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HomeMy WebLinkAboutMiscellaneous - 21 MERRIMACK STREET 4/30/2018l .0 e Date �.,) ................... f TOWN OF NORTH ANDOVER .PERMIT FOR WIRING This certifies that .. � v``` A ........ .. f' 0 n .............................................................................. has permission to perform .��.. P N\ 0 V (L �� � �� A-Ja4 I �- ............................................................... wiring in the building of...� 1 ....................................................................................... at .. 2..f ......'....lE' �' .Q:!. *I .y. ............. . North Andover, Mass. Fee................. Lic. No. ..�P...................................................................................... i ELECTRICAL INSPECTOR Check # y I rs P Commonwealth of Massachusetts Department of Fire Services Q BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. T Z P� I ' Occupancy and Fee Checked [Rev.1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical CoderL 7 CMR 12.00 (PLEASE PRINTININK OR TYPEALL INFORMATION) Date: 7 / S City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 1i ( /�.Ci1 ti i✓l r1•P SGL 'S! Ci Owner or Tenant &4-1-6___tAAAZ " Telephone No. `\ Owner's Address SAv _� Is this permit in conjunction with building permit? Yes ❑ No � (Check Appropriate Box) Purpose of Building 9''S Ju d6ezi *.L-_ Utility Authorization No. - Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Undgrd ❑ No. of Meters 0 Completion of the_following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Cell: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. grnd. o. of Emergency.Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. TotalTons No. of Alerting Devices No. of Waste Disposers HeaTo�mp Number Tons KW,,]Security No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Systems:* No. of Devices or Equivalent No. of Water KW Heaters 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 Equivalent OTHER: 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: 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 ❑ OTHER ❑ (Specify:) I certify, under the p ins and penalties �erJu� , ghat th� information on this application is true and complete. FIRM NAME: �;�Ac- I `� ` �c�''i^ crt � _ LIC. NO.: ,�—� —r r—,� oft. Licensee: U _ LTC. NO.: (If applicable, tte�r " empt" in a license nuyzbrr line.) y,' j Bus. el. No. • Z dg� Address: Alt. Tel. No.: /k 5-1X U E6 *Per M.G.L c. 147, s. 57-6 1, 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 PERMIT FEE. $ � �• Signature Telephone No. 4Z ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the 9 permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed ; on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an �► %H electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass F?1 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass IN Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INS CTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature:a&Z&&An= Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com k., N P l The Commonwealth of Massachusetts _ . F Department of jrtdustrialACcidents M _ _ 1 Congress Street, Suite 100 Boston, HA 02114-2017 �r www.mass.gov/dia �7M Sysµ VVo><kere Compensation Insurance Affidavit: Builders/Contractors/E lectricians/i'lumbers. TO BE FILED WITH THE PERMITTING AUTHORli'y please Print Ley-4bl A licant information Name (Business/Organization/lndividual): Address: City/State/Zip: Phone ih Are you an employer? Check the appropriate box: 1.Q I am a employer withemployees (full andlorpart-time).* 2.❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.0 I am a homeowner doing all work myself;. [No workers' comp. insurance required.] t 4. F] I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.❑1 am a general contracto ' and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6. Q We are a corporation and its. officers have exercised their right of exemption per MGL c. 152, §1(4), and We have no employees. [No workers' comp. insurance required] Type of project (required): 7. [] New'd6nstr6dtion S. [] Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.❑ Electrical repairs or additions 12� [}Plumbing repairs or additions Ro6f repairs 14.[] Other *Any applicant that check's bOX #1 must also fill out the section below showing their workers' compensation policy information i Homeowners who submit•this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such tContractors that check this box must attached in 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. f am an employer that is providing workers' compensation insurance for° my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lie. Expiration Date:., Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requited under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. I ry thatthe information provided above is true and correct do hereby certify under thepains andpenalties ofperju. Date- Signature: ate:Si ature: 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): i 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing inspector 6. Other Contact Person: Phone 1�' 'w i 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 Wh ', 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 a deceased employer, or the receivef'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 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'notproduced -acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(1) 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 Pleasb 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 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 IndustrialAccidents. 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 they 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 thai 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. Anew 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 wwwmass.gov/dia V. July 17, 2014 THER7C08fFII0.OS f�DL�C-0s�fIGROUPo U FORM OF NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B Building Commissioner, or Inspector of Buildings c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Board of Health or Board of Selectmen c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Fire Department or Arson Squad c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 RE: Our File No.: P1477295 Insured: KATE NOONAN Address: 21 MERRIMACK STREET, NORTH ANDOVER, MA Policy No.: H0806010A Loss Date: 07/15/2014 Loss Type: Building or Other Structure Damage A claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Ch. 143, Sec. 6 to be applicable. If any notice under Mass. Gen. Laws, Ch. 139, Sec. 3B is appropriate, please direct it to my attention and include a reference to the captioned insured, location, policy number, loss date and claim or file number. If no reply is received from your office within ten days, we will assume you have no liens of any type against this property, and the claim will be paid in our customary manner. Sincerely, ;��/ 4pa-g- Marie J. Landers Property Claim Examiner 1-800-688-1825 x1136 NORFOLK & DEDHAM MUTUAL FIRE INSURANCE CO. 222 Ames Street, P.O. Box 9109, Dedham, MA 02027-9109 DORCHESTER MUTUAL INSURANCE CO. Telephone: (800) 688-1825 FITCHBURG MUTUAL INSURANCE CO. Fax: (781) 329-1818 July 17, 2014 T H E R7 O P8 ff O d KeD fE D C-0ARfil G R O U N FORM OF NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B Building Commissioner, or Inspector of Buildings c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Board of Health or Board of Selectmen c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Fire Department or Arson Squad c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 RE: Our File No.: P1477284 Insured: 21-23 MERRIMACK STREET CONDO C/O JOHN CRONIN Address: 21-23 MERRIMACK STREET, NORTH ANDOVER, MA Policy No.: R0648033A Loss Date: 07/15/2014 Loss Type: Building or Other Structure Damage A claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Ch. 143, Sec. 6 to be applicable. If any notice under Mass. Gen. Laws, Ch. 139, Sec. 3B is appropriate, please direct it to my attention and include a reference to the captioned insured, location, policy number, loss date and claim or file number. If no reply is received from your office within ten days, we will assume you have no liens of any type against this property, and the claim will be paid in our customary manner. Sincerely, Michelle M. Roust Senior Property Claims Examiner 1-800-688-1825 x1171 NORFOLK & DEDHAM MUTUAL FIRE INSURANCE CO.222 Ames Street, P.O. Box 9109, Dedham, MA 02027-9109 DORCHESTER MUTUAL INSURANCE CO. Telephone: (800) 688-1825 FITCHBURG MUTUAL INSURANCE CO. 1 o Fax: (781) 329-1818 August 22, 2013 THEN DQ81FOO.IIQ(:?�MD[EDHARAGROUPm FORM OF NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B Building Commissioner, or Inspector of Buildings c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Board of Health or Board of Selectmen c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Fire Department or Arson Squad c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 RE: Our File No.: P1363083 Insured: 21-23 MERRIMACK STREET CONDO C/O JOHN CRONIN Address: 21-23 MERRIMACK STREET, NORTH ANDOVER, MA Policy No.: R0648033A Loss Date: 08/10/2013 Loss Type: Building or Other Structure Damage A claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Ch. 143, Sec. 6 to be applicable. If any notice under Mass. Gen. Laws, Ch. 139, Sec. 3B is appropriate, please direct it to my attention and include a reference to the captioned insured, location, policy number, loss date and claim or file number. If no reply is received from your office within ten- days, we will assume you have no liens of any type against this property, and the claim will be paid in our customary manner. Sincerely, Michelle M. Roust Senior Property Claims Examiner 1-800-688-1825 x1171 NORFOLK & DEDHAM MUTUAL FIRE INSURANCE CO. 222 Ames Street, P.O. Box 9109, Dedham, MA 02027-9109 DORCHESTER MUTUAL INSURANCE CO. Telephone: (800) 688-1825 FITCHBURG MUTUAL INSURANCE CO. Fax: (781) 329-1818 TH ER7OP81FOlLIIQeDL DCiIARAG ROU Po December 22, 2012 FORM OF NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASS. GEN. LAWS, CH. 139, SEC. 313 Building Commissioner, or Inspector of Buildings c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Board of Health or Board of Selectmen c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Fire Department or Arson Squad c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 RE: Our File No.: P1252338 Insured: RYAN NOONAN KATE NOONAN Address: 21 MERRIMACK STREET, NORTH ANDOVER, MA Policy No.: H0806010A Loss Date: 12/20/2012 Loss Type: Building or Other Structure Damage A claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Ch. 143, Sec. 6 to be applicable. If any notice under Mass. Gen. Laws, Ch. 139, Sec. 3B is appropriate, please direct it to my attention and include a reference to the captioned insured, location, policy number, loss date and claim or file number. If no reply is received from your office within ten days, we will assume you have no liens of any type against this property, and the claim will be paid in our customary manner. Sincerely, Michelle M. Roust Senior Property Claims Examiner 1-800-688-1825 x1171 NORFOLK & DEDHAM MUTUAL FIRE INSURANCE CO. 222 Ames Street, P.O. Box 9109, Dedham, MA 02027-9109 DORCHESTER MUTUAL INSURANCE CO. Telephone: (800) 688-1825 FITCHBURG MUTUAL INSURANCE CO. Fax: (781) 329-1818 TH ER7OP8ff OdK(: �DfEDHAWG ROU P@ December 22, 2012 FORM OF NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B Building Commissioner, or Inspector of Buildings c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Board of Health or Board of Selectmen c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Fire Department or Arson Squad c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 RE: Our File No.: P1252339 Insured: 21-23 MERRIMACK STREET CONDO C/O JOHN CRONIN Address: 21-23 MERRIMACK STREET, NORTH ANDOVER, MA Policy No.: R0648033A Loss Date: 12/20/2012 Loss Type: Building or Other Structure Damage A claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Ch. 143, Sec. 6 to be applicable. If any notice under Mass. Gen. Laws, Ch. 139, Sec. 313 is appropriate, please direct it to my attention and include a reference to the captioned insured, location, policy number, loss date and claim or file number. If no reply is received from your office within ten days, we will assume you have no liens of any type against this property, and the claim will be paid in our customary manner. Sincerely, Michelle M. Roust Senior Property Claims Examiner 1-800-688-1825 x1171 NORFOLK & DEDHAM MUTUAL FIRE INSURANCE CO. 222 Ames Street, P.O. Box 9109, Dedham, MA 02027-9109 DORCHESTER MUTUAL INSURANCE CO. Telephone: (800) 688-1825 FITCHBURG MUTUAL INSURANCE CO. ® Fax: (781) 329-1818 r DJ.�'..�. ....... ,40RTM TOWN O R H NDOVERo PERMIT FOR GAS INSTALLATION This certifies that ... R,,V/.X11-1/-.. ,�%. has permission for gas installation in the buildings of .. CO /1 v t:t.4-� ............................ . at 2. -S.. 4"AF,.: ....... nn. , North Andover, Mass. Fee..S.�::.. Lic. No.. 3. 7yt... ...i.!. ....... 1 GAS INSPECTOR Check # 3 5 G3b,9 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT Ta (Print or Type) G DO GASFITTING - M C71N A M100 V C L, --Mass. Date /// A? Permit __ Building LocationL J— � �) F1 R i f! k -K.. J T Owner's Name 0oLi J UO 1 / n1 V)P-TH A uDOYCL- HA Type of Occupancy_�'t�/��A17/Al New ❑ Renovation ❑ Replacement ❑ Plans Submitted: Yes[] No ❑ Installing Company Name BAY STATE GAS COMPANY Address 55 MARSTON STREET LAWRENCE, MA 01840 Business Telephone q 7 6-68.7-1105 Name of Licensed Plumber or Gas Fitter Francis X. Corkery Check one: DC7 Corporation ❑ Partnership ❑ Firm/Co. Certificate # 1862 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes K No rJ If you have checked Les, please indicate the type coverage by checking the appropriate box. A liability insurance policy X( 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: Signature of Owner or Owner's Agent owner[] Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in abo knowledge and that all plumbing work and installations performed under the permit iss f r plication appt cation will d a n��mpi ance with all te to the best of my pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s. T e of license: Title Plumber Signature of cense Plumber or Gas Gasfiitter City/Town Master License Number O IC SFO Journeyman y Y � W • N • 2c Z� N N Z = N � W N a O V m H = i i a o u~ j a CC Z 0 a O +- w �o N CO ul W H Q W O F. N G di F Q W W N J Z Q= Q a W= c7 W � w F- _ H I� a (7 H Z J h Z j N W W O > u. (' W. J O W = Q o: W> '.x O = 0 W U. Z, a a 3 ccQ c 0 6 J O U O a W y C a o0. �yy F- O SUB—BSMT. t+ BASEMENT I ISTFLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing Company Name BAY STATE GAS COMPANY Address 55 MARSTON STREET LAWRENCE, MA 01840 Business Telephone q 7 6-68.7-1105 Name of Licensed Plumber or Gas Fitter Francis X. Corkery Check one: DC7 Corporation ❑ Partnership ❑ Firm/Co. Certificate # 1862 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes K No rJ If you have checked Les, please indicate the type coverage by checking the appropriate box. A liability insurance policy X( 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: Signature of Owner or Owner's Agent owner[] Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in abo knowledge and that all plumbing work and installations performed under the permit iss f r plication appt cation will d a n��mpi ance with all te to the best of my pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s. T e of license: Title Plumber Signature of cense Plumber or Gas Gasfiitter City/Town Master License Number O IC SFO Journeyman N) W z v� w x N 0� C• n z_ - h h tL N J n z O O C O N � h w. F- U � 0 0 z a a a 0 0 tt. U. Z O 0 J r W a m U J IL CL a to W LL N) W z v� w x N 0� C• Location �� a� �y1 r N I of 4 r (,( 0 No. D Date 0 a Other Permit Fee $ 6 TOTAL $ Check # 'i 66�� I u ( �/� Building Inspector TOWN OF NORTH ANDOVER O? • 1 • Os 9 r y Certificate Occupancy of $ ;�s'••'°' E<�� s^us cM Building/Frame Permit Fee $ Foundation Permit Fee $ a Other Permit Fee $ 6 TOTAL $ Check # 'i 66�� I u ( �/� Building Inspector F— / � —qs TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATf OR DEMOLISH A ONE OR TWO FAMILY DWELLING .r,^t�•�` d gt'.* rix �"''� ���,. #a'+�1- .a»s -a�. „�,.�:, p r BUILDING PERMIT NUMBER: 0 DATE ISSUED: /� Q SIGNATURE: M M Building Commissioner/I for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: PI -73 144101M MCIZ -0- 1.2 Assessors Map and Parcel Map Number Number: Parcel Number ) � /��, ' n +*� 1 a ak ' �[ 1.3 Zoning Information:' Zoning Dish c ­t Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water SupplyM.GL.C.40. 34) ; Public ❑ Private ❑, J' 1.5. Flood Zone Information: Zone Outside Flood Zone 0 1.8 Municipal Sewerage Disposal System: ❑ On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSIIIP/AUTHORIZED AGENT 2.1 Owner of Record —J6 kK) 6200A) 1144 4CA Name (Print) Address for Service: 6e7 32d'7 gnature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTIO - 3 - CONSTRUCTION SERVICES 3.1 LicenAblt)Afd Construction Supervisor: Not Applicable ❑ i 46Juvna Licensed Construction Supervisor: CS 07� -V" de C t,;t01 C �/ `C License Number Address)7tk n W 14-*�—&KyMUS-2-OOL-1 Signa re Telephone Expiration Date 3.2 RegistTome Improvement Contractor Not Applicable ❑ fd 49 (!A (cwriN Company Name Z 2. S Q —75 e oc /, tw ie &rn c16;' �l °� /�/is Registration Number Addresmw lc. J�' 94-72 0G�f Signature Telephone Expiration Date \IV r - 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 applicabie New Construe 0." w asting Bt!Ving ❑ Repair(s)Alterations(s) ❑� Addition ❑ Accessory Bldg. ❑ Demolition ❑ t Other i to I Spgci fy *A Brief Description of Proposed Work: I SECTION 6 - FSTIMA TIM r0NWV1TrTinN rncTQ 1 Item Estimated Cost (Dollar) to be Copipleted by permit applicant O.FFICIAL USE ONLY 1. Buildin gd,r � f1 < V 6 L.50 (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) /10 •00000, 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number ac�,ilVi� is vwr\1',1( Au1rLVKiL,A11V1� 1V lfr. I;VMYLLlEll WtiN;1V OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, , as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OVA AGENT DECLARATION 1, lJ Ul V l,�'1/V` v V Q d n " ,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 GotiAld e 6AGA)OPO -- Print Name of S112/o3 Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2 ND 3 RD 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 Name The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02911 Workers' Compensation Insurance Affidavit A) -Pr I(Y V UAG 14) 010 Please Print Location: t� /– 23 /YWR/ City /V '6xd'1l/0/2.. Phone # (qP3 y2 0 % I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity am an employer providing workers' compensation for my employees working on this job. Comoanv name: J S I_db' Ae 1� 11�pe Address -75 06CAA4-Vt ('21 41C city: ' "'� !!/IU0b4, - fW Phone* tis Company name: F-1- . 717_7 City: Phone#. Insurance Co. Policv # K Faiture 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_weLas_cadpenaftimjnshelamn-f�a-STDPMRK-ORQER.and_afiae-C(A$1AA.OD)axWyagaiastme. 1 understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. / do hereby eenYy uo@r Me pains and Print perjury that the k*rmadon proviobd above is bus and correct. if— Date 6,10 0,x) Official use only do not write in this area to be completed by city or town officiar (J (/ 9" City or Town PennKicensi . . Check if immediate response is required BuildingDept [� Lkenslnq Board E) Selectman's Office Contact person: Phone # E] Health Department Ei Other I z6 z Of C 00 o..' 0 1 ~ •� bD AN, W L( _ 4 §4 In L `� c` �> © '' f� c I z6 z Of 00 N _ J c` 'C. c a Cl) Z O Lo Y It � 'z' Q Z C i. =• •� O r. .�C . 0 CD ix d w' , d Oow �1 I A ( .� n i . , | - z IM ./ co 00 ` ! ©z g 16 .a ,w \ /\ L) f @ { A o ^ []§E \ )§>\;)m ./ LL. ��z�`�°`� 03r��kL ;j /u`cj 'm . 0=2 .o co 0w ��Q f.■ 9 f y Cl) $@R }| ( \)/)\ \) . , z IM ©z g 2�l �#s - . 0=2 ��Q f.■ 9 f y < ` \\ 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: (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 rA cz �¢ O Q Q C m C w° U w C a°' ro w a w U U W d cn cd w ►-, C7 C M w w w A w p�G w C as d cn v cn N4 400 I V. CD O C L O o s z CD O y � C co I Ccm 0.— co p -0 CD y O O •E 03 CD L � _ O O ® O 0. ca c cc C CD C.3 y O C CL C •� C CO) ti 0 U) U) crW w W vJ V m c Y' :ots ff C H O C v V •C IO CL m O CD CD . y CD C � 0 �: om .r V:om c� ;coag m C E m a Hto03z. cn m ti -m—zip • y O O � H 'E Z� •aC m h m Z = O cm `T Z ti c Q ®� CC2a ` m c E CD ck:W .r .o = .r •H �E il 16 m ,dt C .y W c=a .0 cma cm O G.� m a O ®.t c y mm O� . Cl F°- L Z I V. CD O C L O o s z CD O y � C co I Ccm 0.— co p -0 CD y O O •E 03 CD L � _ O O ® O 0. ca c cc C CD C.3 y O C CL C •� C CO) ti 0 U) U) crW w W vJ Location / I& �IIINIt c" : No. a -� 6 Date 4�- 7 D J TOWN OF NORTH ANDOVER Certificate of Occupancy $ '7b''•°'''tom Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ � Oa Check #lam / Building Inspector 1.1 Property Address: 1.2 Assessors Map and Parcel Map Number Number: Parcel Number 1.3 Zoning Information: Zoning Di;—&ic—t Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) Public ❑ Private ❑ Zone 1.5. Flood Zone Information: Outside Flood Zone ❑ 1.8 Municipal Sewerage Disposal System: ❑ On Site Disposal System ❑ SECr1OIN 2 - PROPERTY OWNERSHMAUTHORIZED AGENT 2.1 OwnerRecord J )! Crd h 1')q ( M 6) f''1;M.4c S>` - Name (Print) �// Address for Service: Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone ,'SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction upervisor: -ela k7 Not Applicable ❑ t PP Licensed Construction Supervisor: ` 00/ Y 2'K Pl easa0- --,"07,- // j �� j010� � License Number G Address Y r /Q F y5 Expiration Date Signature Telephone 3.2 Regi tered Home Improvement Contractor Not Applicable ❑ aUld GdlL0��ah Company Name ! 91 tz Registration Number Address V/ Expiration Date Signature Telephone T rn s 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 checkall applicable) New Construction ❑ 1 Existing Building ❑ 1 Repair(s) Imo' . Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ 1 Demolition ❑ 1 Other ❑ Specify Brief Description of Proposed Work: �Ze Maze1 U46kil abash. ke �VoU- CI seg -5 I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I Item Estimated Cost (Dollar) to beUFFICIAL Completed by permit applicant USE t?NLY 1. Building.i QtrP�, �� (a) Building Permit Fee Multiplier 2 Electrical ©oo. a0 (b) Estimated Total Cost of Construction 3 Plumbing 600 • C9 0 Building Permit fee (a) X (b) p262 c!J 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 • &0d i d® Check Number SEC:IYUIN 7a OWINER AUTHORIZATION IYU HE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, fid v4 64'r('ar as Owner/Authorized Agent of subject property Hereby authorize My behalf, in all matters by this building permit application. _to act on yyr+-e / ©' e"7 Signature of Owner Date SECTION 7b GOWNER/AUTHORIZED AGENT DECLARATION I ot.UI � 4,a -r% r 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 J)C&t, ,Y • L Print Name of Owner/ Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINIBERS 1 ST 2 ND 3 RD SPAN DINIENSIONS 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 i Town of North Andover Building Department 27 Charles Street North Andover, Massachusetts 01845 (978) 688-9545 Fax (978) 688-9542 DEBRIS DISPOSAL FORM 4 NORTH q O 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 c11, s150a. The debris will be disposed of in /at: Facility location Signature of Applicant 4:2 - Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. ../itB V09)7/IILOOLCIJEQ�/L O��ddll!.R161�1f0 _. BOARD OF BUIWD44G REGULATIONS { License: CONSTRUCTION SUPERVISOR:. } Number. `CS 001821• Birthdate: 10/02/1959 Z < Expires: 10/02/200:. Tr. no: 6604 t{ `* Restricted To: 00 ii t DAVID P GULEZIAN I 428 PLEASANT STS . •ANDOVER, MA -01645 Adminitiiator'� , � � �oo�n+�o�wr■salQil o�,..�naaadFueeda ' DVHIEMi-E0N1RAC�8it �~---� ,,; ; kegstratio�: .�2D1f4 �' � •'Ez�ration: '•� '11/1/Di' ~"�• ; "i { # Type: Individai k AVAUT DAVID GULEZIAN 9lFA SANT Si, f -NORTH RNDOV .'flR1e5" ACORon CERTIFICATE OF LIABILITY INSURANCE UAIE LMMIIUDlYYJ 04/28/199 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ' INTERNET INSURANCE AGENCY, INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 522 CHICKERING ROAD HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. NORTH ANDOVER, MA 01845 INSURED DAVID GULEZLAN DEA DAVID GULEZIAN CARPENTRY 428 PLEASANT STREET NORTH ANDOVER MA 01845— COVERAGES INSURERS AFFORDING COVERAGE m uRER A. TRUST 114SURMCP INSURER 8: LEGION INSURANCE INSURER C: INSURER D: INSURER E. THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE 11/10/1999 POLICY EXPIRATIONYYl A GENERAL LIABILITY ® COMMERCIAL GENERAL LIABILITY ❑ CLAIMS MADE OCCUR 401 TMP 1010570 11/10/2000 __UNITS EACH OCCURRENCE S 600, 000 FIREDAMAGE (Any one fire) $ 300,000 MED EXP (Any one person) S 300,000 PEI-SONAL &ADV INJURY S 300,000 GENERAL AGGREGATE $ 50, 000 GEN'L AGGREGATE LIMIT APPLIES PER: ❑ POLICY ❑ PRO ❑LOC JECi PRODUCTS -COMP/OP AGG $ 5, 000 AUTOMOBILE ❑ LIABILITY ANY AUTO COMBINED SINGLE LIMIT (Ea accident) $ ❑ ❑ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per person) $ ❑ ❑ HIRED AUTOS NON -OWNED AUTOS BODILY INJURY (Pe, accident) $ ❑ ---- I ❑ PROPERTY DAMAGE (Pal accident) $ GARAGE LYABtLYN ❑ ANY AUTO ❑ AU '0 ONLY - EA ACCIDENT $ EA ACC $ OTHER ER THAN AUTO ONLY_ AGG $ EXCESS LIABILITY ❑] OCCUR 1c: 11 CLAVAS MADE EACH OCCURRENCE $ AGGREGATE $ _ S ❑ DEDUCTIBLE ❑ RETENTION $ $ WORKERS COMPENSATION ANDVNT RY L MU- TH- EMPLOYERS' LIABILITY E.LEACH ACCIDENT $ 100,000 R WC4-0115728 08/15/1998 08/15/1999 E. L.INSEASE - FA EMPLOYE $ 500,000 E.L. DISEASE -POLICY LIMIT I $ 100,000 OTHER " DESCRIPTION OF OPERATfONSILOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS GENERAL CARPENTRY wNAL INSURED; INSURER LETTER: GANC:tLL.A I IUN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL. ENDEAVOR TO MAIL 010 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR 26.9 W W 0 o AL c c ` O h C 0 V S%. m C Ead ..: s S CE t,. z t c $ O cj vs CD c • �'` y CD ` m 4D ca CD Gom Vcc ca y A c O m o f CID �: v NZ O t;u o aoco a m :gym= '_ m CL — N F— y ev = " m r W �.. •p = r... .y •CL O C Z Sicr- •E Ci .0 V •y O N CL m 'O _ v a`Go O f- z Sa=m co O co L O Z a O H G C CD cm CO) Q W L6 O O �E m m CD O Co CL (D L ca � 3� CD 00 co L .m0 CL CL cma O � � a ow �zCD 0 CL U CO) c C _c CL 0 0 W T - cc uiw U) _f o A a a w Q a W A Q�v� W u ,2 w u z W or. w° (UO U w a w W w°' 2 w a w ,W W E ac cn o cn o AL c c ` O h C 0 V S%. m C Ead ..: s S CE t,. z t c $ O cj vs CD c • �'` y CD ` m 4D ca CD Gom Vcc ca y A c O m o f CID �: v NZ O t;u o aoco a m :gym= '_ m CL — N F— y ev = " m r W �.. •p = r... .y •CL O C Z Sicr- •E Ci .0 V •y O N CL m 'O _ v a`Go O f- z Sa=m co O co L O Z a O H G C CD cm CO) Q W L6 O O �E m m CD O Co CL (D L ca � 3� CD 00 co L .m0 CL CL cma O � � a ow �zCD 0 CL U CO) c C _c CL 0 0 W T - cc uiw U) _f Town of North Andover 0* NORTH , ,�.o OFFICE OF �? y°t OOL COMMUNITY DEVELOPMENT AND SERVICES p 27 Charles Street North Andover, Massachusetts 0 184 �9SSgcNUs�`�y WILLIAM J. SCOTT Director (978)688-9531 Fax(978)688-9542 TO: Dick Diodati FROM: Mike McGuire �--- Local Building nspector Town Of North Andover DATE: 5/17/00 RE: 21— 23 Merrimack St. North Andover, MA 01845 Please be advised that a certificate of occupancy for the above noted property is not required as the scope of work was only for a second means of egress from a preexisting apartment. No work was done to the apartment. If I may be of further assistance please do not hesitate to contact me between the hours of 8:30 —10:00 AM or 1:00 — 2:00 PM @ 688-9545. BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Location ��" a 3 Id.-f r' C- K Jf No. 6�' 7 DateZgej, MCRTTOWN OF NORTH ANDOVER R A Certificate of Occupancy c $ ss�cMusEt� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 3 °� Check # 2d q r Building Inspector 4A SAJ N O }I OR, IZJ z "L � t a� c � N G A C � U = z d w cFs. C C t7 z C C C F � � � N F z U W F Z .0 O F F F Z O � C y C � C F G U U U W F F O G C C C G w z (j G a A C m U Z C Z w v w w w cJ G a x L tom. T4 Z d k z z M z O O v F w w z U ^ O z z O C w C O C7 U C O d N � c c c W vFr. A e1 Or FSI O � z 41 T v N w W o_ s W M F S ^( s c Izz� F In z z Gl z z W c v v }I OR, � z "L � t c � N G A C � U = z d w cFs. C C t7 z C C C F � � � N F z U W F Z .: z z F F F Z O � C y C � C F G U U U W F F O G C C C G w z (j G a A C m U Z C Z w v w w w cJ G a � z z � t c � M G A C � C Z = z d w f C t7 z U C F � � N z - c v F G .: z z w C) U_ _U ! ir• � C �I M or �.J v F C/I .: z z O C) U_ _U FORM U - LOT RELEASE FORM INSTf UCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having.jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *************APPLICANT FILLS OUT THIS SECTION*********************** / APPLICANT b( A �dlvva 0 _ PHONE 09P" LOCATION: Assessor's Map Number PARCEL SUBDIVISION j LOT (S) NSTREET — 2� rl � ST. NUMBER ************************************OFFICIAL USE ONLY********************************* RECOMMENDATIONS OF TOWN AGENTS: o' F- Fyrrss >�^��^-� �ti� ,CY. 7L CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS JV.lk e.�'""a�� �.j��� we, TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS 4 FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR -HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS - SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm 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. 1 The debris will be disposed of in: ux �h��,�t� vqv �UI� (Location of Facility) Signatur of Permit Applicant 004 q 7 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector The Commonwealth of Massachusetts Department of /ndustnal A,�_cidents _ Office of Investigations -Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name WW' -069 Name: �f Wpet(q it � ) Y_Y)"Y1,Y"Wh S has s Please Print aI am a homeowner pertorming all wort[ myse!t. aI am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. - - - Comoanv name:�iJC/' L �� Address of chtwgI-n _- ✓ '] 6 Citv. 4 �` Phone # / Insurance Co Policv # 1 -- Comoanv name: Address Citv: Phone #: Insurance Co. Policv_I- Failure to secure coverage as required under Section 25A or MGL 152 can lead to the impcsifion of criminal penalties of a fine up to 51,500.00 and/or one years' imprisonment as we!I as civil penalties in the form of a STOP WORK ORDER and a tine cf (� i 00.00) a day against me. I understand that a copy cf this statement may be forwarded to the Office of Investigations of the OIA for coverage veriricaticn. t do hereby certify under the pains andpenaltie,s pf perjury that the information provided above is true and cerreyc�;. d Signature Date ►(�� �� / Print name �U �"( � � Phone # F ? / N 7 Official use only do not write in this area to be completed by city cr town cmciai' City or Town " \ Permit/Licensinc Building Dept ❑C'ieck d immediate response is required ❑ Licensing Board ❑ Selectman's Office Contact person: Phone T ❑ Health Department ❑ Other PLAT NO.54 I 4 I ;tea r tzr 4 I IL % i N41- 4�L IL % i N41- N41- a O s.� - w A x W u 0 P. e C v C/) UW P. z z A W Cc: b p .0 T C U w P4 z m G W A C °° up C x W W a w ci s C u. O U a co z ° O 1:4 C w a W W v 7 m z b cn GJ v o cl) caw cc ;, o 1 3�3 .a �•RC� z � 0 0 . o m � C EcL• t� m r • crlmmw H q ♦: y M ` 0Cf) jg,ESV 0 C N � O Cj E 0 75 W 4,' av m _= 'COD tm C h ^ � d C = CC 1� (CD C � V �Z o : 1p H d Q m CD y® C O ~ 4- y m m CO) co W CO � r► t C +r a R a� 0 L 0 O V Z °D CL O y o c ICD C C CO) ' m m CL _0 co s G) O O e2 o a a cma C O 4-0 C O O .v J 'O d O CD CO2 Z co CL V C c C C cc 0 0 w cr LLJ0 LLJW U) .y . A 1;, C •N � Z � = 4- = mall O d o.fl H �:2 = N C = A03 � CL,- ' �( a� 0 L 0 O V Z °D CL O y o c ICD C C CO) ' m m CL _0 co s G) O O e2 o a a cma C O 4-0 C O O .v J 'O d O CD CO2 Z co CL V C c C C cc 0 0 w cr LLJ0 LLJW U) 0 0 0 0 0 0 0 0 0 0 <r 11r— cc INc, cr C> G L.:. on' cx C-1 � -cr t <C W = = :.6 = . :L I— 'X: rL C�4 1�� -tlr Ir) w cz� ::. L cf�) I I I M: 'L CD ct <C <c w w M: Q. a a CI- a- <r Ul .-rl 10 <r U-- "C' 14 I I <C <C Ck- Ck. 1-0 <C0 <c L.1 rz-, 12 Q <C ar ....1.— .— — I= L J 1— 0- O O<r I— Q <r Q <r �r w I= C/1 rn Crl CO CC, 'n .1 a r' a :r_- 1-1 Ch 11 CIII cn 1-1 --Ll Cl Q W. .14 cn cl, r"ll 7' W rn, Irl IV m _LZ. rl1 I <r <r cr, Q. rx. <X <r Q Q Mcr -:w :m -.W at m 'M m CD 4* rl" Q- Ci,- 2 0- is 'j, '53" 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 I-- d.C> 00 00 :sr im Ir P CG 00 c'4 v oc, CL OCD 00 CL w CL 1— 1— I rw CL co L IY 4D 4D G Lf 110IN rj� IZ C.; 1, 4M L= 4X K= Cr- <C rrW Cn rr C-0 7F— cn :;L cn r.0CD <r Z CI CO cr, L— 1.y w Cl. L - cn ull cf�. r= CC. ILn In l C14 114 W C,;, Q cm cm cc CD Q Q 11 I 4- cc, In <C cr, U, cr-, C-- C> C� ..n ,',4 cc,rrJ w I— I— 1— 1-1 I= W I— I— I= L"ly m <C <r 1.; 0- tr) I— I— M: 1 I= => OC, Ih 4r, 1-1 r,4 rf, I— I oz X 0. -h IZI CC, K N ac I <r ..d. cli 22 !t. '7 .:n CC cr I= cc "r co —I W<r Iyl , �x 4(� I= w Q- 0- jI ,1 <r w L w =, al <C Q IC :X 1.1D I= w M: 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 , w Ic!Irj o �. rN N N Oma• O` - w G GL c.> c: <r 1 W •Q !1 9 J I CC. r�r S on, v) v Z w N T. W w p � r Z , 40. <C L li •Q I= Ll 2 c.• v w w A 1 1 d r. 'wry Q Z Q '✓ Q r O C7 .... Q w ¢ G G G r w Q r= G G Z r_J v •S I.AJ t r U C.i O KL L. 1 d G t 1 1 1 1— c G v) O w N T. C7 .... Q cm rl rl n a• w ... 1 � F iJ rx V7 C' 1— C.? N IY 1" G rl rl r � ' li! ^✓ 1 1 !L I 1— � Q1- C r r r a 2 rs r • ili rl 'u,1 1 +E• ap 0 0 0 0 0 Location --V- ata 11�cY�2�YwAef� No. ISSN Date Q w TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ % g w Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ C' 1'+ ff- _� - 7513 Building I Div. Public Works P%Fd1tIT NO. 1-52— APPLICATION 2— APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 MAP K40. LOT NO. ) 2 RECORD OF OWNERSHIP ;DATE BOOK ;PAGE ZONE SUB DIV. LOT NO. LOCATION. ifs „ �j 3 / ewty 4 „`^�iAf/'-' `- A _ // , j� PURPOSE OF BUILDING OWNER'S NAME NO. OF STORIES SIZE OWNER'S ADDRESS c?31 a , 9 -11 -1117* -Ir -IC C r- J BASEMENT OR SLAB ARCHITECT'S NAME BUILDER'S NAME I SIZE OF FLOOR TIMBERS IST 2ND 3RD SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS POSTS DISTANCE FROM STREET DISTANCE FROM LOT LINES - SIDES REAR GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM flO 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 SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 INSTRUCTIONS r 3 PROPERTY INFORMATION 1' Lava= d Oe/Jig-tAe 4 Q� Q� LAND COST �c51n,�.o Vt ����� EST. BLDG. COST / 5'd C, F • ' EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM l ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE_FLED LED `7 1 GNATURE OF OWNER OR KTHORIZED AGENT FEE 191 f5�� PERMIT GRANTED es -1. F4 - OWNER TEL. NiP -7 CONTR. TEL. 1�� _.3 SEPTIC PERMIT NO. 4 APPROVED BY BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN BUILDING INSPECTOR BUILDING RECORD 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—I 8 INTERIOR FINISH CONCRETE 3 1 2 CONCRETE BL K. PINE BRICK OR STONE HA DW D _ PIERS PLASTER DRY WAIL UNFIN. 3 BASEMENT AREA FULL FIN. B M AREA V, 1/1 l/ FIN. ATTIC AREA NO 8 M FIRE PLACES HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS 8 1 2 DROP SIDING CONCRETE WOOD SHINGLES EARTH _ ASPHALT SIDING HARDw D _ ASBESTOS SIDING _ COMMCN VERT. SIDING ASPH. TILE STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. & FLOOR BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAMESUPERIOR _ ADEQUATE I -i NONE 5 ROOF 10 PLUMBING GABLEHIP BATH (3 FIX.) GAMBREL MANSARD TOILET RM. (2 FIX.( FLAT SHED WATER CLOSET ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING TAR & GRAVEL STALL SHOWER ROLL ROOFING I MODERN FIXTURES _1 TILE DADO I� 6 FRAMING II 11 HEATING WOOD JOIST TIMBER BMS. & COLS. STEEL BMS. & COLS. WOOD RAFTERS 7 NO. 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