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HomeMy WebLinkAboutMiscellaneous - 200 CHESTNUT STREET 4/30/2018Date......°�/.` /4t .... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING Thiscertifies that........................................................................................ has permission to perform ..... !` �..� '... ....... �..7f.- ................... plumbingin the b ' d' gs of ................ . fi"J .y ........................................ (9 D S yw .... ............ Fee .-�........ Lic. No... 473. It �� Check # North Andover, Mass. ............................................................. PLUMBING INSPECTOR D`% MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK AP 1 11--7., th.I= Web • • ••- - ••' �0©©0©0000' �®®� I!!!�fN-MlMFIMMFOW�[FN-MFM-- CW mil® mmm • • • . - .. • , •���� �� ®� ��®� �r®ice kITCHENSINK 11100 UNIT, • • FW-VFW-WMWMMWWWFP-WlW1=1W1M WASHNG MACHINE CONNECTION I MW��(©F®�(W�M1r® SFW FM - WA' WA' INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES Q1 NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY Q BOND Q 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 Q AGENT ID SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are tr a and ccurate to the best of my know) and that all plumbing work and installations performed under the permit issued for this application will be Inc ianc with Pertinent provision of the Massachusetts State P; �mbi�ng C—o_de and Chapter 142 of the General Laws. PLUMBER'S NAME%: 1 Kc(I— --- - LLICENSE # {? SIGNATURE IVlP JP 0I CORPORATION a#PARTNERSHIP_i # LLC a L COMPANY NAME ADDRESS CITY�tti ; STATE ZIP FAX _ if CELL�� EMAIL l� -- o o z M ❑ w a iii w LL. The Commonwealth of Massachusetts Department of IndustrialACcidents M X Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia o�M SJ�v Wo�:kere Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TOBEFILED WITHTHE PERIWTTINGAUTHORITY• orQ'eaPrint 1 Name (Business/Orgai&ation/Individual): Address: City/State/Zip:_ Are you an employer? employees (full and/or part-time).* 1.[] I am a employer with__ 2. ❑ I am a sole proprietor or partnership and have no employees Working forme in any capacity. [No workers' comp. insurance required.] 3.E] I am a homeowner doing all work myself. [No workers' comp. insurance required-] t I will 4.❑I am a homeowner and will be hiring contractors to conduct all work on m property- ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.C]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 cozporatiori and its. officers have exercised their right of exemption per MGL c. e have no empldyees. [No workers' comp. insurance required.] --A the appropriate box: Phone #: Type of project (fequired)' 7. ❑ N&0'construction 8. [] kemodeft 9, ❑ Demolition 10 [] Building addition 11.[] Electrical regai, s or additions 12. [] pluinbiug repairs or additions 13•. [] Roof repairs 14.[] Other w *Arty applicant that checks box #1 �siust also fill out the section below showing their workers' compensation policy information.it Homeowners who submit•this alfa aft ched an additionrork and then hire outside al indicating they are sheeett showing the name of the sub c ntractoros and state wrs must hether or npot thoseentigesnhave k TContractors that check this box must employees. If the sub -contractors have employees, they must provide their workers comp. policy number' workers' compensation insurance for my employees. Pelow is the policy and job site X am an employer that is providing information. Insurance Company Name:. policy # or Self -ins. Lic. Expiration Date._ City/State/Zip: Job Site Address: ompensation policy declaration page (showing the policy number and expiration date). Attach a copy of the workers' ce, by a ffie up to Failure to secure coverage as required under MGL penalties inthe form of25A is a aSTOP WORK ORDERal violation Iand fine of p to $250.00 a and/or one-year imprisonment, as well as civil p ay Forwarded to the Office of Investigations of the DIA for insurance day against the violator. A copy of flus statement m uuvGAnr,v YVFiu - - X do hereby certify under thepains andpenalties ofperjury that the information provz e - Date: Siggare: official use only. Do not write in this area, to he completed by city or town official. Permit/License # City or Town- Issuing Authority (circle one): ' 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. plumbing inspector 6. Other Phone #: Contact Person: 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 We, 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 enferprise, and including the legal representatives of deceased employer, or the receiver'or trustee 6f an individual, partnership, association or other legal entity, employing emplbyees. , 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 b6 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 root produced -acceptable evidence of compliance with the insurance coverage requhred. " 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=contractors) name(s), address(es) and phone number(s) along with their certificates) 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 (ifnecessary) 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 burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia This certifies that Date ........ 0�........ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ��.. a . has permission for gas install tion ... - ......./ ...i�' ..................................... in the buildings of. . ........................................................................................ at .... c -,2A0 ......... ^".K. ........................... North Andover, Mass. Fee. ! �- —.. Lic. No. 7 ........................................................................ Check # i 3-2- GASINSPECTOR D% MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATED � II PERMIT# JOBSITE ADDRESS _ OWNER'S NAME G' OWNER ADDRESS p _ TEL.F FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL$l CLEARLY NEW: E . RENOVATION: E] REPLACEMENT: Cd PLANS SUBMITTED: YES Q NO F APPLIANCES 1 FLOORS-- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER._.._._hTl BOOSTER - CONVERSION BURNER COOK STOVE DIRECT VENT HEATER-- DRYER.1 FIREPLACE FRYOLATOR (^_ FURNACE - 1J GENERATOR._ GRILLE INFRARED HEATER- _�► _ _ _ _ __ J LABORATORY COCKS MAKEUP AIR UNIT OVEN-- POOL HEATER ) ROOM / SPACE HEATER ROOF TOP UNIT (-- TEST _ L� ._( - -� -— - UNIT HEATER UNIENTED ROOM HEATER ( i WAI ER HEATERJ l^ I OTHER L_ r INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICr OTHER TYPE INDEMNITY ® BOND OWNER'S INSURANCE WAIVER: I am aware that the icensee 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 0 AGENT 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 com 'ance with al ertinent provision of the Massachusetts State Plumbing Cod and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME tQLICENSE # SIGNATURE MP J MGF E3 JP 0 JGF LPGI ® CORPORATION �J# PARTNERSHIP 0I#= LLC E3#��) COMPANY NAME:. ,moi"[_ ADDRESS CITY �j—%t _� STATE,ZIPTEL FAX �--� t.�: --,- -- - -- - - - -�'�� - - CELLO EMAILVj D% W� O z O H U a n w O � o Z O yrl W r � W O� a Z U w W 3: Q w co o. w O w w w co o a a a U J a � w x w I- LL O z 0 H U a t�7 - rtv Mutual, March 10, 2015 Town of North Andover Attn: Building Inspector 120 Main Street North Andover, MA 01845 Liberty Mutual Insurance New England Region Central Property Unit 75 Sylvan Street Danvers, MA 01923 Tel: (800)566-0323 Re: Property Address: 200 Chestnut St, North Andover, Ma 01845 Policy Number: H3621805010140 Underwriting Company: The First Liberty Insurance Corporation Claim Number: 031484373-0001 Date of Loss: 2/14/2015 Attn: Town/City Official Pursuant to M.G.L. c. 139, § 313, please be aware that a homeowners insurance claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or causes the condition of a building or other structure to render Mass. General Laws, Ch. 143, � 6 applicable. You are required to notify Liberty Mutual by certified mail in accordance with Mass. General Laws Ch. 175, 599, if you intend to initiate proceedings designed to perfect a lien pursuant to Mass. General Laws, Ch. 139, § 3A & B, or Mass. General Laws, Ch. 143, 5 9, or Mass. General Laws, Ch. 111, § 127B. This letter should not be construed as a waiver or estoppel of any of the terms, conditions or defenses afforded by the policy or applicable law. Please direct your notice to the attention of the undersigned and include a reference to the above captioned property address, policy number, claim number, and date of loss. Sincerely, Liberty Mutual Support Liberty Mutual Insurance New England Region Central Property Unit 1-800-566-0323 Date .......—S� d....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........Ay/................................................................... has permission to perform ...... c.,G 1l r.. Tom...... . ; l jt. „............. wiring in the building of ..........�................................................. at .................l.F...S. ��t/r�rl...'..... North Andover, Mass. a Fee .. :5.-��" Lic. No. C S%S f i /LE9CTRI4CALINSPECMR � Check # 3 / 2� �%2� �y r ' / v U l,ommonuwealM of /i"Ia99aclswedi 2epartment 01.}ire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only al Permit No. -Z(737 Occupancy and Fee Checked _ [Rev. 1/071 (lease blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (ME ). -27 .4R 12.00 (PLE.ASE PRINT IN INK OR TYPE ALL INFORM4T10N) Date: I J � V City or Town of: �J©�' � A -xl To the Inspector of Tires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) r l e s+ 1V u.4 S, Owner or Tenant Cc n Q Telephone No. %p - �� %9.4 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: Q Yes ❑ No (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA Generators EVA Ne. of Luminaire Owlet✓ No. o. of Lu;ainaires No. of Recepta.le Outlets No. of Hot Tubs Above In- Swimming Pool arnd. ❑ grnd. ❑ No. of Oil Burners i o. o mergeacy Lighting Battery Units t FIR C° ALAR,°,I, No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of PangesNo. of .Air Cond. Total Tons No. of Alertin� Devices r No. o. e1�Coritair.ed Detection/Alertin Devices No. of Waste ;Asposers Heat Pump Totals: Number fon K.�' No. of Dishwashers Space/Area Heating K`v Local Muni ' al ❑Other onnectio No. of Dryers +;Hearing Kut Appii-€,icesuu ec ritv Svstern �c ivalent Data Wiring: No. of Devices or E uivJent 1' 0. of YVaterKW Beaters No. of No. of " Signs Ballasts No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER:��— Attach aaamoiat detail tJ desired, at -as required by the Inspector of lVires. Estimated Value of Electrical Work: _ (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with NEC 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 ❑ OTHER ❑ (Specify:) Self Insured I certify, under the pains and penalties of perjury, that the information on this application is -true and complete. FIRM NAME: ADT Security Services LIC. NO.: Licensee: Mark A. Brophy Signature LIC. NO.: C-45 _ e (If applicable, enter "exempt " in the license number line.i Bus. Tel. No.: 603-594-5928 Address: 18 Clinton Drive Hollis NH Alt. Tel. No.: *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. 00953 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 ❑ own�r's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ oInd IY 6",ty\x'1.0vilU'h*l -EEZI1 E _: 6 L SoLZSL oiiT�iLa Z09h-Z9.OZ0 del ,. 0001'IaON SNI '. S3S 3 �J i OL 3SH3111 GNL `•3nSS1 .. `doloyNl�lo� Sl! 3s�H�dssdW �O-Hl. VIMNOINWOO vgtri°Ii lY6-(yip I;0c V1'PIG I' EEZL'Y9C (98?7 2131N7� l'itiJ 2-.V7 010 b )I:JV'N C. )000 03�i 4. A.L3:dOlend -10 1N�Wt=td 'vS I \v� �� �jJ•+ arroo:. �� .-••.. G007.1Z00{VOYW:Ji( `00.0Ofd"40� U LY7::d! uo!jc3Ijj)ou sso.ppc �o e0ueyo puo 1dle�o� �o3 doi deo){ �n'•y ti` '; .\ r��j ��, ,� Z90Z0 VW 'OOOM2IOTl (._.' -: = a sajtdx3 E9G000 >D :jegwnN 00 :O1 P0101.13s0�' _ _--__l=L'OZlLOlZO asuil�jl -S 819 -80 eW `uoISog V 1.081 w✓j `aoeld uolinggsy auO �Cuaua . �a�.eS o!Iq d �o edaQ � � ���' ��°e�5- Ofd �- r FORM - U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all -necessary approval /permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. .........................................................................■ APPLICANT 1/�/.L ,U G� L %��2 C�/PHONE ASSESSORS MAP NUMBER 4260 LOT NUMBER f)_3 SUBDIVISION LOT NUMBER STREET®O ��..y��%GL `��= STREET NUMBER OL-52 ..............................................................Bosoms ....won OFFICIAL USE ONLY ............................................................................ RECONIlmENDATIONS OF TOWN AGENTS 11 we snows Oman as snow OWEN ED owns am now Noon" 0 moves MEN soon MEMEM an G— . L,\(,-. . L 4rrr S w DATE APPROVED CO SERVATION ADMINISTRATOR DATE REJECTED L I (U1 �Wj TED ais i -o �L,Le Val DATE APPROVED TOWN PLANNER DATE REJECTED CONM ENTS DATE APPROVED FOOD INSPECTOR -'HEALTH DATE REJECTED DATE APPROVED SEPTIC INSPECTOR -HEALTH DATE REJECTED CONDAENTS PUBLIC WORKS - SEWER / WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPARTMENT DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR DATE TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING IOWA BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioner for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: y Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided R red 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 0 Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Name (Print) Address for Service: 9'� 44 111-2- ff2Signature Signature Telephone 2.2 Owner of Record: Name Print Address for Service: _ D Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervis � �a t7 License Number Addre Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Address Registration Number Expiration Date Si nature Telephone SECTION 4 - WORKERS COMPENSATION (M.G.L. C 1.52 § 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 build'g permit. Signed affidavit Attached Yes ..... No.......❑ SECTION 5 Description of Pro osed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: e!:�7 -7-�`" 1 _�' SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONL 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT e) I&,, as Owner/Authorized Agent of subject property Hereby authorize C L to act on My behalf, in all matters relativ to work authorized by this building permit application. 4;00-:j-k_�S.s9—• 41 1.2 00 1 Signature of Owner Date SECTION 7b OWNER/AUTHORIZE[D AGENT DECLARATION 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 'WSl� Print Name 0 Signature of Owner/A e t Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS 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 .elle, (10W?1Yh"-y 1WeW1N' O)�_.% �Board of Building Regulations ' One Ashburton Place, Rm 1301 Boston, Ma 02108-1618 License: CONSTRUCTION SUPERVISOR LICENSE Number: CS 004613 Expires: 03/19/2002 DENIS P BOUCHER 145 STEDMAN ST #3 CHELMSFORD, MA 01824 Birthdate: 03/19/1959 Restricted To: 00 Tr. no: 19594 Keep top for receipt and change of address notification. --' �x-'------------ ^ - ' rd of Building Regulations and Standards One Ashburton Place - Room 1301 Booton, Massachusetts 02108 Hume Improvement Contractor Registration . Registration: 114800 Expiration: 10/26/01 Type: Individual DENIS BOUCHER CONSTRUCTION DENIS BOUCHER 145 STEQMAN ST' #3 CHELMSFORD MA 01824 d°� ��&�~°°°°°°�� /;��^ r---- HOME IMPROVEMENT 0U0AC08 W^"xmu^uvo' 114800 xpimboo: 10/26/0110/26/01[ �y;o: lodvldux} 008BOUCHER CONSTRUCTION The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print Name: Location: City Phone am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity 0 I am an employer providing workers! compensation for my employees working —on this job. Company name: Address City-�✓?r/y' �� ���i Phone # Insurance Co. - Policy # Company name: Address City Phone #: Insurance 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 and/or 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 understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify under the pains and Sianature �J , that the information provided above is true and correct. Print name 1-;7/ ;S- XOli6_ `7 r`— Phone# 7� l' %J� Official use only do not write in this area to be completed by city or town official' ❑ Building Dept ❑Check if immediate response is required Building Dept ❑ Licensing Board ❑ Selectman's Office Contact person: Phone #: ❑ Health Department ❑ Other FORM WORKMAN'S COMPENSATION Town of North Andover Building Department 27 Charles Street North Andover, Massachusetts 01845 (978) 688-9545 Fax (978) 688-9542 DEBRIS DISPOSAL FORM NORTH Q a 4AK� CO[NKNfwKN . 1' 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 Facility location L lz Signature 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. a 4 9 J \Z n 1 r r 1 1 f f � � 1 1 r o f ~ I a LOT 1 f� l'39.242,,-/- S.F. r r 2+4.3' EasE4sErvr 1 �_3T; r,.ve.1 ! d7• 1 63� w , -r 175.41. o ruECTI\�Iv IV' a Ub, l T .,„ I/ I, „ i �. v c-qmERoN BISHOP CO -V. P.O.Box 52, la" Cmuing, 60 Paine Ave-," 01965 ?ekpfwm (508) 524-8809 FML&n a (508) 524-8810 MORTGAGE INSPECTION RECORD PLAN GRANTEE: MAMAS MARIMA 4U SEXT08 ADDRESS: 200 CWESTRUT ST., KORTH AN DOVER, MA SCALE: f Inch = 50 Ft. I No. 9190 AA(o4 I Date: 5.29.1997 NORTH MARK $ AN K BOOii 3 5 2 5 HERESY CERTIFY TO AND TITLE INSURERS THAT. BASED ON AN AITUAt PACE 139 NSP=ON OF THE PREMISES. ALL BUILDINGS, KNOWN EASEMENTS, AND OBSERVABLE ENCROACHMENTS ARE DCATED APPROXIMATELY AS SHORN HEREON. AND THAT IN MY PROFESSIONAL OPINION THE BUILDINGS PLAN g 9 2 10115 ONFORM TO THE ZONING RDQUIRENENTS OF N Q. -N SZQYF- R j MA APPLICABLE AT THE TiWE OF THFIR DNSTRUCr[ON OR ARE PROTECTED UNDER SECTION 7 OF CHAPTER 40A M.G.L.A, AND THEY DO NOT rAI.L TTHUN THE 100 -YR. FLOOD HAZARD ZONE SHOWN ON F -LP -M. 2 5 O 0 � 8 001 a B DTD, 6 • I .S 158.3 �� ALEXA y� � Y H HUS PLAN MEETS M.A.LS.C.E. STANDARDS FOR MORTGAGE SURVEY$ AND IS TO BE USED FOR MORTGAGE �o OCIQ2 oQa URPOEI£S ONLY AND NOT FOR THE DETERMINATION OF PROPERTY BOUNDARIES OR FOR THE LOCATION OF FCr ERE E ICES OR BUILDINGS. THIS PIAN 13 NOT BASED ON AN TNSTRUNENT SURVEY, BUT ON PIANS AND DEEM l IAWD F RECORD, VARIOUS OTHER SOURCES. AND TAPE MEASUREMENTS, AND IS NOT TO 8E RFCORDED �Jll !; zg 97 DENIS BOUCHER CONSTRUCTION Phone 978-250-9493 Paae No. of Paaes Or= PROPOSAL SUBMITTED TO PHONE DATE STREET JOB NAME CITY, STATE AND ZIP CODE JOB LOCATION Payment to be made as follows: ARCHITECT DATE OF PLANS JOB PHONE We hereby propose to furnish materials and labor necessary for the completion of. L:-L'CL ,. .I �J l'-,�.i L"O iac uL. 1L . L. UCG t- LU f "Committed to Excellence" WE PROPOSE hereby to furnish material and labor — complete in accordance with above specifications, for the sum of: : ..l' - 1 !._-Ly 01J _. --- --- ---———-------- dollars($ Payment to be made as follows: All material is guaranteed to be as specified. All work to be completed in a sub- 1 stantial workmanlike manner according to specifications submitted, per standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an extra charge Authorized ( 1 Signature - - over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado and other necessary in- surance. Our workers are fully covered by Workmen's Compensation Insurance, Note: This proposal may be withdrawn by us if not accepted within days. ACCEPTANCE OF PROPOSAL The above prices, specifications and condi- tions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made trine above. Date of Acceptance: _ �C-= !A-0--- 41 11 10 I Signature Si¢nature "Committed to Excellence" Town of North Andover Office of the Health Department Community Development and Services Division William J. Scott, Division Director 27 Charles Street North Andover, Massachusetts 01845 Sandra Starr Health Director North Andover, MA 01845 Re: Application for P fA L did P �% ':/-- c5 h <-�d Telephone (978) 688-9540 Fax (978) 688-9542 Dear: /✓% S . oG0/�/-)'t�C' Your application for -N& 666 at io ` it T©h"_5o4 has been reviewed by the Health Department. The application was denied on )2001 for the following reasons: 1. P- 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 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 BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANNING 688-9535 Location_! C -L ` O����5 No. l - b Date f!�l I-) TOWN OF NORTH ANDOVE@ Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee r- $ Sewer Connection Fee $ _ 4_ Water Connection Fee $ TOTAL � $ Building Inspector Div. Public Works Location No. ��� Date TOWN OF NORTH ANDOVER 9 Certificate of Occupancy $ o ; ; Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fe ,r fjL $ 76 --- Sewer Sewer Connection Fee $ Water Connection Fee $ TOTAL $ jI Building Inspector 08/ :20 20.00 PAID JAL .; Div. Public Works PER111T NO. 4o Z. APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1 MAP KJO. LOT NO. 2 RECORD OF OWNERSHIP :DATE BOOK :PAGE ZONE SUB DIV. LOT NO. F LOCATION PURPOSE OF BUILDING 'V2/7C- f OWNER'S NAME- V NO. OF STORIES SIZE OWNER'S ADDRESS BASEMENT OR SLAB F rl ' A 4T l C- -/3`RID, ARCHITECT'S NAME N -- SIZE OF FLOOR TIMBERS IST 2ND•V BUILDER'S NAME ,�J� SPAN -- DISTANCE TO NEARESTBUILDING0005vvVV f5jji r7 TT (( DIMENSIONS OF SILLS _ --- " POSTS DISTANCE FROM STREET DISTANCE FROM LOT LINES - SIDES` /- REAR �/i�) ! (, (�G' GIRDERS AREA OF LOT 3/�1 gr n FRONTAGE / fC HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION Q 1 rd A / IS BUILDING ON SOLID OR FILLED LAND 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 SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED 1.071, 161GNATURE OF OWNER OR AUT ORI D AGENT r E E !� PERMIT GRANTED 19 oq� 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST 30 d0 EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY (Ae tO INSPRCTOR OWNER TEL. # CONTR. TEL. # CONTR. LIC. # H.I.C. # �� BUILDING RECORD 1 OCCUPANCY 12 INGLE FAMILY I I Si ORIES MULTI. FAMILY OFFICES APARTMENTS CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH B 1 2 13 PINE HARDw D— PLASTER CONCRETE CONCRETE 8L K. BRICK OR STONE PIERS _ DRY WALL UNFIN. _ 3 BASEMENT AREA FULL FIN. B M T AREA _ '/ 1/2 '/, FIN. ATTIC AREA NO BMT FIRE PLACES _ HEAD ROOM MODERN KITCHEN _ 4 WALLS I 9 FLOORS CLAPBOARDS DROP SIDING WOOD SHINGLES B 1 2 3 _ CONCRETE EARTH ASPHALT SIDING ASBESTOS SIDING HARDV✓'D COMMCN ASPH. TILE VERT. SIDING _ STUCCO ON MASONRY STUCCO ON FRAME BRICK N MASONRY BRICK ON FRAME CONC. OR CINDER BILK. _ ATTIC STRS. &FLOOR I_ WIRING STONE ON MASONRY STONE ON FRAME —ADEQUATESUPERIOR I� ONE 5 ROOF 10 PLUMBING GABLE I HIP BATH (3 FIX.) GAMBRELMANSARD A TOILET RM. 12 FIX.( _ FLAT SHED WATER CLOSET ASPHALT SHINGLES LAVATORY _ WOOD SHINGES SINK SLATE _KITCHEN NO PLUMBING TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR _ Ell TILE DADO 6 FRAMING 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 _ tsr 13rd ELECTRIC NO HEATING THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. o A O w in. cn a a z z C LE ? U w a z O x C w a o u W to L O a u > cit C w a N z C fL C x w a w V w W a+ cn O ur-) A a M .TIT r-+ o O E mC o CD C O c � ~ O c o ` LU Z • G N O GA+�� r C z I W y, O w Q Q, C Q W �p R w m m z > i O co O � l m D fEa : L ry1 m C O i O O � i +� w Cc O Q m y 0 - -O E5 Cc O Q V o 0 z .Q s cm LL Qi CD CL=Ca E L CD V y CD d O O � N N = R = m N CO) a F- z c N R O . m • m oCA y m m � cm � �_O Cf C O Q fl i ice; G.C= o m 0 o V 0 L >Z O «:CLO cc CM c m H m C C 2 m m� p aOH N H O m LiJ O �~... C � •� LL- R C P = _N E dZ v�vN Z Oa Q C R m � O : H � O 2 = � CL, A a M .TIT r-+ J z O E U- CD C O ~ O c LU Z a O GA+�� z z I W y, O w Q Q W c w m m z > i O co CD CD D O i O O � i Cc O Q 0 - -O Cc O Q V z .Q LL Qi Z CD V y O � R = W CO) G3 F- z cc: z w w . Cl -U) 4;:z I� TOWN of NORTH ANDOVER AFFIDAVIT ffime hVmvIeurit Gmttacbcr law aWlanajt bo lit PgAicatim !Itze 8-.-1 ■ wro-17W.1 tERIN16 imiitzi • w • .•:1 11••.• is w •IM60 S•.l1 • III 9—:11zi IL z I I I wrf.II• 0-re-Imeoffais $--I will w • mile, W qW.-MI—MM-11I• • - :,• ■ • • ••• •1 �• • • • �-• •c r ■ i •� •- •• • av o a• •• 1■r. illoo • • a• � u1 - Type of Work: R -C PZ4 C-- ' )) ta K Est. Cost Address of Work Owner Name: Date of Permit Application: I hereby certify that: Registration is not required.for the following reason(s): Work excluded by law _Job under $1,000 Building not owner -occupied Owner pulling own permit Other (specify) Notice is hereby given that: Fcroffice Use Qtly Rpt Pb. Date OWNERS PULLING THEM OWN PERMIT OR DFAIJM WITH UNREGISTERED CONTRACTORS -- FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRA- TION PROGRAM OR GUARANTY FUND UNDER MGI. c. 142A. Signed urkr penalties of perjury: I hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. OR: Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property• \ Date Ow er Name print) D.A. 7 / d Town of North Andover BUILDING DEPARTMENT Homeowner License Exemption tium�Er Stree_ Address ection or tc'.V',, 1,:....:�.^.. '.•.;�.." / C.��i �•/���9/?%h�l� ,��PX�l1/ � ���-505 �"A� ��y r%�_ risme ?hone �lor:: ?!,.one State Z_p .cc_ it}.� 11 Y l ude Q _ = - e.'.a: :-cn Lor homec,,;ners was e tendE^ to include �� c 77C of s_a un_ts or Less and to allow suc^ t.. _c,- for hire who does not possess a LicensE a ins_ . � �_ c -_ :..e owner- ac_S as surer•✓iso.. (State Build- ns Coae Secon ;. owa parol of Land on which he/she res -des o: -- ___,_e, is, or is in_ended to be a one to s_:< Ec - d=--- eC 0r CE_aChE' StruC,.ures acCessor'; to such use aI:d/11r A 7Er_v:l wno constructs more than one home in a t•.;c-. D` ' 71c _ bE COnSidere� a to lEOwner. Such "homeOWner" sna' _ SUG.•_ _ Er C _%G 0ff_c-a1, on a form acceptable to the Buiens Of____ _. s;�e s: -:: be re=sonsib1e fo_ all -such wor:;— ger (�e_t_on 10°.l.i` 11, s er" a5 ='i.: E_ �Cils b� __ For Cc„, . _.._ 71 E a t :. ... ccde- . GG.;C� J �..�-_ _ __ •- Je_ar 7. e M_.._ : u ins VE'. __on pr ,c_c__ i C..._+I/_ _