HomeMy WebLinkAboutMiscellaneous - 18 ARDMORE COURT 4/30/2018 (2)I
Date./� .G.l.. .
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that ..... �
has permission to perform ....:� .1... '
plumbing in the buildings of ... Q (�,9..1. ._
at ... North Andover, Mass.
Fee. ? ..... Lic. No. ? ?. 5.? ..............-'�-r',,, .....
I
UMBING INSPECTOR
Check #
6767
'4
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETT"Permit# Date
Building Location Yk t- Owners Name d ���
g�i�• Type of Occupancy Amount
r
New Renovation Replacement � Plans Submitted Yes 11 1:1
❑
(Print or type)
Installing Company Name
Address
Name of Licensed Plumber:
l Insurance Coverage: Indic,
Liability insurance policy
Insurance Waiver: I, the
threeinsurance
J v Check one: Certificate
l ❑ Corp.
❑ Partner.
`f f Firm/Co.
type of insuranck coverage by checking the appropriate box:
Other type of indemnity ❑ Bond ❑
have been made aware that the licensee of this application does not have any one of the above
Signature I
Owner 0
I hereby certify that all of the details and information I have submitted
best of my knowledge and that all plumbing work and installation4per
compliance with all pertinent provisions of the Massachusetts Stat
By: Sigiiau.W Of lcense t
Agent 11
entered) in above application are true and accurate to the
pedeT-Mt
Issued for this application will be in
ode and hapter 14 f rhP 6.o -e ral Laws.
Title pe of Plumbing License
City/Town
APPROVED (OFFICE USE ONLY
License Numner, Master Pf Journeyman ❑
1'
•
.r
•
f
•
I
I
-------------------------
=1811NN02
0
-----M-------------------
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M-M-MM------MMM-M------M-N
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(Print or type)
Installing Company Name
Address
Name of Licensed Plumber:
l Insurance Coverage: Indic,
Liability insurance policy
Insurance Waiver: I, the
threeinsurance
J v Check one: Certificate
l ❑ Corp.
❑ Partner.
`f f Firm/Co.
type of insuranck coverage by checking the appropriate box:
Other type of indemnity ❑ Bond ❑
have been made aware that the licensee of this application does not have any one of the above
Signature I
Owner 0
I hereby certify that all of the details and information I have submitted
best of my knowledge and that all plumbing work and installation4per
compliance with all pertinent provisions of the Massachusetts Stat
By: Sigiiau.W Of lcense t
Agent 11
entered) in above application are true and accurate to the
pedeT-Mt
Issued for this application will be in
ode and hapter 14 f rhP 6.o -e ral Laws.
Title pe of Plumbing License
City/Town
APPROVED (OFFICE USE ONLY
License Numner, Master Pf Journeyman ❑
P. 0. BOIL # 2229
SALEM, N.N. 03079
TEL: 603-$9$-6505
FAX:SAME CALL AHEAD
INVOICE NUMBER:
INVOICE DATE:
RANDOLPHR WOLF
NA. MASTER PLUMBER # r 22,93
O19
1$ -AUC -05
CUSTOMER: WOODRIDGE HOMES COOP TELEPHONE:
ADDRESS: 10 WOODRIDGE DR. FAX:
Cm: STATE, POSTAL CODE- NO. ANDOVER, MA. 01$445 PO NUMBER:
ORDER DATE sARY: 1$A ARDMORE
START / END DATE
2 NAY 1 `50 $90:00 18 -Am -05 135.00
0.00 $0.00
0
TOTAL ACTIVITY COST: $135.00
�.
1 i 12" EI' SILLCOCK W/ VAC CUT TNROU6I1 KITCHEN CAB 25.00
REPLACE. OUTSIDE SILLCOCK 0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
TOTAL MATERIALS COST: - $25--Oa—
NET. 10 DAYS THANK YOU TOTAL BILLING: $100.90
Invoice
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10 Wood Ridge'Dnve':;'
.
North Andover, -.Massachusetts 01845
Telephone 682 7093 %.
TDD 01pe 1 800 545
1833, Ext 143
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f IA � " T �� a`€�, , "' 4 xthe `tleck approval to ;you in writirig sooner :I ;, e
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' ��"��Jul 21 PP
�` �x is did a rove, viatelephonevote ony,toa 7�
..The ,Board of ' -: : ,r,,. t .: :. _t all the
_ rF :, � x, 4 w � ck at the;rear of .your un,it� Norm xy', ,..,. aLL
our: -request to�erect-a12.,x16c1e T_ v� ��u�eetr shave
?Yi,s ' "° ' `'' ` ti red at£the"I'M ,meetmyl,, Owever, xthe last42 9 y ,
r telephone vote isgra-AViW k M ,� . a r
edit ted;;to the `review and-approv I Alo the 2001 budg r. �4
3 been d s ,* w _ 1 Fs 61!, s�£ 1 � a z s
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uvkp}: Y eT,ownissuing}thepermit the Conservation r
�Pleasebe inforrned�gthat prior to they, AV �ns'ectthearea We
1 � � W�, , -., ` ` . 4 euiew the inforri anon and ;possibly i p .
tiDepartment must also r 1 #
�' somewhatdelay_the ,
.,�. i F 5._.a �r . � E and mays
5qij�:: ve been informedAh!`5 nth s is a new regulation 5 __ . = x
pha 1 { , ;� � „ i :sissued, lease have your c, - eactorYpro,id ,the
,'issuing of said permit . Once it >� P,� _ , # <rK ,,} n ,
r : : surance arida cop_y,ofthe permit pr►or to construct►on �t ��_
certificate of m �,21�ArN- � ,,,
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bk{ 1 h ti �": , i�.rt� . , _ F;. f _t to x our unit if you r 4
t :4 F'Ff,, m r
After the deck is install&&,, ,wVQ -ill be con%sidered an yrnproyemen , �y
r, provide us with a copyaf the paid bill=to be keptin ,your files d .` + t
of :� �. s z 'a..
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�. S i*' v 4 x� t -� } R'�^ '� '� yg ,r X y -.r :., } , k J i Y . ,,,� 'aa
Aiiy es�t�aher questions lease calf x
a 3 .. - 1 .� . s < gee ,� a .
T� a
Best'`regards,r: ' ' i 1-1 ;
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Location
No. Date �v
NORT1y TOWN OF NORTH ANDOVER
�� ' • OL
Certificate of Occupancy $
ACHU <� Building/Frame Permit Fee $ X25
JACMUS
Foundation Permit Fee $
Other Permit Fee $
TOTAL $�
Check # �� r
14050
C� Building Ins pe�ot�or'
I�
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/l-tor of Buildings Date
SECTION i- SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
Number Parcel Number
U V t�
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Area Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Required Provide Required
Provided
R red Provided
+
I
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Infomtation:
Public ❑ Private ❑ Zone Outside Flood Zone 0
1.8 Sewerage Disposal System:
Municipal ❑ On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
I 10 L1 we_ IT c l 0k_C_ ("�)Iti wd -
'Name (Print) Address for Service
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Si nature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 L'censed Construction Supervisor:
V i se0-?C.2?/
d Construc ion Supervisor:
<" -
✓ c 5 e Jt✓•
Addr
AK_,.� I/ w L,_� 0,.-, cc) .-f OW
Signature Telephone
Not Applicable ❑
� j
C S ®^/ C .2? /
License Number
Expiration Date
3.2 Registered Home Improvement Contractor
Not Applicable ❑
Company Name
Registration Number
Address
Expiration Date
Signature Telephone
SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes .......❑ No ....... ❑
SECTION 5 DescHi tion of Proposed Work check all applicable)
New Construction ❑
Existing Building ❑
Repair(s) ❑
Alterations(s) 0
Addition ❑
Accessory Bldg. ❑
Demolition ❑
Other ❑ Specify
Brief Description of Proposed Work:
C_ /C
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
1. Building
Estimated Cost Dollar to be
(Dollar)
Completed by permit a licant
�� x r � � (tFFICIA)(;
r�
(a) Building Permit Fee
Multiplier
USE(?NLY` �
.,
2 Electrical
(b) Estimated Total Cost of
Construction
3 PlumbinE
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
OWNEIM AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner/Authorized Agent of subject property
Here orize to act on
half, n all n tters relative to work orize this building permit application.
o ter Date
SE ON 7b OWNER/AUTHORIZED AGENT DECLARATION
I, as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
Print Name
Signature of Owner/A ent Date
MOVIE 411MIt WEEMEN
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TINIBERS 1 2 ND3
SPAN
DIlvIENSIONS OF SILLS
DMIENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
t�
0
Town of North Andover NORTH
° t`t,`E o
Building Department o r
27 Charles Street
North Andover Massachusetts 01845.' .^
(978) 688-9545 Fax (978) 688-95424-0 `°<
A_ V
DEBRIS DISPOSAL FORM
In accordance with the provisions of MGL c 40 s 54, and a condition of
Building permit # the debris resulting from the work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL cl 1, s150a.
The debris will be disposed of in /at:
a, 6' rep
Facility location
Si n -o-of
Applicant
Date
NOTE: A demolition permit from the Town of North Andover must be obtained for this
`" project` through the Office of the Building Inspector.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Please Print
Name 11VOS3 �C-%AVi-ir
Location: A A rc� V�0�--R.; C �
City / JO sr "k Ao t) t ir' Phone C`t 7 s, 0 C) /
FTam a homeowner performing all work myself.
J�KI am a sole proprietor and have no one working in any capacity
aI am an employer providing workers' compensation for my employees working on this job.
Company name:
Address
Ci • Phone*
Insurance Co. Policy #
Company name -
Address
City Phone #:
In urance Co Policy #
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00
andlor one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I
urierstand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do herby certify yf�ier the pains $fl4t penalties of perjury that the information provided above is true and correct.
Print
i"\
Official use only do not write in this area to be completed by city or town official
❑Check if immediate response is required Building Dept
Contact person: Phone
FORM WORKMAN'S COMPENSATION
Date /"' M 0 G
Phone # (-0, 0'-2 C FZ- ,f'
❑
Building Dept
❑
Licensing Board
❑
Selectman's Office
❑
Health Department
❑
Other
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
APPLICAiVT tJ�/ /� Gt 11 n � � 4, 16 PHONE ' 7Z
LOCATION: Assessors Man Number PARCEL�
SUEDIVISION LOT (S)
STR1== i0
ST. NUh1EERCJ�
OFFICIAL USE ONLY`"
REC-GMMENDATIOPIS OF;OWN AGENTS:
COQ: cVAT10N ADMINISTRATOR
COMMENTSX-n—
Av`
DATE APPROVED
DATE REJECTED_
t�
TOWN PLANNER DATE APPROVED
DATE REJECTED
COMMENTS
FOOD INSPECTOR -HEALTH
DATF- APPROVED
DATE REJECTED_
SEPTIC INSPECTOR -HEALTH DATE APPROVED
DATE REJECTED
COMMENTS
PUELIC WORKS - SEWER/WATER CONNECTIONS
DRIVE'NAY PERMIT
FIRE DEPARTMENT
RECEIVED EY EUILGING ii',ISPECTCR
Revised 919; im
DATE
6 --a Cl' ov
A Q @1 zo
Y Wo®d Ridge
10 Wood Ridge Drive
North Andover, Massachusetts 01845
Telephone 682-7093
TDD Line 1-800-545-1833 Ext. 143
June 28, 2000
SANDY LARSEN.
Property Manager
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