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HomeMy WebLinkAboutMiscellaneous - 182 RALEIGH TAVERN LANE 4/30/2018�'���� y� �s . , z cF J/ r Date ... ...... .............. . TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .......... ..................................... has permission to perform ...... . ..... ...... wiring in the building of ............ .......................................... ...... e7 ........ North Andover, Mass. ....... ................... ...... ark Fee---R5 .............. Lic. No. .................................................. :�.i ------- ELECTRICAL INSPECTOR / Check # �9 "i " 7 C�y i t..ommonwea& o f Mamac4a6etb Official Use Only } cc�� cc77 nn Permit No. a1.JePartment o�,_tire Jervieed G� Occupancy and Fee Checked ff;t5:— 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: �� ��� 1! City or Town of: /�'�dT�� To the Inspector of Wires: By this application the unders' ned gives notice oihis or her intention to perform the electrical work described below: Location (Street & Number) _,X<52"tvjr��,�/ Owner 'or Tenant Owner's Address Is this permit in conjunction with a building permit? Purpose of Building Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Telephone Yes ❑ No KI (Check Appropriate Box) Utility Authorization No. 7e -'?6-77'F Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters No. of Recessed Luminaires ------------ -'-- --._.. ... No. of Ceil.-Susp. (Paddle) Fans ........ ...... .... ............ .. .nc. ..m caw. v rruw. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- El rnd. rnd. 0. o Emergency tg ng Batte 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 g No. of Waste Disposers Heat Pump Totals: Number ""'- Tons """""" ""' """""'""""""""" KW o, o Self -Contained 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 Heaters KW No. of No. of Signs Ballasts - Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: - No. of Devices or E uivalent OTHER: 4�O;� 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.z5kS o1/® 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 coverage is' in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND F1 OTHER F-1 (Specify:) I certify, under the pains and Ities of perjury, that the information on this application is true and complete. FIRMNAME: Aries Electrical Service and_ Controls LLCLIC. N015650a Licensee: Nor and Michaud Signatu. LIC.NO.: 4e (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: 978 687-0544 Address: 290 Broadway suite 117 Methuen ma 01844 Alt. Tet. No.: *Per M.G.L. c. 147, s. 57-61, security work requires Department 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 agent. Owner/Agent Signature Telephone No. PERMIT FEE: S R''✓ r R Office Oflnvestigations 600 Washington Street / Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Aff7dsvit: General Businesses �pplicanr information Business/Organization Name: address Please Print Clry/State/Zip: Methuen MA 01844 Phone 0978 I Are You an employer? Check the appropriate box:. I ❑ I 687 0544 Business Type (required); am a cmpioycr with cmployccs (full sod/ or pan -time).• 5• ❑ Retail 2 1 am a sole proprietor or pa.rmership and have no 6. ❑ Restaurant/Bar/Eatm9 Emabbsbmml employees working for me in any capacity. (No workers' 2 ❑ Office and/or Sales (inc(, real estate, auto, dc.) I' comp..insuranc, required) ❑ We are a corporation and its officers bavc exercised 8. ❑ Non-profit ! tbcir right of exemption per c. 152, § 1(4), and we have 9. ❑ �tc'rtai mem no employees. l(No workers'. comp. insurance required)* 4 ❑ We are a non=profit organization, 10.❑ Manufacturing staffed by volunteers, "'itb oo cmployccs. (No workers' comp. insurance req) 11•❑ Hcal tb Car, 12.❑ Other e If L C cot o that checks box rrl must also fill out the section below showing their workcri' eomprnsation policy in(omiaoon. bavc exempted tbcmselves, but the corporation n Polis rra the corporou bas other org+o�utioo should cheek hoz M1. d c ck employes, a workers' cation tic po y is re4uirtd.and such ao l nm an employer that is providing workers' compensation Insurance for myn r�pioyees. Beton, is 'he -Policy in Losurancc Company.Namc: formaaorz_ Lnsurcr's Address: Ci ry/S to t c/Zi p: Pobcy A or Self -ins. Lic, X Anach a cop)' of the workers' compensation tilt ExPiration Date: Failure to secure covcragc as required under Section 2 A of MGL Page152(canolead tong htbpim number and expiration date). fin" up to St,500.00 and/or onc-year imprisolimcnt, as well as civil position ofcriminal penalncs in the form of a STOP WO Ixnalucs of a of up to 1250.00 a day against the violator..Bc advised that a copy of this statemee form be .forwarded to the Office a lnvcstigatioas of.the D1A for.insurance covers a vrrification �` ORDER and a fire / do itcrcbv cerrifv_ under .'s...._J__ ruins _ and penalties ojperjury that the irrformarion provided above is nue and correct Sig.Da•turc Pbonc u: 97 Official use only. Do not write in this area, to be completed bj' city or Lown o, jftdaL City or Town: Pcrmlt/I;fcense # Issuing Authority (circle one): 1. Board of HcaJth 2. Building Department 3. CitY/TOwn Clerk 4. Licensing 1302rd 5. Selectmen's Once 6. Other Cont2ct Person: Photic f1: w+'+v.m&ss.;ov/iia Location No. C>2 Date 1, TOWN OF NORTH. ANDOVER 0 Certificate Occupancy of $ AC Mu Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # *7J 176 70 Building Inspector W TOWN OF NORTH ANDOVER BUILDING DEPARTMENT BUILDING PERMIT NUMBER: DATE ISSUED: ©, SIGNATURE: Building Commissioner/IEWtor of Buildin Date SECTION 1- SITE INFORMATION 1.1 Property Address: 91;? Itade SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 1.2 Assessors Map and Parcel Map Number Number: Parcel Number 2.1 Owner of Record 1.3 Zoning Information:. Zoning District Proposed Use 1.4 - Prop7ty Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft � i7�-6���a`�`� Wil/ .��✓' Front Yard Side Yard Telephone Rear Yard Required Provide Required Provided Re red Provided NMne Print Address for Service: 1.7 Water Supply M.G.L.C.40. 54) Public ❑ Private ❑ .1.5. Flood Zone Information: Zone Outside Flood Zone ❑ 1.8 Municipal Sewerage Disposal System: ❑ On Site Disposal System ❑ • SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT historic District: Yes No 2.1 Owner of Record ee Name (Print) Address for Service � i7�-6���a`�`� Wil/ .��✓' Signature Telephone 2.2 Owner of Record: 1 NMne Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licenstd Construction Supervisor: ne Add s � / * �/ License Number re ' g 7����Z Telephone Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number `� � �.S Address // --7• Expiration Daatel, Signature Telephone • SECTION 4 - WORKERS COMPENSATION (NLG.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 b ildi rmit. affidavit Attached Yes ...... No ....... ❑ —Signed SECTION 5 Description of Proposed Work check au applicable) New Construction ❑ Existing Building ❑ Repair(s) ` j `Specify Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other 0 Brief Description of Proposed Work: G �a ST)'Lc/c_ e-- A113ir/6:.e_5 SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item 1. Building Estimated Cost (Dollar) to beOI+'ICIAIi,USE Completed by permit a licant� (a) Building Permit Fee Multiplier (}1TLY n; 2 'Electrical (b) Estimated Total Cost of Construction r 3 Plumbing Building Permit fee (a) x (b) O 4 Mechanical HVAC 5 Fire Protection 6. Total 1+2+3+4+5 -2-70 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 i to act on permit application. Date Hereby authorize My behalf, in all matters relative to work authorized by this building Signature of Owner SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION LL7�,U f e (� �i-`� S I, `rjGz� 1 as Owner/Authorized Agent of subject application are true and accurate, to the best of my knowledge property Hereby declare that the statements and information on the foregoing and belief Print Name Dat Si ature of Owner/A ent NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIlvMERS 1 2 3 RD SPAN DMENSIONS OF SILLS DMIENSIONS OF POSTS DINIENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING j X MATERIAL OF CHEVINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE The Commonwealth of,•Vassachusetts Department Of Industrial .4 ccidents Office Of Investigarions 600 lVashington St-eet Boston MA 02111 `Yorkers' Compensation Insurance ,\ fPiriq. it u u, a It 2111 U 1 t t: 3t LU 11 t - Propem Owner `fame job Location: i �--Z Gam. t c1 �1 City /V, A.,GCrS11, U i am a homeowner periormins aii work myself. J I am a sole oronrietnr and have nn �....�,, ,,Yu„sduon rormv �emp og Company Name: CCSw ees tivorkins_o. n.this Address: -1 5 FOND'= (Lc� "' 1/i Insurance Co. j-+- .-�- -1':0 r I ti 57. C r0 V Phone Phone ,= g10 -$�= . 1m; Policy f OR W BK L q,;. Company Fame: .: Address: City: Insurance Co. Phone POlicv # Failure to secure co vetaee as required under Seaton 25A of siGL 152cw lead to the imposition one years' Lmonsonment as well as civil penalties in the r- of a STOP WORK ORDER and a fine ofof cmSl ai penalties of a fine up to S1,500.00 and or cop} or this statement may be forwarded to the Office of Investigations of the DIA for coverage verification 00 a day against me. I understand that a I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Sienature ?runt Name SGaT 1)'0:Zle f e / Iej &j / "Du/.3 Official use only. Do not write -this area. to be completed by city or town official City or Town. Permit/license ## -' Checx ;u :mmediatr rrsnnnse is reatnred Contact person: — Phone ff: 00- 866-9$17( ❑ Building Department ❑ Licensing Board ❑ Selectmen's Office I] Health Department 0 Other -�e &mmowajeaa Board of Building Regula ions and Standards One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration Registration: 129774 Type: Supplement Card Expiration: 11/2/2005 PELLA WINDOWS AND DOORS SCOTT HOUSE 45 FONDI RD. HAVERHILL, MA 01832 DPS-CA1 Co 50M-04/04-G101216p ,o, �iie Vr o�n�no�uvea�i o�✓UGaddac�tuQe�6 �\ Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 129774 Expiration: 11/2/2005 Type: Supplement Card PELLA WINDOWS AND DOORS SCOTT HOUSE 45 FONDI RD. HAVERHILL, MA 01832 Administrator Update Address and return card. Mark reason for change. 7 Address [-� Renewal 11 Employment ; Lost Card License or registration valid for individul use only before the expiration date. If found return to: Board of Building Regulations and Standards One Ashburton Place Rm 1301 Boston, Ma. 02108 Not �with�tsignature I t✓fie �anvnwru�rea�/ a�;�iaasacfucaella BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 081843 Birthdate: 02/06/1966 Expires: 02/06/2006 Tr. no: 81843 Restricted: 00 STEPHEN T DICKINSON 17 BURNSIDE LANE L,�" MERRIMAC, MA 01860 Administrator North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: (Location of Facility) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector ki 1010 WU c -t '-t V) HIC Registration #129774 11ILI() - In*t 21 Federal ID #04-3277886 Pella Windows & Doors of Boston . "Viewed to be the Best" WINDOW CONTRACT Pella Windows & Doors 45 Fondi Road Haverhill, MA 01832 PH: (800) 866-9886 Service: Ext. 124 Fax: (978) 373-7274 Sales: (866) Pella06 Sold To: O C' 13 L'�L c �9I;e Z Date: —op —o Address:- - L 6/6/4" Til (1,E0,1%) L Phone (Home) 71)' K� C City: !• %� �,lf�' Stater Zip: 6,10 y✓— Phone (Work) n 0%R 6000 Job site Address (If different): Phone (Cell) ( ) Approx. Start Date: 3 G o Approx. Completion Date: Pella Boston Will Furnish and Install: YES NO 1:3Remove PLEASE READ CAREFULLY: ONLY THE ITEMS CHECKED YES ARE INCLUDED Windows from they now exist on: t. ®� �ra- the opening where �Gr - 23 24. ,.,r/ FMT, � &V€L• # Openings /,01 # New Window Units �+ vauu-11 11yi���y ano remove ah aeons at completion of job site •�a��ti � Initc / Z Remove and Dispose of existing Windows u ' 25' and/or Storm Doors All workman's compensation and liability insurance maintained 26. ❑ ❑ Warranty mailed to customer upon ompletion whf 11 Total Project Amount $ y� Q � ayment is received 27. ❑ 28. ❑ ❑ ❑ Financed If Yes: Amount Financed $ O ;Z Deposit Received $ (Reference # ) 29. ❑ ❑ Balance on Substantial Completion $ 30. ❑ ❑ Additio I Commnts: PELLA IS NOT RESPONSIBLE FOR ANY EXISTING SECURITY SYSTEMS. PLEASE REMOVE ALL SHADES, VERTICALS, BLINDS, CURTAINS, DRAPES OR WINDOW MOUNTED AIR CONDITIONERS, PRIORTOTHE INSTALLATION OFYOUR NEW WINDOWS. INSTALLERS ARE NOT RESPONSIBLE FOR THE REMOVAL OR INSTALLATION OFTHESETYPES OF ITEMS. CONDENSATION INSIDE THE HOUSE DOES NOT INDICATE A WARRANTY PROBLEM. (Payment Is payable to installer at completion of job) G'. SALESMAN HAS NO AUTHORIZATION TO CHANGE ANY ITEMS OR MAKE ANY REPRESENTATIONS OTHERTHAN CONTAINED INTHIS AGREEMENT AND "OWNER" REPRESENTS THAT NONE HAVE BEEN MADE TO OR RELIED UPON BY "OWNER". YOU ARE ENTITLED TO A COMPLETELY FILLED IN DUPLICATE OF THIS AGREEMENT. CONTRACT SUBJECT TO FINAL INSPECTION BY PELLA CONSTRUCTION DEPARTMENT. TERMS AND CONDITIONS THAT GOVERN THIS CONTRACT ARE PRINTED ON THE REVERSE SIDE. -his contract is a legal document. Your Pella products will be specially made-to-order for you. iN ER :AN ELLATI BEP ISLE BEYOND THE THIRD BUSINESS DAY AFTER THE CONTRACT HAS RFFu e�r�,�., ANCEa wr IELOW YOU ARE ACKNOWLEDGINGTHATTu= Aowo S R NO CIR .uMaT LL REVIGI his OR 'ella Rep. Signature: ustomer Sig i� White - Original Yellow - Customer Date: / L Date: C— . 6 — Li `/- Pink - Store m m m m cn m m CO) 'O OZ CD o 06O C2. a� CD .o 0 o p CL Q cc Vo C CD O CO) .p CD O CA .7 d O CO) C!* O y so Cl) CD O CD CD CO) CD CO! I C 0 s C Z� O m = d O do y spm C2 Cl) �mc a Mw WIC w -� 0=ILN c =r a •+ a c in CD -�OmmC y O m a Z s e°1j o w ejm : sc"cA: V ay= � =a. m m y o � CL cr CD ♦off 1 o � �t, g CD CD o CD =CO) CDO 1 =r CD m m o r CD �o a o L�l z 0 1 Inq 0 c '^t1 W0 9j Ti-Q�p z p 0 �O C O 1] L�l z 0 1 Inq 0 c I �.�Gle- FORM U - LOT RELEASE FORM =� o INSTRUCTIONS: This form is used to verify that all necessary approvals/permits fro rin 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 )6� 4,11,' uny UA Q �G�CC t� igonavl U i a��� ��J� PHONE R? ,_ # jr LOCATION: Assessor's Map Number a�o m PARCEL SUBDIVISION LOT (S) I STREET R-41. E1 6Y Tuuen L q✓/ a ST. NUMBER fsa `OFFICIAL USE ONLY I FiECO ENDATIONS OF�TOWN AGENTS: CONSERVATION i COMMENTS TOWN PLANNER. COMMENTS DATE APPROVED p DATE REJECTED ' s' DATE APPROVED DATE REJECTED . FOOD INSPECTOR -HEALTH DATE APPROVED 11 A . ' A,\ DATE REJECTED SEPTIC INSPECTOR -HEALTH COMMENTS DATE APPROVED. DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECT Revised 9197 jm DATE ['i;T,-TlTAWm(mimwm, ,, �0, I for MM' I CUM THAT T146 ADM PROPERTY DMS NO;r us Wait THE AS DELMTED On At I rit - MORT-GAGE SURVEY PLAN Lm Sc& I Imm 40 IL ode—QE9.27 y1ije PIM nionme A—Obk.A ........ iNAS ..... -ASSOr--.DAMD.....IOZ301.W...-WVISEQ i EC% np IDEEDSAWn FASERSTRM I hwAy =I* " t6 hwl&s Am= on tins plan is 6cabW 00 thin VouW as shown them ,on aud to 16 m&g mW buil&mg iters o� dal o� F -R ........ ;00 1.1 Property Address: 1.2 Assessors Map and Parcel Number: R yerrn ne- Kg�(cn e�[u�r�e�Gl e�`y`, Name (Print) Address for Service Tci,,Qs Lgi G9? 30 ;),5-GOa,6-A 2.2 Owner of Record: Name Print Address for Service: Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Not Applicable ❑ jLiicensed Construction 2 ( n / / [ R\/UhJ(4''(+JHh D,o-A. 1JICIGk\ F�IQtmo✓tr�t l.Rr`O-estTflY LicensedConstruction Supervisor: '� vggo( y 3Y65-0 / P 0, ( 0 )r �(d & fr (A/es fi4lorol �tT _ 01. - Zoning Dia6c—t Proposed Use Lot Areas Frontage fl 1.6 BUILDING SETBACKS ft 3.2 Registered Home Improvement Not Applicable ❑ Front Yard Side Yard Company Name Rear Yard Required Provide RegWred Provided Rapired Provided too, 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 DiB ct Yw .No 2.1 Owner of Record Kg�(cn e�[u�r�e�Gl e�`y`, Name (Print) Address for Service Tci,,Qs Lgi G9? 30 Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Supervisor: Not Applicable ❑ jLiicensed Construction 2 ( n / / [ R\/UhJ(4''(+JHh D,o-A. 1JICIGk\ F�IQtmo✓tr�t l.Rr`O-estTflY LicensedConstruction Supervisor: '� vggo( y License Number / P 0, ( 0 )r �(d & fr (A/es fi4lorol �tT _ 01. - Address �to A6�� 4" %� yo2 I3 ExpirationD Sign re Telephone 3.2 Registered Home Improvement Not Applicable ❑ +Contractor / / / [ I3l� 4 Alciy'. C R��o euI �lS� Gvtal 1���1 Po4l Cott l'/4G1,%I 1377/1 Company Name Registration Number r V . o L(D £s �j10 2S f �ovc/ �G. (� Address Expiration Date Si nate a Telephone ou M X ic 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 ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition IV Other B' Specify Brief Description of Proposed Work: / / -rRke down o(�f -eGK Ct01�t / /P of / (4L2 ✓1-ewolerik SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be00FMi�lSL+ Completed by permit a licant _ , (Di 3 s 1. Building / l o (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-`+ +,x+,,1+5 '�I -Mil a 'f V U C2 0 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, Ka%,i IJ ic (( Ci r9('-e/j , as Owner/Authorized Agent of subject property Hereby authorize RV � [�, ✓4 h ��/t _ (4GYI Oe'uv»onGr 6g4e fn fey to act on My b half, in all matter,,rellatiivelto work authorized by this building permit application. QJLP_//c6� �l Jl ,P� 26 gla Signature of Owner Date SECTIOON 7b OCAGENT DECLARATION /WNER/AUTHORIZnED 1, Qn J �t ! (r ✓4 h D-13 F . 13%4c h Of'o,",J Cre -c-17 ✓k as Owner/Authorized Agent of subject ! 1 Y Property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief f'l V ct rlScf Print Na— n Si at uree Owner/A ent ? Lklg 7 Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR T ABERS I ST2ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DMIENSIONS 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 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 properly licensed solid waste disposal facility as defined by MGL Chapter 111, S 150 A. The debris will be disposed of in: 1-5 INOQc'1 11CeS5rhc4 n Sc�r2 ✓Vi . '(Location of Facility) 4� At Signature of Permit Applicant 7 Ld-10L Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector Name The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02 919 Workers' Compensation Insurance Affidavit Please Print S, lft;dr,'1 1J. 1 ?, 13 �4r.Vi L'i�Oiu�and ( u0(0 2� �/Y Cth�i L��,1 efz( l /j/If/4c�`",7 Location: P0. Oo Ci tv U/esf �aI-Ct /�lu• Phone # OF qct LIa 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 rry employees working on this job ComDanv name: Address city.. Phone # Insurance. Co. Policy # Company name: Address �Itv Phone Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of aiminat penalties.. of:a fine up to $1;50( and/or one years' imprisonnent.as_velLas_c bd penalttesjn-theda-STOPWORKOFOERgW-afte-0(01MW)-a.AVigaiw;;j 1 understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage Verification. , / do hereby certify under the pa=ns and na/bes of perjury that the /nforrnatiian prOW16d above is true and correct. Signature4ve-, Date Print name M Va vl Sq I 11V g n Pho e-# Official use only do not write in this area to be completed by city or town official' City or Town Per -m U& censing. Building. Dept E) Check Y immediate response is required [j Licensing Board ❑ Selectman's Office Contact person: Phone #. - Health Department ❑ Other Board of Building Regulations and Standards HOME IMPROVEMENT. CONTRACTOR Registration: 137711 Expiration:_ 12/1812004 Type;- DBA BLACK DIAMONO .CARPENTRYBGEN CONTRACT RYAN SULLIVAN p� -.49 ROBBINS ST.�--p"' HOWELL, MA -01851 Administrator s , BLACK DIAMOND CARPENTRY & GENERAL CONTRACTING P® BOX 4088 WESTFOR® MA 01888 Bill To: Karen Bellaire 182 Raleigh Tavern Lane N. Andover, MA BILL DATE: DATE DESCRIPTION QTY AMOUNT Tear down existing 14x12 Pressure treated deck & remove all trash. Build new 20x16 deck with pressure treated frame, mahogany decking & cedar rails Build two sets of stairs Build gate at top of both sets of stairs Enclose bottom of deck with 1x4 pressure treated lumber Subtotal TOTAL 1 $16,000.00 BLACK DIAMOND CARPENTRY & GENERAL CONTRACTING APPRECIATES YOUR BUSINESS. THANK YOU! TOWN OF NORTH ANDOVER PUBLIC HEALTH DEPARTMENT 27 CHARLES STREET NORTH. ANDOVER, MASSACHUSETTS 01845 Sandra Starr Public Health Director August 15, 2003 Ryan Sullivan Westford, MA DBA: Black Diamond Carpentry P.O. Box North Andover, MA 01845 Re: Application for open deck at 182 Raleigh Tavern La., North Andover Dear Mr. Sullivan: � eaORTy 4 � tt4lD ;b! yo 4S�ACF6USEt Telephone (978) 688-9540 FAX (978) 688-9542 Your application for a 20' X 16' open deck at 182 Raleigh Tavern Lane has been reviewed by the Health Department. The application was denied on August 15, 2003 for the following reasons: 1. X Missing.information 2. ❑ Passing Title 5 inspection of septic system required 3. ❑ Location of structure not acceptable To address the problem(s): If #1 is checked, please supply: a. Floor plan of existing and proposed addition — all rooms b. Certified plot plan showing house, septic system and proposed project in scale If #2 is checked: a. Have the septic system inspected by a certified Title 5 inspector to determine the size of the system and whether it is operating properly: OR b. Tie-in to municipal sewer If #3 is checked: a. Relocate the project Please feel free to call the Health Office at 978-688-9540 with any questions you may have. Sincerely, Reviewer Cc: Building Department File Date. % 2. ...! ....... . TOWN OF NORTH ANDOVER 30 PERMIT FOR GAS INSTALLATION This certifies that .ti9.�'!.c; ... (��................. . has permission for gas installation.. (.(. : ................... in the buildings of ... T3 �. `:y. /. ......................... . at /?.�t.' ,�.%!/, / -7.' -. , North Andover, Mass. FeeU.Lic. No..l?�G.�....'}�....... �INSPECTOR Check # 4354 MASSACHUSETTS. UNIFORM APPLICATION FM P f <O DO GASFnMNG QMM or Type) (,� t1J w C/ .Mass Date ' I q — Q 0 3 Permit # L 3 Jl Buwkv -Location � r�� )� c,) e b91�7u✓P�n owners Name_ fZbbr-� )Be /lair e 97w " �P� `��-� Type of Occupancy G New p Renovation. ❑ RQa Plans Submitted: Yesp No p Installing Company. Name• yQp�tc.�2�n �s �1.�tib,� . Chedc_one::. Address5 X14 C3 Corporation ❑ Partner�h� Business Telephone -7F5 r - f 4 - ?SG ztt vP Firm/Cm Name of Ucensed Plumber or Gas FrdwSW Lxev► zz AacL-,y2sa -T Q . INSURANCE CnI VERAGE: I have aYeuffmViabilty i Qnoe policy or Its sit equivalentwhidrmeets the requirements of.4MGL-:CtL If you have-dmei sdaM*• m*dioate*wiWe=vemge-by chw*ingthe appoopdate.box A IWAIty insuranoe.pok7 )( Other:.type-sof-indefra ty. ❑. Bond ❑ OWNER'S INSURANCE WAIVER: l am -aware that the ftensee.does not have - the Marrone .coverage requk ed by Chapter,142 of the .Mass. General -Laws, and Ghat my signature on -this permit -application waives .this requirement. Check one: Owner❑ Agent.❑ Signature of OwrnrAr.�Owrwrs Agent.. I hereby certify that as of the detaas and information l have submitted for entered) in above application ata true and aoauafe to -the bed of my knowledge and that as plumbing work and installatm perlomed under the permit awed for tttis apparition will be in compliance with all pertinent provisions of the Massachusetts State Gas Cods and Chapter 142 of the General LzwjL Tj of License: zYa6k Title Plumber u or Master License Number ) SSI aCo. City/Town Joumeyrrar —_' C � � O Z I V d b O N z O � � W p O 416 16 O W O z IC a �06 ti Z J O 16 O 4c W t W m V } O 16 ■ W Z d ' 96 W • W S v W 39 W v W d 2 Z Date. Ao..3...... . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION .... This certifies that .................. has permission for gas installation 6 114 1. ............. in the buildings of (Z.11 1 ............................ at .............. North Andover, Mass. Fee..A�- .-: ... Lic. No.. 3 ?� . . . ... I-- . . ........... /GASINSPECTO� Check# 117 )- c, 4368 Nv u�D5 U -f Fir uVLL1 4+ v MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print oc Type) I 0 RA) Aiy� , Mass. ,Date Building Owner's L/ Type of New Renovation ❑ Replacement ❑ L/ Permit #,4 Plans Submitted: Yesp No ❑ Installing Company Name YANKEE GAS Check one: Address 1 4 0 SOUTH MAIN STREET ® Corporation MIDDLETON , MA 01949 ❑ Partnership Business Telephone 978-774-2760 ❑ Firm/Co. Name of Ucensed Plumber or Gas Fitter WILLIAM R. HARRIS Certificate . 103C INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes X No ❑ If you have checked yes, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy EX . 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted (or entered) in above apprication are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit Issued for this appli 777 with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the I Laws. � T of Ucense: Plumber gnature o um r or as atter Title Gastitter 3785 aster Ucense Number City/Town Journeyman ■■.■■EA■■■■N■■ IN■■■■■ ■E■ . • ■t/����������tt��n0 NUNN MIT .. ���������t��l��t���t��■ RON • ■■■.■..■..■■■■ KE■SE■....■■ Installing Company Name YANKEE GAS Check one: Address 1 4 0 SOUTH MAIN STREET ® Corporation MIDDLETON , MA 01949 ❑ Partnership Business Telephone 978-774-2760 ❑ Firm/Co. Name of Ucensed Plumber or Gas Fitter WILLIAM R. HARRIS Certificate . 103C INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes X No ❑ If you have checked yes, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy EX . 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted (or entered) in above apprication are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit Issued for this appli 777 with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the I Laws. � T of Ucense: Plumber gnature o um r or as atter Title Gastitter 3785 aster Ucense Number City/Town Journeyman