Public 0 Private 0 Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT rn 2.1 Owner of' Record Iiat( otd,�k � i Name(Print) Address for Service Signature Telephone 2.2 Owner of Record: S I . O Name Print Address for Service: M Signature Telephone SECTION 3 CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable 0 LicennO Con ruction upervisor. O License Number Addressj) D r Expiration date Signature Telephone r t.2 Registered Home Improvement Contractor Not Applicable ❑ v ,ompany Name 1 1 Registration Number r ,ddress r Z Expiration Date ianature Telephone SECTION 4-WORKERS COMPENSATION(M.G.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. Si ned affidavit Attached Yes.......❑ 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 Description of Proposed Work: Ig ' 33 ' b SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to beOC�IC}NixY 3 Completed by permit applicant 1. BuildingO (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee ta)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 • Wo I VLi K as Owner/Authorized Agent of subject property Hereby authorize 1JL,4 eco o o S to act on My I#ja t; i� a1 matters ative o work authorized by this building permit application. W 411, Si nature of biv r Date SECTION 7b WNER/AU(THORIZED AGENT DECLARATION 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 ff _ IOlkt� G ` Print%JdAA& a ` Si at4l of O� er/A ent Date 4 NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TM/IBERS I ST 2 3 SPAN DIMENSIONS OF SILLS DDAENSIONS OF POSTS DtTvNSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CH]NINEY IS BUILDING ON SOLID OR FILLED LAND i IS BUILDING CONNECTED TO NATURAL GAS LINE FORM - U - LOT RELEASE FORM INSTRUCTIONS: .This form is used to verify that all-necessary approval[permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. FENN on onommonammus Enameling IF FORESEEN onommungesonso owns 0 11413111 IF 0 V � — APPLICANT QQ' V� Vb�ul �'`! I! PHONE / — O �C.� ASSESSORS MAP NUMBER 16 LOT NUMBER (A SUBDIVISION LOT NUMBER STREET D 'C C--nowamonnonSTREET NUMBER 0PO OFFICIAL USE ONLY RECOND ENDATIONS OF TOWN AGENTS 1, DATEAPPROVED 3 CONSERVATION ADMINISTRATOR DATE REJECTED COND/fENT'S loo DATE APPROVED TOWN PLANNER DATE REJECTED COMMENTS DATE APPROVED F D INSPECTOR-HEALTH DATE REJECTED r ` DATE APPROVED ✓� Z O SE C INSPECTOR-HEALTH }— DATER,EJECTED COMMENTS c' ✓ l") �Z^ ! ^ o �c �—r— V CP T.+ PUBLIC WORKS—SEWER/WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPARTMENT DATE REJECTED i COMMENTS RECEIVED BY BUILDING INSPECTOR DATE • NORT#t S Town of North Andover * s 1 Building Department 27 Charles Street 9SSaCHus�t North Andover MA 01845 Tel: 978-688-9545 HOMEOWNER LICENSE EXEMPTION Please print. DATE ©� JOB LOCATION 0 0livLO L.4� Number V Street Address Section of Town "HOMEOWNER 5�kffid- 6 g fO,6 b l d Number Home Phone Work Phone PRESENT MAILING ADDRESS I�IV� r City Town State Zip Code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. (State Building Code Section 109.1.1) DEFINITION OF HOMEWOWNER: Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is, or is intended to be, a one to six family dwelling, attached or detached structures ac- cessory to such use and and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official, a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned homeowner"assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned"homeowner"certifies that he/she understands the Town of No.Andover 1 Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFICIAL Note:Three family dwelling 35,000 cubic feet, or larger, will be required to comply with State Building Code Section 127.0 Construction Control. I� MORTGAGE INSPECTION • ®AY STATE SURVEYING ASSOCIATES INC. JOB # 100 CUMMIN , GS CENTER SUITE#316J, BEVERLY,MA., 01815 . N4R i N A 4 Da vER ti1A HOTes: LOCATION :.........................................*.......... 1)This is a mortgage inspection survey and not an instrument survey,therefore this Piot pian is for SCALE : r = So DATE ..............' .. .......�Z............. mortgage inspection purposes only.it is NOT to .... be used to estabilsh boundaries or for the construction of any type of improvements. REFERENCE : . �K' `��5.....f'•�•--'..•---•--.••••••••••• 2)This survey is based on survey marks of others. �S ^ �+••- j - ............ 3)3)Bushes,shrubs,fences and tree tines do not . ..................... ................................0.................... necessarily indicate property lines. 4)Whenever an offset is 1't-or less,an instrument TO.,EyFSR 7 tJ61 lav'A .»..64;14y survey Is recommended to determine property The location of the building(s)as shown,either Ones,and any possible encroachments. complied with the local zoning setbacks at the time of 5)Offsets shown are approximate,and.am Wbe construction or Is exempt from violation enforcement action used only for the determination of zoning,Not to under Mass.Q.L Title VII Chapter 40A Section 7 be used to establish property tines. 0)in my professional opinion the building(s)aro not located In the special flood hazard zone,as defined by H.U.D.MAP# Z,So p 90 -z-g3 z36 L MEQ/ Q (A-r44353 o L.07' ell ZZ 7-62 Arlo 4 Rollo E THE SURVEYOR'S THE Pt SEAL 15 NOT EMBOSSED,THE PSN IS A COPY ru.T cwni 110 BE ASSUMED TO NORTH Town of ^.. Andover °�A coc.Ic dower, Mass., 3 �,p �RA7ED C, S E BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System THIS CERTIFIES THAT..... BUILDING INSPECTOR .��. a.. .. ............ ...... . ..................................................._................ Foundation has permission to erect... .. X....+ _._.... buildings on ................IQ............. Rough p A..6.O.V.%....... .r� �00 �.' �► a h (� Chimney to be occupied as ..... f v .............................. . provided that the person accepting this p it 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 Inspe tion, Alteration and Construction of j Buildings in the Town of North Andover. 'O& / ' ��� �O� PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough 4�Asta�N Id' PERMIT EXPIRES IN 6 MONTHS Final e UNLESS CONSTRUCTIONSTARTS ELECTRICAL INSPECTOR `►O4 t o~+% r Rough mo .......................................................... Service _ BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFina, No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner s I Street No. SEE REVERSE SIDE Smoke Det. n Date. . . .�... . .°... .. .. . . f ,4ORTH pf ­to ,°140 of TOWN OF NORTH ANDOVER F 9 • PERMIT FOR GAS INSTALLATION . � h SS us This certifies that . . {:: . . . . . . . . .. y 2�'f ) . . . . . . . . . . . . . has permission for gas installation :.-P � - . . . . . . in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . at ./.71 ... . . .r.� --�!. . . . , North Andover, Mass. Fee.�. "�. Lic. No.. . . . . . . . . . .�. . . . . . . . . . . . GAS INSZY G'OR Check# � 444 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) — /II iAf) 1� Mass. Date City, Town Permit # Building Owner'st AT: Location jh1 Name j7QYjL fi(/hln/K Type of,Occupancy: A New Renovation ❑ Replacement ❑ Plans Submitted Yes ❑ No N N W U; 1C Z W N N N U N OC N O M N = F W J Npm W O V m H = N Z O W 1. Q 0 Z = O Z W 00 N N W W O C a W F^ W 4 1� N > 4 W W O W Z a x W N W 4 O O N z 0 f- Z s H Z r W W O O > W N J fN- W Z Q W 6 OC f >' ta) O z O Z W O 0 S Q W > oc W Z 4 W tti 4 O O W O W H OC s O 0 Z W M >+ o tti J U W > A a. H O SUB—BSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RDFLOOR .4TH FLOOR STH FLOOR 6THFLOOR 7TH FLOOR 1 8TH FLOOR IIIII H ] I III 11111H (Print or Type) Check One: Certificate Installing Company Name Sc& A Re-MI& ❑ Corp. Address CeNiP—A SA ❑ Partnership i 'Z't>5w �lg• ❑ Firm/Company Business Telephone 33-&- 01931 Name of Licensed Plumber or Gasfitter 1 I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate tolthe 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 State Gas Code and Chapter 142 of the General Laws. I have informed the owner or his agent that I do not have liability insurance including completed operations coverage. r Signature of Owner/Agent I have a current liability insurance policy to include completed operations coverage. ❑ By TYPE LICENSE: Plumber Signature of Licensed Title Plumber or Gasfitter City/Town ❑ Gasfitter APPROVED (OFFICE USE ONLY) ❑ Master Journeyman License Number i FORM 1243 A.M.SULKIN CO. 1989 1 I or BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES PROGRESS INSPECTION FEE NO. APPLICATION FOR PERMIT TO DO GASFITTING NAME & TYPE OF BUILDING LOCATION OF BUILDING PLUMBER OR GASFITTER LIC. NO. PERMIT GRANTED DATE GASINSPECTOR Date.. .......... ' NoRTM it ot TOWN OF NORTH ANDOVER A PERMIT FOR WIRING ro �sSACHUSE� This certifies that ....... ..................................... 'hIs permission to perform .. - -QA..................................................... wring in the building of...:�� .:............................................................. at.f 7�? r.'`'f✓�^` � � ,North Andover,Mass. ......................................... .......... Lic.No.� ` . A j .............................................. f..,..,. ELECTRICAL INSPECTOR Check # -Wc 4563 TBECOMMONWEALTHOFMASSACHUSETIS Office Use only DEP4R77111 NTOFP[jT,UC,W,M BOARD OFFIREPREVEWONREGULATIONS527CA R 12..00. Permit No. Occupancy&Fees Checked APPLICARONFOR PERMIT TO PERFORMELECMCAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Town of North Andover To the Spector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location(Street&Number) -7D -- NC4 1C Z423 e Owner or Tenant InI Owner's Address �m Is this permit in conjunction with a building permit: Yes a No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amp �Volts Overhead Underground No. of Meters New Service Amps / Volts Overhead Und ergiound No.of Meters Number of Feeders and Am aci P h' Location and Nature of Proposed Electrical Work No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total No.of Lighting Fixtures Swimming Pool Above BelowGenerators —VA round round No.of Receptacle Outlets No.of Oil Burners No.of Emergency Lighting Battery Units I KVA No.of Switch Outlets No.of Gas Burners No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones—� Tons No.of Disposals No.of Heat Total Total No.of Detection and Pum s Tons KW Initiating Devices No.of Dishwashers Space Area Heating KW No.of Sounding Devices No.of Self Contained Detection/Sounding Devices No.o>f•Dryers Heating Devices Key LocalMunicipal Other No.of No.of No.of Water Heaters KW E Connections signs Bailasis No.Hydro Massage Tubs No.of Motors Total HP OTHER laws imuanoeCrvt Rust� tathetagtmana>fsofMassad» haveaama�>rLiabililyhmuanoepblicy>n�g�]� wworitsCos alapiivalant YES NO ha 'gT dvalidploof tatheOhice YES ffyutharedled�dYES,Pleaseir>tethetypeofocwerapby VSURANCE BOND OTS SPAY) / 3 101k to StartEshrn d VahiedE1xftxal Wc&$ ignodundcrtrr t M iescfpqjuT.. --�-^ hWocfiiD& RoughFinal `./ bA V �U �C LicaiseNo. _� 33 BtisQmTel.N0. / GlCt�!'l�� iW1V�'S INSURANCE W Alt Tel.No ANFRJamawarethatthe doesnothavetheit�sutanceooveiageorZatstarMegnvalfflasmgiuudbyMa%whiismGeneW am Jthatmysignahueonthispentritapphcati(riwaivesthisiegtmei ut lease check one) Owner M Agent Telephone No. PERMIT FEE$ Signature or Owner or Agent � Location-/7,9 No. ��5� Date TOWN OF NORTH ANDOVER 3? o c c A Certificate of Occupancy $ CHU Building/Frame Permit Fee $ Foundation Permit Fee $ A Other Permit Fee $ TOTAL Check #47-121 - i 70/ 86 ' ..._,� Building inspector 4 - TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMTr NUMBER: DATE ISSUED- / SIGNATURE: i t Buildin Commissioner/I for of Buildings Date r SECTION 1-SITE INFORMATION IO l.1 Property Address: 1.2 Assessors Map and Parcel Number. 0 0 P P1 C Lan t_ Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area Fronts ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required- Provided Reqtlired Provided v 1.7 Water Sapply M.G.L.C.40. 34) 1.3. Flood Zone Information: 1.8 Seweage Disposal System: Public 0 Private 0 Zone Outside Flood Zone ❑ Municipal 0 On Site Disposal System 0 _J SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 11171711c; >>Sti iCt: `/, (,10 M 2.1 Owner of Record Name(Print) Address for Service: Signature Telephone /� �,� 2.2 Owner of Record: i Name Print Address for Service: 0 M Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: 0 License Number tAddress ` Expiration Date 4gnature Telephone �.. 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company-Name I - J 7 M S r� fi s"r kQ to e Mqss Registration Number r ess 1 V l 7 R (/D�S' ro r�yrr G sG. ' ��� ! �.� � � V1 Expiration Date Signature I elephone SECTION 4-WORKERS COMPENSATION(XG.L C 152 1 25c(6) J 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 ao a licabk 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 OFFICIAL USE ONLY i' Completed by permit applicant 1. Building 660(), 00 (a) Building Permit Fee Multiplier 'S 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)x(b) 4 Mechanical HVAC c 5 Fire Protection � 6 Total 1+2+3+4+5 Up 60 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 l c,k+;-e- D U to act on My, alf, all tter r lati a to work authorized by this ldnrg permit application - 0 Signature of jr Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION / p I, I '/y�l 1 I L'h a e L ' ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are Lrue and accurate,to the best of my knowledge and belief P�ir Namelie J f ature of Owner Agent Date / NO. OF STORIES SIZE r BASEMENT OR SLAB SIZE OF FLOOR TIIv1BERS 1 2 3 i SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CBRVINEY 1S BUILDING ON SOLID OR FILLED LAND IS BLUDING CONNECTED TO NATURAL GAS LINE C NpRT►y '9 0 0Andover r LA o dover, Mass., O COCMICHEWICK V 7 ADRATED 9`S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT........ ... L400.0 .�am�.. ... ....... ....................................... ..... Foundation has permission to erect........................................ buildings on ...1.7............................. .... .... ...... .. ................. Rough to be occupied as . .... .... .... ... .. ....... ........ . ... .. .... .. ...... ............................ ............................. Chimney provided that th perso ccepting this permit shat n every respect conform to the terms of the application on file in Final this office, and to the p visions 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 6 MONTHS UNLESS CONSTRUCTION STARTS. ELECTRICAL INSPECTOR � r ugh .,,..:� .. ...................................... Service B ILDING INSPECTOR Final Occupancy Permit Required t0 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 Det. ' 1 g The Commonwealth of Massachusetts M Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers'Compensation Insurance Af davit Name i G��- o Please Print Name: Location: ' City Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity dI am an employer ploy p rovidi ng workers compensation for my employees working on this job. I Address CAS M t . r-1 O)!2 S`t' C Owe//q S 1 J L' —/0 Insurarm.Co. \1D V Company name: Address Cox. Phone# Insurance Co. Policy 9 Feikue to some coverage as required under Section 25A or MOL 152 can lead to the imposition of criminal psnattlea af,a fine up to$1,5W.00 andtor one yeas'imprlsorrrrent_as.WBU.as_chdl peaa0min!helcr dASTQPWDRK..ORDERaud.a.fine of.01W.0W-8j*against ale. I understand that a copy of this statement may be forwarded to the office d Investigations of the DIA for coverage verification. 1 db hereby under the alai and senalHes or perjury that torr provided above Is&W and correct, !7 Signature1 Date Print name Mtc- C( e. c1 n s @,.t Phone# Of lel use only do not write in this area to be completed by dty or tam official' City or Town P ai ❑Check it Immediate response Is requfed ❑ Building Dept ❑ Licensing Board ❑ Selectman's Office Confect person: Phone#k ❑ Health Department ❑ Other e t -"� Board of Building gpgplations.and Stands-Rh- HOME IMPROVEMENT CONTRACTOR Registration: 120097 F_ ` Expiration: 10/17/2005 Type: Individual MICHAEL J. DOHERTY MICHAEL DOHERTY 165 MT. HOPE ST. � LOWELL, MA 01854 Administrator North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. The debris will be disposed of in: A1�1)U CD e5Cib (Location of Fa ility) Signature of Permit Applicant /0, Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector PROPOSAL I r f PROPOSALNO. I SHEET NO. DATE PROPOSAL SUBMITTED TO: WORK TO BE PERFORMED AT: NAME ADDRESS o L l ADDRESS, DATE OF PLANS PHONE NO. ARCHITECT We hereby propose to furnish the materials and perform the labor necessary for the completion of t d 4 _ �r .. ,•.f;,,;. '� wf°}�- J _� tf°�,, t�� c �+` �. �.. �t ' � ;i� �J`' :��`-�, k? =,+..l ��� �' 4 f '9++. rc�.�!_ � ��'4.� i. � �. { `t`�.'�„t �•'ilxx °,3 iJr F '�`���e '�.,.•'Erik � "` t;: ..s: f '°� 1...+�A 4 �"4� r '`t. '� ��Y�f 4 w # C. E 't 1 l✓ ` C f-+ ta..� �./rr� i._t ( 'r 'A x < f—v L Nk pj c `l (11' r" I �.t: !`i :_ -."'t h 4(�! s.' � ice' �` � '�� i•�.+..! t✓` +'`r ���.,,, ' AL1 1.'. L `t `� } U of t n 7_- " 0:N (V 1 t U k�> J --'IN (fir 1'f ('p ' E. / F i * t All material is guaranteed to be as specified, and the above work to be performed in accordance with the drawings and specifi- cations submitted for above work and completed in a substantial workmanlike manner for the sum of Dollars ($ ) with payments to be made as follows. Respectfully submitted Any alteration or deviation from above specifications involving extra costs will be executed'only upon written order, and will become an extra charge Per over and above the estimate. All agreements contingent upon strikes, ac- cidents,or delays beyond our control. _Note-This proposal may be withdrawn by us if not accepted within days. ACCEPTANCE OF PROPOSAL The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payments will be made as outlined above. Signature II ��t� �� ✓ -`f' ` I Date Signature McAdams381850 PROPOSAL MADE IN USAA - ,�• 3...'` \ i.� " # t 'M '"fit