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HomeMy WebLinkAboutMiscellaneous - 20 CAMPBELL ROAD 4/30/2018 (2) / 20 CAMPBELL ROAD l 210/106.B-0064-0000.0 1� B j UILDI E i Location ' No. Date -' NORTh TOWN OF NORTH ANDOVER Ott.•o ,•,4, p Certificate of Occupancy $ Building/Frame Permit Fee $ s •E Foundation Permit Fee $ s�CHus t Other Permit Fee $ Sewer Connection Fee $ W��yy7t,!_ ater Connection Fee $ J 1t n TOTAL-'-` $ r Building Inspector Div. Public Works PNtt,iTF 4io. T AGE I APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. MAP K40. LOT NO. 12 RECORD OF OWNERSHIP IDATE (BOOK 'PAGE ZONE I SUB DIV. LOT NO. LOCATION ` PURPOSE OF BUILDING /�rl J1- 7- Ov� OWNER'S NAME / / L�� G/L41 NO. OF STORIES 'SIZE /` LS OWNER'S ADDRESS` 0 • �1�y t`G/G•! Jb BASEMENT OR SLAB -- ARCHITECT'S NAME ,+�- [ .VGG.�` SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME/,�p/(`d- %J7V NS*7" SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES-SIDES REAR " GIRDERS 40iN6 ,NF AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESSTQI�� IS BUILDING NEW - SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY (,� / ('If TP-1,04 IS BUILDING ALTERATION - t�� IS BUILDING ON SOLID OR FILLED LAND` 41156F 4-,je,4 WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES EST. BLDG. COST PAGE 1 FILL OUT SECTIONS 1 - 3 EBT. BLDG. COST PER SQ. FT. PAGE 2 FILL OUT SECTIONS t - 12 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FI D BOARD OF HEALTH SIGNATURE OF OWN OR AUTHORIZED AGENT F E EYO fa OWNER TEL PLANNING BOARD PERMIT GRANTED CONTR.TEL # G2' 19 Cj CONTR. BOARD OF SELECTMEN • �7 /-,4, J1 {' y /1� / JZ V OILDiNG PECTOR l✓[i7 BUILDING RECORD i 1 OCCUPANCY 12 SINGLE FAMILY STORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES _ LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION $ INTERIOR FINISH CONCRETE _ B 1 2 I3 1 CONCRETE BL'K. PINE _ BRICK OR STONE HARDW D PIERS PLASTER ' _ DRY WALL _ UNFIN. 3 BASEMENT AREA FULL FIN. B'M'T' AREA _ - '/, '/� 3/, FIN. ATTIC AREA _ NO B M FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE WOOD SHINGLES EARTH _ ASPHALT SIDING HARDV✓'D _ ASBESTOS SIDING _ COMMON VERT. SIDING ASPH. TILE _ STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. & FLOOR I_ BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIOR I� POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE I HIP BATH 13 FIX.) GAMBRELMANSARD TOILET RM. (2 FIX.) _ FLAT 11 SHED WATER CLOSET ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. &COLS. STEAM STEEL BMS. & COLS. _ HOT W'T'R OR VAPOR WOOD RAFTERS AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL • B'M'T 2nd _ ELECTRIC 1st 13rd I NO HEATING SEW E 9 PA7A T, 77, FINAL PLANNING F FINAL CONElotEt' FINAL .0 tx Ti T 0 ,own o „N , ndover I " ' / No-345 I V E V Ando er, M hl V"AY C-�J- T R 7777 o T k ass. CK 0, V PERMIT T 0 L 0 BOARD OF HEALTH THIS CERTIFIES THAT-e-A-/--^o0#-.#t...... ................. A64)&f­ BUILDING INSPECTOR haspermissiontN" 4Y Rough 4 .1��..... Chimney to be occupied as....P-A...e ..111104.11..d . ................................... Final provided that the person accepting this permit shall in every respect conform to the terms of the application on rile in PLUMBING INSPECTOR this office,and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Rough Buildings in the Town of North Andover. Final VIOLATION of the Zoning or Building Regulations Voids this Permit. PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR Rough UNLESS CONSTRUCTION STARTS Service Final STARTS �W'96i GAS INSPECTOR Occupanc.v Permit Required to Occupy Building Rough Final Display in a Conspicuous Place on the Premises FIRE DEPT. Do Not Remove Burner No Lathing to Be Done Until Inspected and Approved by Smoke W",/-/,/ ;� Building Inspector Det. �e loanrira�zuma�/�r��.llwdn��u,u•/!a HOME IMPROVEMENT CONTRACTOR Registration 102658 Type - DBA Expiration 07/02/94 Mike Antoon Construction 1 Michael J. Antoon 14 Bearse Ave ADMINISTRATOR Methuen MA 01844 Date.. .!..—• .... HORTM TOWN OF NORTH ANDOVER p A • - PERMIT FOR GAS INSTALLATION 49 �o ,SSACMUSES This certifies that . . . . . . . . . . IJ has permission for gast i�nst Ration . .job? . . .��?.� . . . . . . in the buildings of . . e. -r '. . . . . . . . . . . . . . . . . . . . . . . at . . .2- . . ©`�'`�'� �� . . . . . . ., North A ov ass. FeeZ�-� . Lic. Nom-����. . . . . qb.A/ . x4. . . `!fit '4 17 16" GAS INSPECTOR Check# 8242 C MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CIN ��r i4c' MA DATE \Na PERMIT# JOBSITE ADDRESS 8.�.-.__ v 0 �___..,_.._..�.._.__.___— OWNER'S NAME JG1%��g� GOWNER ADDRESS 3 TE _�• (� FAX TYPE OR OCCUPANCY TYPE COMMERCIAL I EDUCATIONAL E] RESIDENTIAL PRINT CLEARLY NEW:CJI RENOVATION:0 REPLACEMENT: 1 PLANS SUBMITTED: YES .[]_I NO& APPLIANCES 7 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER1 - BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER I I+-_. L— J DRYER FIREPLACE --j L—J FRYOLATOR FURNACE GENERATOR --_J L- —1 GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER 0v ' ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER '— OTHERr !' INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF OVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ___. OTHER TYPE INDEMNITY ( I 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 [ 1 AGENT 0 SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complia ce with II Pertir� t provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. C� PLUMBER- SFITTER NAME ��-� e�c`S ( LICENSE#r �135_I SIG ATURE MP I MGF ___ JP Ell JGF LPGI CORPORATION'S]# _�N f PARTNERSHIP 0#[� =!I LLC[f]#= COMPANY NAME:N�F�ra�ic�Cx+ d►S �� DDRESS CITY STATE - {ZIP 0\4)' % EL Q► �'174-"'1A� - (� FP, 3- CE"`'C EMAIL I ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes tjo THIS APPLICATION SERVES AS THE PERMIT ❑ �❑ . ;; / Ile FEE: $ PERMIT# PLAN REVIEW NOTES d ' The Commonwealth of Massachusetts - Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 Uf www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): C �'`� Address: City/State/Zipv��C: otiq�,� Phone#: re you an employer?Check the appropriate box: Type of project(required): rN I am a employer with 4. ❑ I am a general contractor and I ' 6. El New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.# �• E]Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 1 Roof re a' insurance required.]f employees.[No workers' 13. Othe comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. a� r Insurance Company Name:. V Policy#or Self-ins.Lic.#: C- Expiration Date: I 1� Job Site Address: �d C- `� City/State/Zips 4 5�yip\-%C Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereb cert and the pain �Itlesfperjury that the information provided above is trueand correct.Si ature: eDate: Phone#: � U\ Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - Contact Person: Phone#: a Information and Instructions ' Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or.written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-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 affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or'-permit not related to any business or commercial venture (i.e.a dog license or permit to 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 ofMassachvsetts Department of Industrial.Accidents Office of Investigations 600 Washington Street Boston.,MA 02111 Tel,#617-727-4900 ext 406 or 1-877-MASSAFB Revised 5-26-05 Fax#617-727-7749 wvvw.inass,goV1dia