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This is an e -permit. To learn more, scan this barcode or visit northandoverma.viewpointcloud.com/#/records/20821
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TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that Gregory W Stark
has permission to perform water heater
plumbing in the buildings of SVENDSEN. EARL E
at 201 HAY MEADOW ROAD, North Andover, Mass.
Lic. No. 11027
Date: July 01, 2016
1/1
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY-� fti NeY MA DATEU-T, . .. /� PERMIT #
JOBSITE ADDRESS) OWNER'S NAME
P
rdii
OWNER ADDRESS TEL �/ FAX
TYPE OR
OCCUPANCY TYPE COMMERCIALS EDUCATIONAL [,1 RESIDENTIAL
PRINT
CLEARLY
NEW: Q RENOVATION: 0 REPLACEMENT: PLANS SUBMITTED: YES NO[
FIXTURES 7 FLOOR- BSM 1 2 3 4 1 5 6 7 8 9 10 11 12 13 14
BATHTUB :I
- --- _:_
_ __.._ _._.:.......--...:, _..
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM=IF
DEDICATED GAS/OIUSAND SYSTEM _
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM I
DISHWASHER
DRINKING FOUNTAIN --
FOOD DISPOSER
l
FLOOR / AREA DRAIN ----
_.
_
INTERCEPTOR INTERIOR
KITCHEN SINK "
LAVATORY -- r.._.._.
-- --.. _ _
1.
ROOF.DRAIN .._ ..."
SHOWER STALL ; �..-.. - - - - _ (- - - . _ ( ___ I _ :.._. __:_.._._.
_)
SERVICE / MOP SINK
TOILET - _ .�
URINAL _ ......
WASHING MACHINE CONNECTION AF7 F-77
WATER HEATER ALL TYPES -
�....._ ,
_.....
WATER PIPING ;
OTHER .. ... ;
......- .
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES E] NO E]
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY r OTHER TYPE OF INDEMNITY 0 BOND L�_
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this
permit application waives this requirement.
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY OW ER n AGENT [j
I hereby certify that all of the details and information I have submitted or entered regarding this application are true an c., best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complian th
all ant provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME _Gregory W. Stark Jr. LICENSE # _11027 G WRE
MPF� JP[_ ] CORPORATIONE,I#:2486C PARTNERSHIP[#F-----
LLC F -#
COMPANY NAMEStark & Cronk Plumbin & Heat—in - -_—---'-'- --'-'
_ _ 9 g ADDRESS x308 Main Street
CITY Groveland-'--'--- `--
STATE MA ! ZIP 01834 TEL -372-6981
FAX 978 374 0837 j CELL EMAIL re starkcronk.com
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- The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
i 1 Congress Street,Suite 100
Boston, MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Stark & Cronk Plumbing & Heating
Address: 308 Main Street
City/State/Zip: Groveland, MA 01834 Phone #: 978-372-6981
;Are you an employer? Check the appropriate box:
Type of project (required):
-1 . ❑■ I am a employer with 10
4. ❑ I am a general contractor and I
6. ❑ New construction
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet.
7. ❑ Remodeling
ship and have no employees
These sub -contractors have
g• ❑ Demolition
workingfor me in an capacity.
Y p tY•
employees and have workers'
comp. insurance.#
9. ❑Building addition
[No workers' comp. insurance
required.]
5. ❑ We are a corporation and its
10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work
officers have exercised their
11.❑ Plumbing repairs or additions
myself. [No workers' comp.
right of exemption per MGL
12.0 Roof repairs
insurance required.] t
c. 152, §1(4), and we have no
//
13 �] Other ( i7eCti72i'
employees. [No workers'
comb, insurance reouired.l
*Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp, policy number,
I am an employer that is providing workers' compensation. Insurance for my employees. Below is the policy and job site
Information.
Insurance Company Name: Travelers Insurance 1 Cabot Road, Suite 250, Hudson, MA 01749
Policy # or Self -ins. Lic. #: UB5D097396 Expiration Date: 09/01/2016
Job Site Address : �Cp/�rJ%P2nl6b) Ecy' City/State/Zip: $11 _AhCY�lI�}�,
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one;;ear imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day agains the iolator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for in r nce coverage verification.
I do hereby certify un to a allies of perjury that the Information provided above is true and correct.
09/01/2016
2-6981
Officlal 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 #:
Location Ql , ! Y_A& AZ1 /dPr-
y No. l d V Date 6 �� D 7
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ I`14() s
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ Y(�
Check # j l
i 7536 V114 ----,--
Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPMR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER: DATE ISSUED:
SIGNATURE: C.
Building Commissioner or of Buildings Date
IBJ vl ■l.JkMa JWE 7.\r.a.J..\I.1......-
1.1 Property Addr
J
1.2 Assessors Map and Parcel
13
Map Number
Number:
Parcel Number
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Area
Frontage ft
1.6 BUILDING SETBACKS fit
Front Yard
Side Yard
Rear Yard
Required Provide
ReqWred Provided
ReQWred
Provided
1.7 Water Supply M.G.L.C.40. 54)
Public 0 Private p
1.5. Flood Zone Information:
Zone Outside Flood Zone 0
1.8
Municipal
Sewerage Disposal System
❑ On Site Disposal System ❑
air,%. uvilq c - ravrr.na i vvrl�licJillC/AU lilVani.n:L AliLP11 �• �. co i v v
! 2.1 Owner of Record
Name (Print) Address for Service
N o rte' A- cx>v
Record:
i Name F
Telephone
algRULUM 1 cie none
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
i�=�l�✓�1� J � %iii I �; � . c
Licensed Construction Supervisor:
� - s 1
AddAs �If
S iUX-R
Address for Service:
Not Applicable 0
_6 �z_
License umber
ill/ z r mots'
Expiratidh Date
X
3. egistered Home Improvement ntractor_ Not Applicable 0
Company Name32
W�1 Registration Number
Add
`` � - /u l off / Z�� V T_. -� Expiration Itate
SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 2546)
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
a cable
New Construction ❑
Existing Building ❑
Repair(s) ❑
Alterations(s) ❑
Addition ❑
Accessory Bldg. ❑
Demolition ❑
Other ❑ Specify
Brief Description of Proposed Work:
J '
SECTION 6 - ESTIMATED CONSTRUCTION
COSTS
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
OFFICIAL USE ONLY
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
l?
Check Number
SECTION 7a OWNER AUTHOR ON TO BE COMPLETED WHEN
-T
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 4VJ-t_ as Owner/Authorized Agent of subject property
Hereby authorize lVtl+rLrc 'Ye-n/VeQ,'V5 to act on
My behalf/. --in all in rs relative to rk authorized by this building permit application.
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
fps
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 Nam
Si at e of Owner/A t Date
NO. OF STORIES' SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TUVlBERS 1ST2 NU 3 RU
SPAN
DBAENSIONS 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
It
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:
(Locatiogkf F cility)
r
Sig ature of Permit Applicant
�✓O
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
I
Name
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Please Print
F-1 I ani a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
F-1 I am an employer providing workers' compensation for my employees working on this job.
Corricany name:
Address
City: Phone #
Insurance Co -(r 1 i� l�'j'/1 // /.' _ J/� Pnliry it
Company name:
Address
City: Phone #
Insurance Co. Policv #
Failure to secure coverage as required under Section 25A or MGL 152 can I=to the imposition of criminal penalties of,a fine up to $1,500.00
and/or one years' imprisonment -as -well-as _civil..penafties in fhe form da..STOP WORK..ORDER..and..a.fine .of (.$100.00).a1* against me. I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
ti
that the (formation provided above is true and correct.
Official use only do not write in this area to be completed by city or town official'
City or Town Permit/Ucensina
Building Dept
❑Check if immediate response is required l]
Licensing Board
p
Selectman's Office
Contact person: Phone #.
Health Department
o
Other
Town of North Andover
Building Department
27 Charles Street
North Andover, MA. 01845
D. Robert Nicetta
Building Commissioner
(978) .688-9545
(978) 688-9542. Fax
HOMEOWNER LICENSE EXEMPTION
Please print.
DATE
JOB LOCATION
Number Street Address Map / lot
"HOMEOWNER
Name
PRESENT MAILING ADDRESS
City Town
Horde Phone
State
Work Phone
The current exemption for "homedwners" was extended to include owner -occupied dwellings
of two units or less and to allow such homeowners to engage an individual for hire who does
not possess a license, provided that the owner acts as supervisor. (State Building Code Section 108.3.5.1)
DEFINITION OF HOMEWOWNER:
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which
there is, or is intended to be, a one or two family dwelling, attached or detached structures ac-
cessory to such use and/or farm structures. A person who constructs more than onehome in a
two-year period shall not be considered a homeowner.
The undersigned "homeowner' assumes responsibility for compliance with the State Building Code and other
Applicable codes, by-laws, rules and regulations,
The undersigned "homeowner' certifies that he/she understands the Town of No. Andover
Building Department minimum inspection procedures and requirements and that he/she will
comply with said procedures and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING OFF
Zip Code
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SPECIFICATIONS
• Remove existing siding and cornerposts
• Renail any loose sheathing
• Replace up to one 4x8 sheet of V2" plywood as necessary
• Install Tyvek Home Wrap to sidewall area
• Install rainshelf to bottom 8" sidewall area using 5/4x10
preprimed pine
• Install corner boards with 5/4x6 and 5/4x5 preprimed pine
• Install 1x6 cedar clapboards (preprimed clear vertical grain) to
sidewall area
• Remove all debris
Mark Jenkins
35 Clinton Avenue
Cheln&sford, MA 01824
Builder General Contractor
Roofing Specialist
Free Estimates
25 Years Experience
PROPOSAL
Customer Name: Earl Svendsen
201 Haymeadow Road h
North Andover. MA 0182r
Job Location: Same
Proposal: Siding Removal and Replacement
Job Cost: $19,400.00
Downpayment: $1,400.00
% Completion: $4,000.00
Start Date: July/August 2004
I Ir-U.SE I ELUI rL
Delivery of Material: $10,000.00
Completion: $4,000.00
Completion Date: 2 weeks
This proposal is valid for a period of 60 days.
Workmanship guaranteed for a period of S years.
Th You, ,
Mark A. Jen . s
Customer Acceptance: /4/cate: D ,7 D
Location
No.
Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee
ottier'Permit Fee
Sewer Connection Fee
'Water Connection Fee
T TAL,"
Building Inspector
Div. Public Works
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FORM U.
TOWN OF NORTH ANDOVER
LOT RELEASE FORM
SUBDIVISION
ASSESSORS MAP
.SUBDIVISION LOT(S)
PERMANENT ADDRESS (ASSIGNED BY D.P.W.
STREET �2
APPLICANT/�/� / ���_PtiS cmc/ PHONE
,DATE OF APPLICATION
G
TOWN USE BELOW THIS LINE
PLANNING BOARD
TOWN PLANNER
CONSERVATLGN COMMISSION
CONSERVATION ADMIN. U "V
DATE APPROVED
DATE REJECTED
BOARD OF HEAL
DEPARTMENT OF PUBLIC WORKS
DRIVEWAY PERMIT
SEWER/WATER CONNECTIONS
FIRE DEPT.
RECEIVED BY BUILDING INSPECTION
DATE
DATE APPROVED
DATE REJECTED
DATE APPROVED t� .
DATE REJECTED
YS
This form shall be signed by the agents of the Planning and Health Boards,
the Conservation Commission prior to the issuance of any building permits
for the subject lot. This form shall not releive the applicant from the
compliance of any applicable Town requirement or Bylaw.
r
�p
DRAFT -
FORM U SIGN -OFF PROCEDURES
1. If no filing has been made:
a. check town wetland maps
b. if unfamiliar with site, complete a site visit to confirm
no work in wetlands or buffer zone
2. If a Determination has been issued:
a. make sure Determination has been recorded
b. make sure person seeking Form U has copy of decison and is
aware of any setbacks, if applicable
c. check and make sure erosion control properly installed, if
applicable
3. If an Order of Conditions has been issued:
a. make sure Order has been recorded
b. make sure bond has been posted
c. make sure DEP File # sign is up
d. make sure erosion control has been properly installed
CERTIFICATE OF OCCUPANCY SIGN -OFF PROCEDURES
1. If no filing has been made:
a. if Form U has been signed N/A or you are familiar with
site and no wetlands, ok
b. if any suspicions, check
2. If a Determination has been issued:
a. make sure 2A through C under Form U Sign -off Procedures
have been followed
b. make sure no violations
c. all exposed soils within buffer zone seeded and mulched,
all slopes at least temporarily stabilized
3. If an Order of Conditions has been issued:
a. make sure 3A -D under Form U Sign -off Procedures have been
followed
b. make sure no violations
c. all soils within buffer zone must be seeded and mulched,
all slopes at least temporarily stabilized.
d. check to make sure all setbacks have been adhered to
e. all wetland replication/restoration areas must be planted
f. all detention/retention basins must be installed and in
working order
If the above conditions are not met, then the Form U or Occupancy
will not be signed off until the situation is rectified or until
a majority of the Commission has agreed as to what action should
be taken.
02/13/91 13:11 WSI 'Fi1,r7DEFORD 207 252-2423 001
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,FEB -13-'03 WED 12:37 ID: `EL, NO; #171 P02 •
FOR FINAL RE IEW ANCI APPROVAL: BY BUILDING DESIGNER
7u'6*d'l'n
b for an;;'NMual bundinp potent. It may be Inoor�oraKtsd Into a bulitllrip deep at the n of tha
d nor. Teta buldlnp designer must oheok the loadlnq, supporta, dMaotlon, bnoing andl0 roprlats, Vie binding doeipner nt6y need to s oonneedon details to use this component In his p dsslgn.
Job NAME: MYLZ IaUM>$i1i . BOB HSR A91-169
UM %ASL! FMF MIM F0#425
3.51Ix12" 3.Ob ParallamDimexts ons are
Arterthe rw red wipports.
L41-3 15/ 11611 ! 31-6 2/16" A
www vsr 4A=jM w,r,a► (ossa to det�mine load moan tributary width)
Roof Load : 40 Live + 17 Dead 7 PSI Tonal
a'* nIStTRIB[]TED LOAM ***IL=4 Duration Factor (LDF) : 1.13
RM+GLS L�IDNG idth Aoar ( loads shown are additive)
wpp
1 to 3 96 to 0 9W Rob L va
* * * ACTION$ M7LECTIONS aid ALTAiM1mzS
Shear: : �29,B -- s ���occcaaait itllo�As of 2
Doi. Live: 0.55" I4'-3" a of 2
Do - Totalt 0.74" �'-4"e of 2
8 T Li4�Ki'I!I ammo 11� (LDDC)
1-2 131-3 15/16" 13. 15 tp 436
Z-3 3'-8 1/16" 13.1 486.0
www Rp" stn www
Igntion:P29�P� �3��= �3 �� U �
Allowable Sasis "I
low.
33345 ft -lbs 1.16 69
9338 1,
1.13 9240 9
1.07" L/160 73%
----- i3iTFAR ---- --------
Rt -lby) Rt
4193 (lam) -2182 0 (19
11176
-2182 -3905 11176 -0
1. Analysts is basad on drys sorvicai conditions (max moisturecontent 194).
2. Anal 1A sumes aslatsrallsupportof the compression edge at tervals of
24 lsra t
3. >jaam be knnsschscked fo loin May b* gdds 0holwn only. For other loading c wAitions
red
4. k= bearing l ba on the l,lowable bearing for Parallam L�
(600 1) over tho aknes of the beam. ager bearing lengths y
S ` raa�ud ed b the t sh 11 be ter a}l�. contractor
Installation is by others.
AFoollr 9u el es see Pa.ral am PSL ns aliat on Guide*
02-13-1991 Ver:1.5 by: scott eoffman at Parallam Nr Inearing Services
Post -It" brand tax transmittal memo 70711 # ci p"*$ r
{V
This otruotural member shell not be co, notched, roled or aUmO unless shaft herein. Dolt holes for aconnsot:ons
may be dr1led up to 3/4 In. dlamets Into the wide Taos and at least 31n. from top or bottom edg" or other holes,
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MORTGAGE PLOT PLAN
• EK SURVEY
17 ROYAL STREET, LAWRENCE, MA. 01841 Tel. 508-794-9896
MORTGAGOR PRUDENTIAL DEED REF.2532 PG. 171
ADRESS OF PRINCIPLE BUILDING PLAN REF. 7588
201 HAYMEADOW DATE OF INSPECTION: JUNE 18, 1991
_N, ANI)OVE R ; MA, SCALE � I"=40'
LOT 64
115,30`
0 ,
DRAINAGE
EASEMENT
LOT 15 LOT 17
46, 23 5 5, f.
36.
LOT 13
STORY
WOOD
137, 63�
H AY MEADOVi
NOTE: 71+18 rnortpsps hspeat18n was
epealllady, for mortgopa purposes and M�
to be rolled, upon as a survey. JX Survey oompts
no rsmpafse/!ty for damages r=Wthp from sold
reliance by anyone other than the eald mortgagee
WW Its ossfon In connection with Its proposed rnmtgoge
rawrefeq_to saw martagogor.
CER IFICATIM TOr
PRUDENTIAL HOME MORT. CO.
ROAD r --
Yhb the TmMjoal St a far N *n was ��rtgop h a��« �
as
ir� b1i tts Nevem wiwfts Assoolctlon of L� Surveyors
I FURIM STALE THAT IN NY PROFMONAL
OMON the principle awl/a and a, samy
CON FOR M
rfh the setback reminirnernb of the local zonkq
ardlnancee, and that there we no anaoodwrw+b of
mapr Mnpraremonto after May aarose property lines,
s�otw�e0ptt a acorn.
�f 0 property 18 not In a Flood Hared Neo.
2 Is h a Flood Hazard Area.
3. h b hwtRb18et to detennhe Flood Haaard.
Hood detam> ad Ran latest Federal Flood haranoe
Rote lko Pbkel.
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