HomeMy WebLinkAboutMiscellaneous - 174 CANDLESTICK ROAD 4/30/2018w
6 �;
Date ........ 7 .......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ....................►�f .... ..................
has permission to perform ....... 44. L C .. / 'q/ 4ih.
.... ........
wiring in the building of ............................ ff. ... ft (� ................................
at .... j.... 7..V.!:� ........................... . North Andover, Mass.
Fee .*�- i ...... ... Lic.
..... .... '.z.........
��EMICAL NSUCTOR
Check it
L.UIIIII/U/IWCQ/LII UI IwICIJ 0C7L,1/LIDCLLD --- - q- - '
Permit No.
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 7 � 30 ,-
City or Town of. NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives tice of his or her intention to perform the electrical work described below.
Location (Street & Number) ! 7
Owner or Tenant 110 .4 ;-c T d A#,. je -eole f Telephone No. �— Yd
Owner's Address .S /9'!!,'
Is this permit in conjunction with ab ' ding permit? Yes No ❑ (Check Appropriate Box)
Purpose of Building 06 �- . Z4 G -e Utility Authorization No.
Existing Service Amps Volts Overhead ❑ Undgrd ❑ No. of Meters
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: W♦ /'Lo Jo,7SiAOi'.� s�j
Completion of the following table may be waived by the Inspector of Wires.
No. of Recessed Luminaires
No. of Ceil: Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑ In-
rnd. grnd. a
o. of Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
I No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Number
...................................................
Tons
KW
No. of Self -Contained
Totals:
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water KW
No. of No. of
Data Wiring:
Heaters
Signs Ballasts
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: 7,30-/6 Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such �pqs in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
I cert, under the ams antipeiLaities ofperjury, that the info Mggtion on this application is true and complete. ��J
FIRM NAME: G!t{�^ e LIC. NO.: 11?" l`
Licensee: � j Signature LIC. NO.: '
(If applicable, ent "exnzpt" in the license nu �� `/ ` ,.� Bus. Tel. No -9-v—,460r-%�G 7
Address: 'i'f tom'' Alt. Tel. No.:
*Per M.G.L c. 147, s. 57-61, security work requires D@frartment of]Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's
Owner/Agent PERMIT FEE. �
Signature Telephone No.
r
l�
PO C -
Vim, ok
i
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information 9-40_eC1__
Please Print Legibly
Name (Business/Organization/Individual): �y�
Address:
City/State/Zip: Wt n .es ,41<X !Aryl O/FlOPhone �. 33&_3
Are you an employer? Check the appropriate box:
1. am a employer with
4. ❑ I am a general contractor and I
_/
` employees (full and/or part-time).*
have hired the sub -contractors
2.•0I am a sole proprietor or partner-
listed on the attached sheet. t
t, ship and have no employees
These sub -contractors have
I working for me in any capacity.
workers' comp, insurance.
[No workers' comp. insurance
5. [:1 We are a corporation and its
required.]
officers have exercised their
3. ❑ 1 am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
*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 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 N
Policy # or Self -ins. Lie. #:
Expiration Date:
I '`
Job Site Address: �2 `� � �Us6,i /� City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify ynder the pain penalties of perju at the information provided above is true and correct.
Phone #: f :�_ 15�� / ZMK�7
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
TOWN OF NORTH ANDOVER
Office of the Building Department
01* %40 oT',' �,to Community Development and Services
1600 Osgood Street, Bldg. 20, Suite 2035
" North Andover, MA 01845
978-688-9545
Donald Belanger, Inspector of Buildings
To: Peter and Denise Roemer
Fr: Donald Belanger
Re: 174 Candlestick Road, North Andover, MA
Dear Mr. and Mrs. Roemer,
September 1, 2016
This office received a complaint concerning a commercial vehicle parked overnight on your
property at 174 Candlestick Road. This is a violation of the North Andover Zoning Bylaw, Section 8.1 Off
Street Parking; 8.4 Screening and Landscaping Requirements for Off Street Commercial Residential
Districts.
You are hereby ordered to cease and desist and further parking of your commercial vehicle at
the aforementioned property; report to the Building Department within fourteen (14) days of the
receipt of this notice to resolve this violation.
If you feel that you have been aggrieved by any actions I have taken or failed to take, you have
the right to appeal to the Town of North Andover Zoning Board of Appeals or the Massachusetts State
Building Board of Appeals accordingly.
Ark. `Tromblj
9'7g- L17? - 5 F70 Ce- ► t
F7 8 103
Sincerely,
Donald Belanger
Inspector of Buildings
1-7q CaOco 10-41ck
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TOWN OF NORTH ANDOVER
f NORTH Office of the Building Department
Community Development and Services
a.:• 6 O
1600 Osgood Street, Bldg. 20, Suite 2035
North Andover, MA 01845
978-688-9545
Donald Belanger, Inspector of Buildings
September 1, 2016
To: Peter and Denise Roemer
Fr: Donald Belanger
Re: 174 Candlestick Road, North Andover, MA
Dear Mr. and Mrs. Roemer,
This office received a complaint concerning a commercial vehicle parked overnight on your
property at 174 Candlestick Road. This is a violation of the North Andover Zoning Bylaw, Section 8.1 Off
Street Parking; 8.4 Screening and Landscaping Requirements for Off Street Commercial Residential
Districts.
You are hereby ordered to cease and desist and further parking of your commercial vehicle at
the aforementioned property; report to the Building Department within fourteen (14) days of the
receipt of this notice to resolve this violation.
If you feel that you have been aggrieved by any actions I have taken or failed to take, you have
the right to appeal to the Town of North Andover Zoning Board of Appeals or the Massachusetts State
Building Board of Appeals accordingly.
Sincerely,
Donald Belanger
Inspector of Build Hw4j I
TOWN OF NORTH ANDOVER
NORry
Office of the Building Department
6tio
�ttlD ,.6
Community Development and Services
1600 Osgood Street, Bldg. 20, Suite 2035
'
70
North Andover, MA 01845
�L
978-688-9545
o ATfD
SSACHU`���
Donald Belanger, Inspector of Buildings September 1, 2016
To: Peter and Denise Roemer
Fr: Donald Belanger
Re: 174 Candlestick Road, North Andover, MA
Dear Mr. and Mrs. Roemer,
This office received a complaint concerning a commercial vehicle parked overnight on your
property at 174 Candlestick Road. This is a violation of the North Andover Zoning Bylaw, Section 8.1 Off
Street Parking; 8.4 Screening and Landscaping Requirements for Off Street Commercial Residential
Districts.
You are hereby ordered to cease and desist and further parking of your commercial vehicle at
the aforementioned property; report to the Building Department within fourteen (14) days of the
receipt of this notice to resolve this violation.
If you feel that you have been aggrieved by any actions I have taken or failed to take, you have
the right to appeal to the Town of North Andover Zoning Board of Appeals or the Massachusetts State
Building Board of Appeals accordingly.
Sincerely,
Donald Belanger
Inspector of Buildings
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7/28/2016 2967.] peg
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NORTH
Of At�.o ,°qN
1
�.9 DAATeD �PP,�'(DJ
SSACHUS�
Inspectional Si
Complaint Inve:
Date 7L12 4SK—Cor
Address In Question % ! �� 6"cor-�,ra
Property Owner �� �� y z -one
Complaint 14�71�� t. �kc2SS L i„�,, /s e!AL(:a
c K yr a 1 v¢u-'-, W 7 /4V
Person Making?� �l
Complaint ��lS rG Phone
Complainant's Address'�S _;-f C (/�
By Telephone In Person By Mail
Inspector Assigned
Action Needed: Return Call Site Inspection
Send Letter Date Sent
6-7 z5- 2,0/6 "At ro erzl�cf— ��k•�cy c�.v°r. ��.�7,
Inspector's Notes
Further Action If J
Reid 7` - YID4V p67 b /SC GS
Complaint Tracking
Initial Date of Complaint '1�'72�Xy Additional Action Required
Site Visit Date
Letter Sent Date Date Investigation Closed
Follow Up Date Time Spent On Complaint.
A NORTH
O�4t�1D Me�'Y
Complaint #
Inspectional Services
Complaint Investigation
Date 7 2-/,70 Complaint Taken By
Address In Question �� ���/t�S'�lC�� p �d Lot
Property Owner Zone
Complaint 14 -,✓`-tri✓ �xceSS'firt�. %S %�c c�
b tv- h;--4 t K Vr 6 i
f121 Ct VE -
Person Making r
Complaint �'1"I.S �-� Phone
Complainant's AddressJ> S�
By Telephone,
Inspector Assigned
In Person
Action Needed: Return Call Site Inspection
By Mail
Send Letter Date Sent
0-7 z.� 2,0/ 6 CAU To C& -11111441114 -7 -
Inspector's
& -1111149..-T
Inspector's Notes
Complaint Tracking
Initial Date of Complaint 1 Additional Action Required
Site Visit Date
Letter Sent Date Date Investigation Closed_
Follow Up Date Time Spent On Complaint,
practicable, existing trees shall be retained and used to satisfy this section. The following graphics
are intended as illustrations and examples only and have not been incorporated into the
requirements of this Bylaw. (See graphic after Tables and Footnotes at end of Bylaw).
6. All artificial lighting used to illuminate any commercial or industrial parking lot, loading bay or
driveway shall have underground wiring and shall be so arranged that all direct rays from such
lighting falls entirely within the parking, loading or driveway area, and shall be shielded or
recessed so as not to shine upon abutting properties or streets.
Village Commercial Dimensional Requirements
In the Village Commercial Zoning District the following requirements shall be adhered to. The
following requirements are only to be placed upon the Village Commercial Zoning District and shall
take the place of the proceeding regulations found in paragraph 1-5.
Screening
Objective: Due to the high aesthetic standards to which the architecture shall be made to conform, the
maul purpose of the screening shall be to screen the parking and other accessory structures which may
be a part of the development, the Planning Board may require any additional screening as may be
reasonably required.
a. All buffer zones must be designed by a registered landscape architect, or other professional as
approved by the Planning Board.
b. The Planning Board recommends that materials to be used in the buffer include but not limited
to the following material:
Natural/existing vegetation, natural topography, berms, stone walls, fences, deciduous and
coniferous shrubs/trees, perennials, annuals, pedestrian scale walkways, gazebos and other
landscape material as it addresses the aesthetic quality of the site. The final approval of all
material used within the buffer zone shall be at the discretion of the Planning Board.
c. Parking lots containing 10 or more spaces shall be required to provide one tree for every five
spaces. All trees shall be a deciduous mix of at least 2.5 inch caliper when planted. Native
trees and shrubs shall be planted wherever possible, in order to capture the "spirit of the
locale" through indigenous species (such as lilac, viburnum, day lilies, ferns, red twig
dogwood, oak, maple, sycamore, linden, hawthorne, birch, shadbush, etc.). In instances where
healthy plant material exists on the site prior to its development, in part or in whole, for
purposes of off street parking or other vehicular use areas, the Planning Board may adjust the
application of the above mentioned standards to allow credit for such plant material if, in its
opinion, such an adjustment is in keeping with and will preserve the intent of these standards.
d. To produce parking which is aesthetically pleasing, well screened, accessible and broken into
smaller parcels that may directly and adequately service adjacent structures, a minimum of 5%
landscaping and green space must be provided for all parking areas. This 5% is not intended to
include the buffer zones, but shall include all internal landscaped islands in the parking areas.
In all instances where natural topography lends itself to the screening of these parking areas it
shall be left in its natural state. The Planning Board may at their discretion require additional
screening at the owner's expense.
Residential Districts
Commercial vehicles in excess of one (1) ton capacity shall be garaged or screened from view of
residential uses within three hundred (300) feet by either:
a. A strip at least four (4) feet wide, densely planted with trees or shrubs which are at least four
(4) feet high at the time of planting and which are of a type that may be expected to form a
year-round dense screen at least six (6) feet high within three (3) years, or
102
b. An opaque wall, barrier, or fence of uniform appearance at least five (5) feet high, but not
more than seven (7) feet above finished grade. Such screening shall be maintained in good
condition at all times, and shall not be permitted to exceed seven feet in height within required
side yards. Such screening or barriers may be interrupted by normal entrances or exits and
shall not be required within ten (10) feet of a street lot line.
c. Garaging or off-street parking of an additional two (2) commercial vehicles may be allowed by
Special Permit. When it is deemed to be in the public good, parking for additional pleasure
vehicles may be allowed by Special Permit.
8.5 Planned Residential Development (PRD)
2. Purposes: The purpose and intent of the regulations contained in this section are to promote the
public health, safety and general welfare of the citizens of the Town by providing for the
following goals:
a. To promote the more efficient use of land in harmony with its natural features;
b. To encourage the preservation of open space;
c. To protect water bodies and supplies, wetlands, floodplains, hillsides (1994/40), agricultural
lands, wildlife, and other natural resources;
d. To permit greater flexibility and more attractive, efficient and economical design of residential
developments;
e. To facilitate economical and efficient provision of utilities;
f. To meet the town's housing needs by promoting a diversity of housing types.
3. Applicability: An application for a Planned Residential Special Permit (PRD) shall be allowed for
parcels of land in the R-1, R-2, and R-3 Districts in accordance with the standards set forth in this
section. An application for a Planned Residential Development Special Pernnit shall be deemed to
satisfy the requirements for Site Plan Review.
4. Permit Authority: The Planning Board shall be designated as the Special Permit Chanting
Authority, and shall grant special permits for PRD's consistent with the procedures and conditions
set forth in this section as well as in Sections 10.3 and 10.31 (Special Permits) of this Bylaw.
5. Procedure for Approval:
Preliminary Plan -
The applicant must submit a preliminary plan per Section 6(G) (1994/40) and schedule pre -
application conference to discuss the proposed PRD with the Planting Board before the
submission of the final special permit application and supporting documents, to the Board for
review in a public hearing.
Final Plan Submittal
The applicant shall follow the procedures and standards contained in this section and Section 10.3
(Special Permit) in submitting a set of final plans to the Planning Board for review.
6. Information Required: Any applicant who desires a special permit under requirements of this
section shall submit an application in writing in such form as the Planning Board may require
which shall include at the minimum the following:
A. Development Statement: Which shall consist of a petition; a list of the parties of interest with
respect to the PRD parcel and any parcel proposed to be used pursuant to the subsection 5a
below. A list of the development team and a written statement meeting the requirements of a
site evaluation statement under the Subdivision Rules and Regulations of the Planning Board;
103
'i
Date.�.��� .........
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ...../ Z'.%�
has permission for gas installation . / 4r: V . � ............
in the buildings of
at .../ C,&, 4 .......... North Andover, Mass.
y
Fee..}'1.. .. Lic. No../.):?./ `... .....
GAS INSPECTOR
Check #
Ti 57
F�oo�
MASSACHUSETTS USH ORM APPLICATON FOR PERMIT TO DO GASG
7
(Type or print) Date
–3. 7�
NORTH ANDOVER, MASSACHUSETTS
Building Locations 7 ' 1�
2 y Permit #
—`—
Owner's Name Amount $ / ,� /
New ElRenovation Replacement V11 Plans Submitted ❑
G
SUB-BASEM ENT
BASEM ENT'
1ST.
F L 0 O R
2ND.
FLOOR
3RD.
FLOOR
4TH.
FLOOR
5TH.
FLOOR
6TH.
FLOOR
7TH.
B.TE.
FLOOR
FLOOR
(Print or type)
Name
Name of Licensed Plumber or Gas Fitter �j e
C((heckk o e: Certificate Instal Company
L� °rp' -
Partner.
Firm/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes No ❑
If you have checked Les, please ' cate the type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnity ❑ Bond
13
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Signature of Owner or Owner's Agent Check one:Owner ❑ A ent ❑
I hereby certify that all of the details and information I have s
best of my knowledge and that all plumbing work and installa
compliance with all pertinent provisions of the Massachusetts
Title
City/Town
(OFFICE USE ONLY)
g I
(Or entered) in above application are true and accurate to the
-Ormed under Permit Issued for this application will be in
s C# pter 142 of the General Laws.
tt# of Licensed Plumber Or Gas Fitter
PlArnber l/
Gas Fitter lcense umber
Journeyman
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w
w
m
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W
m
w
F
Q
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a
H
p
Name of Licensed Plumber or Gas Fitter �j e
C((heckk o e: Certificate Instal Company
L� °rp' -
Partner.
Firm/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes No ❑
If you have checked Les, please ' cate the type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnity ❑ Bond
13
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Signature of Owner or Owner's Agent Check one:Owner ❑ A ent ❑
I hereby certify that all of the details and information I have s
best of my knowledge and that all plumbing work and installa
compliance with all pertinent provisions of the Massachusetts
Title
City/Town
(OFFICE USE ONLY)
g I
(Or entered) in above application are true and accurate to the
-Ormed under Permit Issued for this application will be in
s C# pter 142 of the General Laws.
tt# of Licensed Plumber Or Gas Fitter
PlArnber l/
Gas Fitter lcense umber
Journeyman
Date.
•�� TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
MGIC '� '09 Ila
This certifies that .............. ...'....... .
has permission to perform ...... ..`.. .............. .
plumbing in the buildings of ... ..................
at .. /.. ....... .. , North Andover, Mass.
Fee. A...... Lic. No.P .) /! .. ...... :�. ^. '..... .
PLUMBING INSPE40j
Check #
B5 Li 4
�r
y
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or Print)
NORTH ANDOVER, MASSACHUSETTS
((�� Date 7
Building Location /L� S A) Permit
Owner t
R / 6 / t Amount `
New 0 Renovation rl Replacement Plans Submitted Yes No
FIXTURES
(Print or type) / , /i � � 1 / / Check ne: ���grttficate
Installing Company Name /-�-c't [� (�/ 7`C, 1311"Orp. �- (J
Address / /3 r a c L❑J Partner.
QV; /
Business Telephone 7 Firm/Co.
Name of Licensed Plumber: J EJ:: - L �u lNj
Insurance Coverage: Indicatethe type of insurance coverage by checking the appropriate box:
Liability insurance policy IJ Other type of indemnity 11 Bond
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner
I hereby certify that all of the details and information I have
best of my knowledge and that all plumbing work and instal
compliance with all pertinent provisions of the Massachuset
By: igna
Zcens`e"ONTIF
Title
City/Town
APPROVED (OFFICE USE ONLY
Agent ❑
Led (or entered) in above application are true and accurate to the.
r under Permit Issued for this application will be in
Pl -Chapter 142 of the General Laws.
License
Master Journeyman
E
t7c/
Location/
_ a?3 d y
No. Date
NORT1y TOWN OF NORTH
ANDOVER
0:.•o ,•�ti0
Certificate Occupancy
$
of
s roe &Eta' Building/Frame Permit Fee
sACMus
$
Foundation Permit Fee
$
Other Permit Fee
$
TOTAL
$
Check #
174u`i
' Building Inspector
r
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER: DATE ISSUED: OZ��
SIGNATURE:
Building Commissioner/Inspectilfof Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map
Map Number
and Parcel Number:
r
Parcel Number
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Area (sf) Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Required Provide Required ProvidedRequired
Provided
T—
—+ I
-
1.7 Water SupplyM.GL.C.4& 54) 1.5. Flood Zone Information:
Public ❑ Private ❑ Zone Outside Flood Zone 0
— 11
1.8 Sewerage Disposal System:
Municipal ❑ On Site Disposal System 0
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZEDAGENT
liSr.OrIC (St(ict: Yes NO
2.1 Owner of Record
Name Print) Address for Service
Signature Telephone
2.2 Owner of Record:
NaAie Print Address for Service:
Signatvre Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor:
Address l
,MW c774 UGC XIW-1
Signature Telephone
(Y�
Not Applicable ❑
—
License NumY--�
(�s)
Expiration Date
3.2 a 'stered Home Improvement Contractor
Not Applicable ❑
d J
Company Name
j, C/% ��C��,)G^
/ / ` 7
Registration Nu ber
`
6
Expiration ate
Address
Si36aj,re Telephone
a
SECTION 4 - WORKERS COMPENSATION (NVLG.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 buildinE permit.
Signed affidavit Attached Yes .......0 No ....... 0
SECTION 5 Description of Proposed Work check all
applicable)
New Construction 0
Existing Building ❑
Repair(s) ❑
Alterations(s) ❑
Addition 0
Accessory Bldg. 0
Demolition ❑
Other ❑ Specify
Brief Description of Proposed Work:
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
OFFICIAL USE ONLY
1. Building
(a) Building Permit Fee
Multiplier
`
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
I, as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf, in all matters relative to work authorized by this building permit application.
Si rature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
I, as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
L
Prin a e
� 23 ate(
Si a e of Owner/A t Date
NMI INEI
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 15 2` 3RD
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GMERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHEVINEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUR,DING CONNECTED TO NATURAL GAS LINE
The Commonwealth ofMassachusetts
Department of Industrial Accidents
f = Office oflnl/estigatinns
_ - 600 Washington Street, 7" Floor
' 4lv Boston, Mass. 02111
Workers' Compensation Insurance Affidavit: Building/Plumbing/Electrical Contractors
name: HCl CAG—
address: 6-6 e- - OL< �2
city 4f LI i= 7;V J (' y► state: /144 zip: 6/9 If Y phone #
work site location (full address): / �7 51/
U I am a homeowner performing all work myself. Project Type: ❑ New Construction ❑Remodel
❑ I am a sole proprietor and have no one working in any capacity. ❑ Building Addition
❑ I am a sole proprietor, general contractor, or homeowner (circle one) and have hired the contractors listed below who have
I do hereby ce ' u er th ains a d penalties of perjury that the information provided above is true and correct.
Signature \ Date
Print name L1 a `�h A An Phone #
official use only do not write in this area to be completed by city or town official
city or town: permit/license # ❑Building Department
❑ check if immediate response is required ❑Licensing Board
❑Selectmen s Office
[]Health Department
contact person: phone #; ❑Other
(revised Sept 2003)
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the "law", 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 section 25 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, 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.
x t
Applicants
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation. Please
supply company name, address and phone numbers along with a certificate of insurance as all affidavits 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.
!'y EM
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,x
City or Towns
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. The affidavits may be returned to
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions,
please do not hesitate to give us a call.
k E }
The Department's address, telephone and fax number:
The Commonwealth Of Massachusetts
Department of Industrial Accidents
Office of investigations
600 Washington Street,7a' Floor
Boston, Ma. 02111
fax #: (617) 727-7749
phone #: (617) 727-4900 ext. 406
A
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
c11,S150A.
The debris will be disposed of in:
I �, C- op- 5 Lk- Q2h 06:50 sem(
(Location of Faci
LZ3
ture�laermit Applicant
+S
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
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Chimneys
Siding
Mass Toll Free
1 -800 -WAIT -4 -US
(924-8487)
W" -ALL UNDER
ONE ROOF
Residential & Commercial Roofing
CHIMNEYS POINTED -REBUILT -CAPPED
Roof Leaks Experts *
Locally Owned & Operated Stnce 1976--
IKO® azff woz n or 90Aw l
Proposal Submitted To
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street
City, State &Zip Code ,
UI;A_1q-J
All Types Of
Expert Masonry Work
Licensed & Insured
License #034200
We Work Year Round
Phone
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Job Name
Job Location
Date
Job Phone
We Propose hereby to furnish and labor in accordance with specifications below, for the sum of:
r -1,14C Li -r- S 11K i Q/%� ���Q Dollars ($ %d , u� )•
All material is guaranteed to be as specified. All work to be completed in a workmanlike Authorized
manner according to standard practices. Any alteration or deviation from specifications be- Signature:
low involving extra costs will be executed only upon written orders, and will become an
extra charge over and above the estimate. All agreements contingent upon strikes, accidents NOTE: This proposal may be
or delays beyond our control, Owner to carry fire, tornado and other necessary insurance. withdrawn by us if not accepted within )G days.
Our workers are fully covered by Workmen's Compensation Insurance.
We hereby submit specifications and estimates for: t f
Ulnstall 3 feet of special "Eave Seal" ice and water barrier protection along all bottom edges of roof
and top to bottom in each valley. 0 roof is stripped, we will apply conventional ice and water shield
( _3 ) ft. high in the same locations previously described and tar paper will cover the
remaining bare wood. Any rotted or damaged boards will be replaced at ( ) per linear ft.
or ( ) per sheet of plywood.
Wnstall heavy gauge aluminum drip edges along every edge surface of each roofline. Yom;,
Cover entire roof (s) with IKO 25 year all asphalt, non -fiberglass, premium grade shingles
(Color of choice).' ',c5�'fi
- ---
U Replace all pipe boots where possible.
U'Seal all flashings with clear Geo -Cel sealant. No black tar unless previously applied.
U(Remove all work-related debris.
Contractor warrants roof against all leaks due to defects in his workmanship for 12 years under
normal circumstances.
I,d Local current references and proof of workman's compensation insurance gladly given.
Remarks C� y2/f A1Q C_ tic-�17 i
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Acceptance of Proposal - The above prices, specifications
and conditions are satisfactory and are hereby accepted.
You are authorized to do the work as specified. Payment Signature:
will be made as outlined above.
Date of Acceptance: 3 - Signature:
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