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HomeMy WebLinkAboutMiscellaneous - 177 CHADWICK STREET 4/30/2018o � BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION i Permit NO: Date Issued: IMPORTANT: LOCATION I/ PROPERTY OWNER Date Received must complete all items on this fes-- </1- Print Cn r 00 'A T t h T ^� • . 1e */ 9_ Print °MAP NO: PARCEL: ZONING DISTRICT: Historic District Machine Shop yes no yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic Well , Floodplain Wetlands > Watershed District Water/Sewer DESCRIPTION OF !L110 ve D S OWNER: Name: &,I/ r5 -v BE ED:/% ': 77 1 �61x�� i� h 0A e or Pknt Clearly) Phone: r ARCHITECT/ENGINEER Address: Phone: Reg. No. FEE SCHEDULE: BOLDING PERMIT.$12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ - ; "906, FEE: $ GI Check No.: _ G� R 4ceipt No.:�- NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund nare of Agent/Ovvner Si nature.of contractor Sigtu Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private (septic tank, etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS P DATE REJECTED DATE APPROVED Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE'DEPART.M:ENT -Tem. Dumpster on. ite ,yes no Located --at 1,24:;Main Street ',Eire Department-signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.s100-s1000 fine NOTES and DATA — (For department use) ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Building Permit Application Revised 2.2008 Location_f Date TOWN OF NORTH ANDOVER w • °w / s �b V d 2— Certificate Certificate of Occupancy $ Js,K„usat Building/Frame Permit Fee $ Foundation Permit Fee $ I Other Permit Fee $ _ TOTAL $ Check # 217 Building Inspector M.S. Nyman Contracting 123 Corliss hill rd Haverhill Ma 01830 1-978-372-7710 Licensed and Insured Job Name: Jo ;' Job Location: 177 Chadawidk st Andover Ma Job Phone#: 1-978-681-8409 Job Fax #: Job Contact: Jo 1,4 IV's Job Description ( Roof Remove and Replace) 1: Remove existing asphalt roof on center addition and front of main house.( approximately 1200 square feet.) 2: Install 6 feet of ice and water shield on roof edge. 3: install 15 lb. felt paper on remaining of roof substraight_. 4: Install mill finish edge metal around roof edges. 5: Install ridge vent 6: Install 25 year 3 tab shingles ( approximately 1200 square feet) 7: Remove all job related debris. Total job price $3900.00 * * * * New roofs come with M.S. Nyman 5 year labor warrantee * * * * Payment schedule as follows , 1/3 down ($1300.00), 1/3 at '/2 way point ($1300.00), and the remaining 1/3 ($1300.00) when job is. complete. * * * * Color of shingle to match the existing house as best as possible .( There may be a difference in the shade of the color ,darker or lighter). X ✓xZea�rLmar�cueaecael Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 1331,80 Expiration: 5/1V2009 Tr# 131250 Type: DBA MS.,-NYMAN CONTRACTOR MATTHEW NYMAN 5$ MIDDLE RD. �.��C�aa•-� �� AMESBURY, MA 01913 Administrator _ Massachusetts - Department of Public Safet% Board of Buildim, Ret ulations and Standards Construction Supervisor Specialty pecialty License License: CS SL 101045 Restricted to: RF,WS,SF,DM MATTHEW NYMAN 123 CORLISS HILL ROAD HAVERHILL, MA 01830 ------------------------- ununissi�mrr Expiration: 5/19/2012 Ti-. 101045 . fZN r llul i l www-mass.gov/dia Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Workers' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Name (Business/Organization/individual): Address: City/Stale/Zip: Al Vath. Phone #: Are you an employer? Check the appr 1.❑ I am.a.employer with employees (full and/or part-time).* I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ l am a homeowner doing all work myself. [No workers' comp. insurance required.] t ,t,4_ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. $ These sub -contractors have workers, comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no 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. l�Roof repairs /�,,v`O`jV0 1.3.❑ Other *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. + Homeowners who submii•kbis ai,.idavit indicating L'iey al -t drill_• a i t:rp; atisl ih-n hire outside contractors ii,usl submit a new atndava !nalcanngsuch. '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 ann employer that is providing workers inffoormation. ' compensation insurance for my employees. Below is the policy and job site i Insurance Company Name:_*""' L4 �_i ve Policy # or Self -.ins. Lie. #: �����Z-- �-D Expiration Date: Job Site Address:_ /-2,7 — 4fAA Jj,, , JT<` 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 under the pains and penalties of perjury that the information provided above is true and correct - ---� Official use only. Do not write in this area, to be completed by city or town official City or Town: Issuing Authority (circle one): Permit/License # 1. Board of Health 2. Building Department 3. City/Town Clerk 6. Other IV�� 4. Electrical Inspector 5. Plumbing Inspector Contact Person: Phone Vit 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 includin.g 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 o r 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 compl-etely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an_LLC or LLP does have _ employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The,affiidavit 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 lava, 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 appiicant. Please be sure to fill in the pennitAicense 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 ext 406 or 1-8:77-MASSAFE Revised 5-26=05 Fax # 617-727-7749 wvm,.mass.gov/dia 6/2/2016 20503 This is an e -permit. To learn more, scan this barcode or visit northandoverma.viewpointcloud.com/#/records/20503 OF r10RTF/ 4ti y��OL m O T 5 �ASSACHUS��� TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that Richard P Byrnes has permission to perform replace water heater plumbing in the buildings of OJA. GAIL E at 177 CHADWICK STREET, North Andover, Mass. Lic. No. 15435 Date: June 02, 2016 Is 6/2/2016 20504 This is an e -permit. To lea more, scan this barcode or visit northandoverma.viewpointcloud.com/#/records/20504 �F NORTy Sti S�� OCL # # x �5 ACHUS�� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that Richard P Byrnes has permission for gas installation replace water heater in the buildings of OJA. GAIL E at 177 CHADWICK STREET, North Andover, Mass. Lic. No. 15435 Date: June 02, 2016 1/1 CN- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO=PERFORM PLUMBING WORK CITY r �7 c MA DATE - ( PERMIT # JOBSITE ADDRESS OWNER'S NAME/ L' , OWNER ADDRESS -�----�— P �n TEL �Yd ` r[�%S�FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ( EDUCATIONAL ® RESIDENTIAL c( PRINT CLEARLY NEW: El RENOVATION: ® REPLACEMENT: PLANS SUBMITTED: YES ® N0[j FIXTURES 1 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 DEDICATED'JdATER 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 WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES [D NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY + OTHER TYPE OF INDEMNITY ® BOND OWNER'S. INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the 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 bei mplian�th��inent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBERS NAME 11 Richard B mes Jr. LICENSE # 15435 ATURE MP[j JP® CORPORATION Q# 3498 PARTNERSHIPEI# LLC[]# COMPANY NAME Nurotoco 1 -of MA d.b.a Roto -Rooter ADDRESS .175 Ma le Street STATE MA ZIP _02072` CITY Stoughton �� �TEL .781-297-7049 FAX 781-341-8817 CELL 617-212-4589 EMAILRichard.yrqes@rrsc.com W F O z z 0 F U W a a d z P* w on Z z : � o w � w p rA W O IL ftz W G ~ 2 C a a � L O N � O o a W a v J a a a � N W = W F- 1L rA W F z0 z 0 F U W a UD z 0 z 00 0 a a x 0 a QA U,p MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATEE2k!&j PERMIT # JOBSITE ADDRESS LZ_ ( �lJ rr%� OWNER'S NAME �{ GOWNER ADDRESS C TEL t L.b FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: Ej 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 BOOSTER 1 t CONVERSION BURNER COOK STOVEi DIRECT VENT HEATER IIF DRYER FIREPLACE FRYOLATOR m:. FURNACE GENERATOR k ) i E i GRILLE INFRARED HEATER LABORATORY COCKS € . MAKEUP AIR UNIT I I' OVEN j POOL HEATER" ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER I ------ L UNVENTED ROOM HEATER WATER HEATER OTHER " I I 3 t INSURANCE COVERAGE I 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 Evj OTHER TYPE INDEMNITY Ej 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. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER Lj AGENT El I hereby certify that all of the details and information I have submitted or entered regarding this application are tand 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 c rice wi�Perti ht provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAMERichard B rnesJr. LICENSE #i 15435 ATURE MP MGF ED JP El JGF � LPGI � CORPORATION �# 3498 PARTNERSHIP (�#� LLC �# COMPANY NAME: Nur�otoco 1 of MA d.b.a Roto Rooter ADDRESS = 175 Ma le Street �� CITY tou hton STATE A ZIP02072 STEL j 781-297 7049 FAX 781-341-8817 CELLL17-2124589 EMAIL Richard.Bymes�a rrsc.com w F O z z 0 F U W a z a d z ONw >" C ❑ a Z z o ❑ w � ~ w W z° z a w W>W �+ W N z a a a J� a � a N Y1 2 W H U - w F O z z 0 F U W a d L7 C7 O a The Commonwealth of Massachusetts kilDepartment of Industrial Accidents s 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Nurotoco of MA d.b.a Roto -Rooter Address: 175 Maple Street City/State/Zip: Stoughton, MA 02072 Phone #: 781-297-7049 Are you an employer? Check the appropriate box: 1,1D I am a employer with 66 employees (full and/or part-time).* 2.[:] I am a sole proprietzr or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.aI am a homeowner doing all work myself [No workers' comp. insurance required.] t 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 proprietors with no employees. 5.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 7. ❑ New construction 8-E] Remodeling 9. ❑ Demolition 10E] Building addition 11.0 Electrical repairs or additions 12. ❑✓ Plumbing repairs or additions 13 Q Roof repairs 14. ❑ 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 state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Old Republic Insurance Co Policy # or Self -ins. Lic. #: MWC11826416 Expiration Date: 04/01/17 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cttfy un�er tye paand penalties of perjury that the information provided abp6e is tlue and correct. Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # �b . 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 #: AC'OR0® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 03/2412016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. ,If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this.certificate does not confer rights•to the certificate holder in lieu of such endorsements). PRODUCER. MARSH USA INC. 525 VINE STREET, SUITE 1600 CONTACT NAME: PHONE ac No): E4WL CINCINNATI, OH 45202 Aftn: Cincinnd.Cerftuest@marsh.com I F: 212-948-0785 INSURER(S) AFFORDING COVERAGE NAIL # INSURER A: Old Republic Insaranoe Company 24147 00015 INSURED 15 - ROTO -ROOTER SERVICES COMPANY 175 MAPLE STREET INSURER e.: XLy Insurance Company. 37885 INSURER c : Mdwed Employers Casualty Company 23612 INSURERD: STOUGHTON, MA 02072-1130 INSURER E PRODUCTS - COMPIOP AGG $ 6,000,000 INSURER F: A COVERAGES CERTIFICATE NUMBER: CLE -004860325-22 REVISION NUMRERc6 THIS 1$, TO CERTIFY THAT THE POLICIES. OF INSURANCE LISTED BELOW HAVE 85EN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD :Q INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE. TERMS, . EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.. UR LT TYPE OF INSURANCE POLICY NUMBER POLICY EFF POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR MVCY6013216 04/01/2016 04/0112017 EACH OCCURRENCE $ 2,000,000 DAMAGE TO RE PREMISES$ .750,000 MED EXP (Any.one on $ 5,000 PERSONAL & ADV INJURY $ 2,000,000 GEN L AGGREGATE LIMIT APPLIES PER: X POLICY a JECT LOC OTHER: GENERAL AGGREGATE. $ 6,000,000 PRODUCTS - COMPIOP AGG $ 6,000,000 $ A AUTOMOBILE LIABILITY 'X ANY AUTO. X ALL OWNEDSCHEDULED AUTOS AUTOS X HIRED AUTOS X NON -OWNED AUTOS MWrB2195716 04101/2016 0410112017 COMBINED SINGLE LIMIT $ 5000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ P S. X UMBRELLA LIAS EXCESS LIAS X OCCUR CLAIMS -MADE 19961870 04101/2016 04/0112017 EACH OCCURRENCE $ _ 5,000,000 AGGREGATE $ 5,000,000 DED X I RETENTION$ 25,000 $ A C C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRWTORIPARTNERIEXECUTIVE YIN OFFICERIMEMBER EXCLUDED? . (Mandatory In NH) If yes, describe under. DESCRIPTION OF OPERATIONS below NIA MWC11826416 (AOS) MWC3019M 02 (TX) EWC0063808 (XS OH) 04/0112016 04%01/2016 04/01/2016 04101/2017X 04/01/2017 04101/2017 PER &H- STATUITIE E.L44CH ACCIDENT $ 1,000,000 E.L. DISEASE -EA EMPLOYEE S 1,000.000 E.L.DISEASE -POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached H more space is required) EVIDENCE OF COVERAGE. ROTO -ROOTER SERVICES CO. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 175 MAPLE STREET THE EXPIRATION DATE .THEREOF, NOTICE WILL BE DELIVERED IN STOUGHTON, MA 02072.1130 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukhegee alno s.: Qp4.,w.tc. s.c ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (201,4/011 The ACORD name and loco are rea(stered marks of ACORD This certifies that Date. . /16 GJ TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING �/ le . . . . . .. .... zt/l' , , , has permission to perform ./:..4, . !.(.-.�!�. !'-r'.�- ........ . plumbing in t e, buildings of :* .� � �! ......... at.1..!f�t�r f . __ . .... , North�J ndover, Mass. .. Lic. No. Check N C'' / '' PLUMBING INSPECTGR G5uo NiAbbACH,USETTS UNIFORM APPLICATION FOR -PERMIT TO DO PLUMBING (Print or T e) 4JL� ass. ate a 20 C„ Per It # Building Lo atio— l Z n Own me i� Type of Occupan New ❑ Rennvmt;— n Plans Submitted: Installing Company Name 4d Corporation --------------- 3usiness Telephone lame of Licensed Plumber or Gas Fitter ! IDA 5,!r nn..,-.. . a current II blllty insurance policy or Its substantial equivalent, which meets the requirements of MGLCh. 142. ,Yes 1 No . ❑ If yr, ve checked Yes, please indicate the type of coverage by checking the � 9 appropriate box. A liabili y Insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURNACE 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 ❑ Agent ❑ 413-3 ereby certify that all of the details and information I have submitted (or entered) In above'appiication are true and accurate to the best of knowledge and that all plumbing work and Installations performed u r the permit Issued for t&.Pllca'tion will be In compliance with pertinent provisions of the Massachusetts State Plumbing Code4dhto 42 of eG eral La By Title of of Plum r CIryrl owrr APPROV);`D (OFFICE USE ONLY) Type of Licenser EL9ster 0 Journeyman License Number_ T J I I LocationLnn C L"r- r- �- � r / No. D D q Date Check # TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ r _ TOTAL $ Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: C2 DATE ISSUED: 3 SIGNATURE: Building Commissioner/Inspector of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: /I2 CA4dw/c4 J7, 7y l V) d i ,Q 0 ve V- /Infform�ati` Map Number Parcel Number 1.3 Zoning on: 1.4 Property Dimensions: Zoning Dish c—t Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide ReqWred Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes No 2.1 Owner of Record / ,Q Gal z DT//My , /72 l�/^ [�lOw ILk sT, Name (Print) Address for Service ,*161�fl 619-1(1c', Signature Telephone ` r/ 2.2 Owner of Record: r Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ /�A/?(c ` 1NtgL60 ��$dl Licensed Construction Supervisor: License Number /a %re��/ �� A vC , Aet lte `t Address G 1ff lI to �� /�� nn // per. 1 c�-N.�:,x 4-- 6 — G'.? f � Expiration Date �� 6 0 Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ A A14 � C r'/1U14 L � 0 Qmpany Name / I/ Registration Number Address 8�—GAF S (ala SDS Expiration Date Signature Telephone 00 M z O YR�J V v n M O Z M 90 0 Mn r v M r ^Z Y/ 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 .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check au applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: �j /( C'A0Vd j6 A O� X %�//V(e to/X �'/ C.CGe e 6000 Ale �V0b '. OJALLSJ 6tr/n1D0WT 1 .2,v -re PYoe SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY 1. Building Vo o (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X tbl 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, a, r�. �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. wt o� tg�' � `/" d10 -7 Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, '))-La,%_ � c.� ,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 MR hG 4 b0 Print Name Si ature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS iST 2 ND 3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIlANEY IS BUILDING ON SOLID OR FILLED LAND 1S BUILDING CONNECTED TO NATURAL GAS LINE NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-954 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 properly licensed solid waste disposal facility as defined by MGL Chapter 111, S 150 A. The debris will be disposed of in: Pihu&k 77VANsfPP' d7a% 0 K (Location of Facility) Signature of Permit Applicant �4ih-3 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector 1 Name The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02 919 Workers' Compensation Insurance Affidavit Please Print Name: AA 7 C Y /,V A t,a Location: /% CAi&W 1 c K NV , .41td I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity 1 am an employer providing workers' compensation for my employees working on this job. Comoanv name: Address Cifir. Phone* Insurance Co. Policy # Company name: , Address. Cifv : Phonb #- Failure to secure coverage as required under Section 25A or MGL 152 can lead to the in position of criminal penalties cf a.fine up to $1,i and/or one years' imprisorment.as_vias_c h4l4mmaitiesin ftoarra d,a STQPYj O.RK O�ER�and;.afine�f understand that a copy of this statement may beforwarded to the office of investigations of the MA for c&verMe verification. t alb hereby certdy under the pains and penalties of perjury that the avWmation provided above is true and correct: Signature �"`'1a� — Date?Z4�,VW Print name *A iO e IP11­14C .D c Phone.# Official use only do not write in this area to be completed by city or town officiar City or TownPemut/Lieensinn QCheck if immediate response is required Building De, Licensing B( El Selectman's Contact person: Phone # 0 Health Depa E] Other J%ze �oanamo�uveu�� nt � l%�ravaciruse��3 BOARD OF BUILDING REGULATIONS �T License: CONSTRUCTION SUPERVISOR ` Number: CS 043801 Birthdate: 11/19/1952 Expires: 11/19/2003 Tr. no: 7849 Restricted: 00 MARC W RINALDO 12 KENSINGTON AVE METHUEN, MA 01844 Administrator i . � �` ize �amnza�uueull� o�,� tfr4 Board orButidiug Regulations and Stand0d.1 'f 1' HOME IMPROVEMENT CONTRACTOR `3 Registration: 101177 Expiration: 6/25/2004 . Type: Individual MARC RINALDO Marc Rinaldo 12 Kensington Ave �o Methuen. MA 01844 Administrator r 979534/NC3822 rV-r 8/98 carbonless . CAdarns NC3822 3 PART CONTRACTORS INVOICE WORK PERFORMED AT: T0: All Material is guaranteed. -to be as specified; ihd-the,.above work was performed in accordance with the drawings and specifications provided for the above work and was completed in a substantial workmanlike manner for the agreed sum of Dollars ($ ig This is a ❑ Partial ❑ Full invoice due and payable by: �r Month Day Year in accordance with our 0 Agreement 11 Proposal No. Dated YbuR WORKORDER NO. f DESCRIPTION OF WORK PERFORMED W/M 1W.11 r , ,j.�_ _ , AWA WE a r r ( r / r * i• r .. r VA— All Material is guaranteed. -to be as specified; ihd-the,.above work was performed in accordance with the drawings and specifications provided for the above work and was completed in a substantial workmanlike manner for the agreed sum of Dollars ($ ig This is a ❑ Partial ❑ Full invoice due and payable by: �r Month Day Year in accordance with our 0 Agreement 11 Proposal No. Dated C/) m m U) 0 m H d C � d CA n 10 0 CD MZ CO) r o d� y 0 CD CD O rF Cr d CD CD o CD ww C CD y� dv y -• Cl �C I a y O 10 Z CD O o CD 0 CD C C �� C =rx O -• VN O Q N EL :5 o y , cc .m a m n 0 C. O M Z y.CD wC ?.0 N �a o 0 �o an d G y N oN �m m -=CIS ipw n •� O tO �.O _ .••► f� O Z.'W O H O C � : W o o '� �• H '= A ( rL y o V/ m H CD n M d c O` O N � H -•' d d Q a.CCD�r_CL .-► p1 :E 0 y CA rte" • � ,l/" �` fA O_ .�•' �C m o c7 ? CD ►�y . Cn H 40.0 o go d CH rZ ` a's AZA oma: A =o: y; o = cn d 7C 0 . Iiiw S- G) w cp n y w r n m n x o a � r z C -ce a o x (DItd O a z 0 O C Date .... /. .. v..' .... .. ....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that ............................................................................................... has permission to perform ... % ........ .......................................... wiring in the building of .............. ..... i .............. I ................................................................ at .... 7.X ...... ................ ..................................... ,North Andover, Mass. t. ........... ; ................................................ Fee ..... 1� ................. Lic. No.:.........:.. . ELECTRICAL INSPECTOR Check # 4. u I 7 F% 1;. TBE COA MONWEALMOFAM94CHUSE7TS Office Use only DEPARTI&NT0FPUX1CS4FM Permit No. 09 BOARD OFFIREPRE�ONREGUL4770NS521CNIRI2:I ay Occupancy & Fees Checked APPLICA77ONFOR PERMIT TO PERFORM ELECTRICAL WO 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 th elect cal work described below. Location (Street & Number) f% l , m r` (/c Owner or Tenant (--,0,T1- f n-.10— Owner's 0 - Owner's Address �;am r Is this permit in conjunction with a building permit: Yes Purpose of Building Existing Service Amps 'Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work J -No (Check Appropriate Box) P s Utility Authorization No. _ Overhead Underground No. of Meters Overhead M Underground No. of Meters No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above M Below F1 Generators KVA ground around No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipal _ Othe Ido. of Dryers Heating Devices KW El Connections M Ito. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER - 1 • I 1 ) • : - ' S .: o the MW=Iff.6 Of .AX .:II. lba,&aamutlitkkn==PblI I •II ✓_ • i : • • •:.i 1' . • : critsmbstaMmlivalat YES NO - ItMeabuinandptoofofsanielDdicOffim ��/ i • Y :•a pbasem&a1etheWofoomr4pby INSURANCE rM BOND moz A &nxM1VahrofEkbkalWo&$ III ..1 •' •:1' ,r WO&IDSW r•:•1• •sr':• :." '• u ` FM Sigtrd urjdff I •• :Ilw of ••. 4�4, War LicetmNo. FIRMNAME 1cuw-_ Signat<ue * ac LkmseN0 Busum Tel. No. Wess_( Ot L a.y 4 �/' (f �G�hy 2�� fy!/� B At Tei No. '2,P OWNER'S INSURANCEWAIVER;Iamawaredial theLio wdoesnothavethe it1stu 11Mcovet-ageoritssuWmtWepvala1asteptedbyMassachusettsC,efitetuiLam nd that my sign&tte on this pmnt application waives this tegtta T=L Please check one) Owner Agent Telephone No. PERMIT FEE $ Z �• Signature ot Uwner or Agent The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name IPlease 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 I am an employer providing workers' compensation for my employees working on this job. Company name: Address City: Phone # Insurance. Co. Policy # Company name: Address City: Phone # Insurance Co. Policv # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to $1,500.00 and/or one years' imprisonment_as_wPA-as.civil,Renaltiesinsheiorm-da_STOP WORK.ORDFR.and.a.fine_of.($1DO-OD)-atlayagainst_me. understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is tale and correct. Signature, Print name Pbone.# Official use only do not write in this area to be completed by city or town official' . City or Town Permrt/Licensi D Building Dept ❑Check If immediate response is required ❑ Licensing Board ❑ Selectman's Office Contact person: Phone A- ❑ Health Department ❑ Other 4142 Date../O- �-*7 - 0 a .. NORTH °ft °:•�"° TOWN OF NORTH ANDOVER p PERMIT FOR WIRING F This certifies that ............. � 3 �� L. G ..................................................................... C c' n a has permission to perform ......" ....................................................................... wiring in the building of at ..... /.1.... G ��! u v ` l � '�....... , North dover, Mass. ....................................... Fee ....3.5-... Lic. No. A. � 9 ��....... � � Co ................... .......... ........ ELECTRICAL I PECTOR Check # a / " THECOMMONWEALTHOFMASSACHUSETTS Elie e DEPARTMENTOMMICS4MY BOARDOFFNEPREVLIV770NRW"A770NS527CV1R12:019 Permit No. Occupancy & Fees Checked APPLICA77ONFOR PERMIT TO PERFORMELECTRICAL 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 The undersigned applies for a permit to perform the electrical work describe below. To the Inspector of Wires: Location (Street & Number) ( ,jI ` G k Owner or Tenant Owner's Address Is this permit in conjunction with a building p rmit: Yes (9 IalloED (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service �� Amps =�Volts Overhead Underground� No. of Meters New Service �I d Amps / Volts Overhead � Under round � --� -- g No. of Meters Number of Feeders and Ampacity --... 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 BelowKVA Generators KVA No. of Receptacle Outlets No. of Oil round round Burners No. of Emergency Lighting BatteryUnits 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 Pumps Tons KW Initiating Devices --� No. of Dishwashers Space Area Heating Key No. of Sounding Devices No. of Self Contained _ No. of Dryers Detection/Sounding Devices Heating Devices KW Local Municipal Oer- No. of Water Heaters KW No. ofNo. of ED Connections Si ns Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER_ t� 1 i %==CotierdT_ PUWattttatheiatgritarff1sofA4a%adxisftG,ffrtWLam hawacumlLiali&y Poky>r cmp]ge ComaWoritsmbsUnUequivalat YES NO hawSubmhAvalid sarnetatheOffim YES Ef hoddrgde x Ea If}whavedletlociYES, ir>di�e#re Veofc0WrWby vSURANCE BOND � � ( > �otktostatt O Esti "ValUedJJearcaIW«k $ gnedME� �RMN �.1D� �✓(� � L) `�T LioarseNo. A`FTER'S INSURANCE WAIVER Iam awate dia &ffcl wsi does notha, 3thatmysgmUeondmpmr� tappl � Tai t lease check one) Owner Agent Signature of Ownei or Agent LimmNo Bus�nmTel.No. / + �/i • At Tel • - i c .i .00wraWOSR*sLmUeciLiy,lataswgikdbyNl%sadxwm:: . . • • 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 I 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: M eTk IL e� (VaSTe 7-eAA;S,-e1? parr ort (Location of Facility) nnw r"4Ju, 1C, Signature of P rmit Applicant `�./ -7 J/ , / Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector Location t f C No. Date MORTq h.TOWN OF NORTH ANDOVER 16. Certificate of Occupancy $ �$JA�M� st<� Building/Frame Permit Fee $ 3 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 300— Check oO-- Check # `f aq 157 J' Building Inspector ' TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: — SIGNATURE: Building Commissioner/I for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Iq — X2 Map Number Parcel Number flq h,d, rC U (` /Zoning 1.3 Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area (so Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard R red Provide- ReqWred Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54)t, ' 1.5. Flood Zone Information: Public 0 Private -E] Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Gc>6 1 E, `a. r "7 CI�acQw1 ck 5+ Name (Print) 1j Address for Service -2 0 Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: 1 Licensed Vistruction Supervisor: r' Adder Signature Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone T rn X Z O 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 .......❑ No ....... 0 SECTION 5 Description of Proposed Work check all appUcable New Construction A Existing Building ❑ Repair(s) ❑ Alterations(s)i -.❑ Addition ig 1 1 4 • ..1 r Accessory Bldg. ❑ Demolition ❑ Other ❑ • Specify Brief Description of Proposed Work: Lian+ i -o la u; 2Z' x 2`/+40c led— inr n 10' k z eC-k 2oo — I �© 3y3ao 35SXL' SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be OFFICIAL USE ONLY Completed by permit applicant 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of ��/ O �' Construction 3 Plumbing Building Permit fee (a) X (b) 3 Q 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, G 0.i I QiG. ,• Owner/A horized Agent of subject property Hereby authorize G 0.� © k e• to act on My beh lif jin all matters re ative to wo uthorized by this building permit application. 711162, Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I,�� d• j , e_ 040--% as Owner/Authorized Agent of subject property el Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Gcc� 1 E . Oia— Prm N me { Sigrilalfture of Owner/Agent Date NO. OF STORIES ! SIZE 2.2 x BASEMENT OR SLAB S 1a 6 SIZE OF FLOOR TIlvIBERS iST2ND 3RD SPAN DIIv1ENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS to X -L,0 SIZE OF FOOTING X MATERIAL OF CHDANEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 94 t PLOT PLAN 126.40' t �do - t Lor r 20,010 5Xt: 14OUSE �� J- o d'i�ta' oP�N �Fct� q I 123 4D 5 r, i MORTGAGEE : Stouchaw Savings Bank MORTGAGOR: Gail E. O•ja ��+c�e�e�'cik�Yde�l�k�e�Fik�Y9e�'e�Y9c�'eok9c�k�'e��F�e*�F�*�e�'ede��e�9ede9e�'e��ede9ede*�k�'ex�9e9e�*�k�c���ede��k��'e�'c*9e�k�'e�c��e Scale: 1'° = 30 ft. Date: June 10, 1998 Location: 1.77 CHADWICK STREET, NORTH ANDOVER, MA. " References " { Deed Book: 4780 & Page: 141 { Plan No. 3115 ( Lot # F ) Recorded at It -'lip Essex County North District Registry of Deeds. Notes : - This Plot plan for Mortgagee use only, offsets are trot to be used to establish property lines. 1 hereby certify that the building(s) shown on this plan islare situated approx imalely as shown and entirely within the boundaries of the parcel and that is (or- ti>>as at the lime of construction) in corn l' t! ' p tance 1i c z tree :;onrno '� ° w14sregulations of the CilylTown o��North Andover. �v Y i -CEL ��� I also certify that the location of'the building(s) on the above properiv 7�gsii�;,41Z �1 does not lie within the Flood Hazard Area as delineated on a plan for the community Panel 4 250 098 0003 C. rfe Y (for North Andover, MA.) bythe Federal Department of Urban Development, Federal Insurm-ce Administration Baled: June 2, 1993. FORM U - LOT RELEASE FORM 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 E. V'0.. PHONE 13i t` LOCATION: Assessor's Map Number PARCEL_ (_ SUBDIVISION LOT (S) STREET (I/A CIWIC ST. NUMBER ************************************OFFfCIAL USE ONLY*********************************** I RECQMMENDATIONS OF TOWN AGENTS: VATION ADMINIS,7'RATOR DATE APPROVED DATE REJECTED COMMENTS�,,44LA< Lu , TOWN PLANNER COMMENTS DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED SEPTIC INSPECTOR -HEALTH DATE APPROVED DATE REJECTED 10101IT, IN, PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9\97 jm Town of North Andover Building Department 27 Charles Street North Andover, MA. 01845 D. Robert Nicetta Building Commissioner (978) 688-9545 (978) 688-9542 Fax HOMEOWNER LICENSE EXEMPTION Please print DATE JOB LOCATION - /77 Chadwick- s+, N tuber Street Address "HOMEOWNER V LTat 1 if • Name Home Phone PRESENT MAILING ADDRESS_ City Town State Map / lot Work Phone Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings of two 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 Budding Code Section 108.3.5.1) 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 it intended to be, a one or two family dwelling, attached or detached structures ac- cessory to such use and/or farm structures. A person who constructs more than one horne in a two-year period shall not beconsidered a homeowner. The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other Applicable codes, by-{aws, rules and regulations, The undersigned "homeowner" certifies that he/she understands the Town of No. Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNER'S SIGNA APPROVAL OF BUILDING OFFIC it I E w A a` W° T V) O w z W o w° c � v U is w o U w d w 0 W co chi id w p H m m w w w 4 w' o z �' cn D 0 cn LLJ z 0— C G .O C c � o � C N O co O m C rc O cc E a lu C,m _ �cm T` ti E a •co �aftum: o m m C4y . y Cc C C Er E .v Ya�� � m a� 442 cm � O C C �c Q y C L • � md c� Z m a ca o 0 las a 0 CL a m = :gym O:mo o = W - o N ►� m r0+ Z �y O F- y at C ui E v�4y Z o V O p O C m� COO CL O � 0 Go CD = . a� m � N 0 C/) cc LULli LL w Cn • Date ...................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION o .ty This certifies that . o,, �.:...... / ` has permission for gas installation .. ? .? <.:............ . in the buildings of ......,..::�................................. at ... i......... ...�......... North Andover, Mass. Fee. 2v. "... Lic. No. .............: r....... . GAS INSPECTOR Check # ) JJ A MASSACHUSETTS UNIFORM APDL ICATON FOR PERMIT TO (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locations Owner's Name dew Renovation ❑ Replacement L! Plans Submitted 1 ; 1'°"- ,, (W ,r ... P -int or type)check one:. Certifi4 installing Company `ame Andover Md. & Ht4. Co.. Inc. ❑✓ 1,?� Corp.�� address 20 Agean Dr., Unit -10 ❑ Partner, Methuen. Ma. 01844 Business Telephone (978) 685-8383 ❑,Firm/Co <ame of Licensed Plumber or Gas Fitter George LaRosa INSUKANCECOVERAGE Check one: v ! have a current liability Insurance policy or it's substantial equivalent. Yes © NO ,a !you have checked yes, please indicate the type coverage by checking the appropriate box. _iapilin' insurance policy ,j Other type of indemnity ❑ Bond ❑ G%vner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my'signature on this permit application waives this requirement. Check one: S i enature of Owner or Ownees Agent Owner ❑ Agent'; ❑ i'.. nerehv certify that all of the details and information I have submitted (or entered) in above application ')rst of my knowledge and that all plumbing work and installations performed under Permit Issued for t4 _ompiiance with all pertinent provisions of the Massachusetts State Gus CAe and Chapter 145440"! ay: Title C'rvi Tow n -�PPROVEDt()frlcF USE ONLY) Signature of'. Plumber . Gas Fitter Masser ❑ Joumeyman T sed Plumber Or Gas Fitter 9983 License Number wnx accurate to the m will be in y C ~ r^• tw C �Y F iJ rr H 0. = Ci Z ti F C (r�j. �1 t3 L 2 `�s v M L iG tz ,� C I z itl.:r . lie I= 19 I 13ASE.H EN IST. 1;L0-0 K I 2N U. FLOUR 7K D. FLUOR 6T I1. F L 0 0 R iT 11 FLOG R °" -r'=l` IST I1 . F 1. 0 0 R P -int or type)check one:. Certifi4 installing Company `ame Andover Md. & Ht4. Co.. Inc. ❑✓ 1,?� Corp.�� address 20 Agean Dr., Unit -10 ❑ Partner, Methuen. Ma. 01844 Business Telephone (978) 685-8383 ❑,Firm/Co <ame of Licensed Plumber or Gas Fitter George LaRosa INSUKANCECOVERAGE Check one: v ! have a current liability Insurance policy or it's substantial equivalent. Yes © NO ,a !you have checked yes, please indicate the type coverage by checking the appropriate box. _iapilin' insurance policy ,j Other type of indemnity ❑ Bond ❑ G%vner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my'signature on this permit application waives this requirement. Check one: S i enature of Owner or Ownees Agent Owner ❑ Agent'; ❑ i'.. nerehv certify that all of the details and information I have submitted (or entered) in above application ')rst of my knowledge and that all plumbing work and installations performed under Permit Issued for t4 _ompiiance with all pertinent provisions of the Massachusetts State Gus CAe and Chapter 145440"! ay: Title C'rvi Tow n -�PPROVEDt()frlcF USE ONLY) Signature of'. Plumber . Gas Fitter Masser ❑ Joumeyman T sed Plumber Or Gas Fitter 9983 License Number wnx accurate to the m will be in Location C iw� No. r r� Date /•��Oon TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ ��ss�cMost�� Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL _ $ Building Inspector 47/14/98 08:40 PS.Qd PAID Div. Public Works r Location Date 01 NORTPI TOWN OF NORTH ANDOVER n Certificate of Occupancy $ Building/Frame Permit Fee $ SE S Foundation Permit Fee $ sACMU Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ 1 ; Building Inspector Div. Public Works rn Q x Qi N — � a � u z z C s opo 1 ^ 3 N W ~ C _ _ V) G � Z Q L N N G z 17�R tz CZZ Q F � x h ZS 3 * x V z z z W Q W •� Z z z z _ W .d 9 f� C •z Z ^W N N 1^..� N C In vi w N W CL v Qi N — � a � z z ^ 3 W ~ _ V) C z W Z Q L N N G z 17�R tz CZZ F- s •— x h ZS 3 * x V z z z W Q W •� Z z z z _ W .d 9 f� M N Z ^W N N 1^..� N C O �( O Z h O uj + r u t z C. '+` N LU LU LW t tS d C T '0 C N W dit �g cc = Z ^ O z z f u O _• r � T, m_ Z fl� � C ., W s 0 Q N F N H s Z Z a Z C r Z 'C •� W �' � C�gi� C �� J W Q Q '� Q In vi w N W CL v v A Qi N — v A z n FORM U - LOT RELEASE FORM 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 Ga; LOCATION: Assessor's Map Number 6 7 y 0 60 It 00 a0 SUBDIVISION STREET CA a. d u_ji G k S�-• PHONE 9 7 8- 6 8 1- R y p 9 PARCEL P I an No . 31 1 S LOT (S) F ST. NUMBER 17 *** ************************OFFICIAL USE ONLY*********************************** DATIONS OF TOW%AGENTS: / I \ r I/ 1 /.i v 1 V v COWSEkVATION ADMINI$TRATO DATE APPROVED �e DATE REJECTED i jrv-\� -- s-4 0 I.a. CLd - 0 I - TOWN PLANNER DATE /APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR -HEALTH SEPTIC INSPECTOR -HEALTH COMMENTS DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWERIWATER CONNECTIONS DRIVEWAY PERMIT ` FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Z4 PLOT PLAN 126. L. O r r 20,010 s.Kt e#4;0W1eK MORTGAGEE : Stoneham Savings Bank MORTGAGOR: Gail E. Oja S r, a 0 Scale: 1" = 30 ft. Dane: June 10, 1998 Location: 177 CHADWICK STREET, NORTH ANDOVER, MA. " References " { Deed Book: 4780 & Page: 141 { PIan No. 3115 ( Lot # F) Recorded at the Essex County North District Registry of Deeds. Notes : This plot plat: for Jl urtgagee use only. offsels are Piot to be used to establish property lines. C I hereby certify that the building(s) shown on this plan is/are situated approximately as shown and entirely within the boundaries of the parcel and G that is (or was at the time of construction) in compliance with the zoning regulations of the City/Town oJ'North Andover. ; IviICCTEL �, 1 also certify that the location of the building(s) on the above property MAR � �1� does not lie within the Flood Hazard Area as delineated on a plan for the No. 39666 � community Panel # 250 098 0003 C. ( for North Andover, IIIA) by rhe µ\ . Federal Department of Urban Development, Federal Insura?ce ' y y Administration dated.- June .2, 1993. 070Y7.5-sc17f HEARTLAND Industries, Inc. nc Gene Frulla a r t Sales Representative 1 c 4 t c c Q,%) . 96 Main Street, Rte 28 978 664-0896 No. Reading, MA 01864 Fax 978-664-0896 00 a b\ y O b 10 vs CA cz Cii o c� M O � J C ... N O C V V .Q C O ea O Ea z .0 a `V:oo r�cm ti m E Hc` C y co �J � 3 Jl: O� y C m � y Cc C O =y CD _ Eta O cm CL r y O to Z Z Ocm C 02 r 00 h= O .�Ocm C O C to m C C _ CL*- O N H y oma~ O t LTJ o r-. -0 Z C *� y O.Z C Z �"' Lcr- .E U � els CDa _ m v ad • CD O coL _O Z CO 0. O y D C co I Ccm � p 'O CO) O O co L-Aca = .� CL CD G) � � o L !D O Q CL MQ O cc .Q C CD 0 CL V CO) � C C cc C. p a a a a a a w a w a aX top. j w 0 a C7 o c a rA o G ui u Cii o c� M O � J C ... 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