HomeMy WebLinkAboutMiscellaneous - 21 ROCK ROAD 4/30/2018W
Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS, Ch. 139, Sec. 3B
To: Building Commissioner or
Inspector of Buildings
1600 Osgood Street
North Andover, MA 01845
RE: Insured:
Property Address
Policy Number:
Date/Cause of Loss
File or Claim Number:
Nancy Lever
21 Rock Road
HP3077636
10/1/2015, Water/Plumbing
32667-R
Claim has been made involving loss, damage or destruction of the above captioned property,
which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER
143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS,
CHAPTER 139, SECTION 3B is appropriate, please direct it to the attention of the writer and
include a reference to the captioned insured, location, policy number, date of loss and claim or
file number.
Ryan Werner
On this date, I caused copies of this Notice to be sent to the per ons named above at the
addresses indicated above by First Class Mail. 7 a
Signa'te and Date
ANDERSON ADJUSTMENT CO., INC.
50 Nashua Road, Suite 303
PO Box 1098
Londonderry, NH 03053
Location
No. S Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $+
Building%Frame Permit Fee $
�Fo,u,r)dation Permit Fee $
Other f ermit Fee $ /SSU
Sewer Connection Fee $
Water Connection Fee $ g
AUG 1.1 T Tq
,may
Building Inspector
-` `\IN
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6340 4 Div. Public Works
Pjm-mIT N. & yt APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS.
v
PAGE 1
MAP h40.
LOT NO.
2 RECORD OF OWNERSHIP "DATE
BOOK "PAGE
ZONE
SUB DIV. LOT NO.I
LOCATION
PURPOSE OF BUILDING
/ f� Y
OWNER'S NAME
NO. OF STORIES SIZE
OWNER'S ADDRESS e'1i0�1�
e�
BASEMENT OR SLAB
ARCHITECT'S NAME
SIZE OF FLOOR TIMBERS 1ST tl G 2ND 3RD
of
- ny
BUILDER'S NAME SCI p` I YY} V .Y�yY7 `�/
l , `
SPAN f
DISTANCE TO NEAREST BUILDING
DIMENSIOCNi'S OF SILLS
DISTANCE FROM STREET
POSTS
DISTANCE FROM LOT LINES - SIDES `�1 (� REAR N i
1 b
GIRDERS
FRONTAGE / +
AREA OF LOT 17�1 IJIJ -f
J b 1
HEIGHT OF FOUNDATION THICKNESS
15 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 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 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 FILED 17, 1lq Ic� qq
! SIGNATURE OF OWNER OR
FEE
ZED AGENT
PERMIT GRANTED
t9 9 v
OWNER TEL. #kgs'— L41��"'')
CONTR. TEL. #� `f g - a 15
CONTR. LIC. # Q4_5
3 PROPERTY INFORMATION
LAND COST
EST. BLDG. COST
EBT. BLDG. COST PER 6Q. FT.
EST. BLDG. C06T PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
BOARD OF HEALTH
PLANNING BOARD
BOARD OF GKLECTMEN
���'
�
j
e 7 // BUILDING IN6PECTOR
I _ V.
BUILDING RECORD
1 OCCUPANCY 12
SINGLE FAMILYSTORIES 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 8 INTERIOR FINISH i o+
CONCRETE 1,, 2 I3 (Iyt_n
CONCRETE BL K. PINE_
BRICK
PIERS OR STONE PLZSHARD-
PIERS
D _ — PIERS PLASTER
_ DRY —WALL _
UNFIN.
3 BASEMENT
AREA FULL FIN. B'M'T' AREA _
'/ 1/1 1/. FIN. ATTIC AREA _
NO BMT FIRE PLACES _
HEAD ROOM MODERN KITCHEN
4 WALLS I 9 FLOORS
CLAPBOARDS B 1 2 3
DROP SIDING CONCRETE
WOOD SHINGLES EARTH _
ASPHALT SIDING HARDW D _
ASBESTOS SIDING _ COMMCN
VERT. SIDING ASPH. —TILE
STUCC
ILESTUCCO ON MASONRY
STUCCO ON FRAME
STONE ON MASONRY I WIRING
STONE ON FRAME
SUPERIORI� POOR _
ADEQUATE NONE
5 ROOF 10 PLUMBING
GABLE 1HIP BATH 13 FIX.)
GAMBREL MANSARD �I WATER RM.
CLOSETFIX I
HED
FLAT I I
SLATE
NO PLUMBING
i
• • '�
-••• ^�^^ " ""
)
TAR 8 GRAVEL
STALL SHOWER
_
ROLL ROOFING
MODERN FIXTURES
_+
TILE FLOOR
TILE DADO
6 FRAMING
11 HEATING
WOOD JOIST
PI PELE55 FURNACE
FORCED HOT AIR FURN.
TIMBER BMS. 6 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
GOAL
ltf 13rd I II NO HEATING I I
a
FORM U - IAT REIFASE FORM
INSTRUCTIONS: 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 local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: �� a�-� (Yi UYDL �A Phone �� Fs
LOCATION: Assessor's Map Number Parcel
Subdivision Lot(s) 6 3
Street ll�e�F- St. Number
************************Official Use Only************************
RECOM ENDATIONS OF TOWN AGENTS:
• Date Approved
Conservation Administrator Date Rejected
Comments
Date Approved
Town Planner Date Rejected
Comments ao kcLA�Lija�rl 0
1rn Q
Date Approved
Food Inspector -Health Date Rejected
Date Approved
Septic Inspector -Health Date Rejected
Comments
Public Works - sewer/water connections
- driveway permit
Fire Department
Received by Building Inspector Date
OFFICES OF: � - •
APPEALS ; ;. ;.; NORTH ANDOVER
BUILDING
CONSERVATION DIVISION OF'
HEALTH
PLANNING PLANNING & COMMUNITY DEVELOPMENT
KAREN H.P. NELSON, DIRECTOR
120 Main Street
North Andover.
Massachusetts 01845
(617) 6854775
In accordance with the provisions 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 c 111, S
150A.
The debris will be disposed of in:
V) C.,s b OYD o `() as s
(Location of .Facility)
Signature of Permit Applicant
91 -910�3
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector.
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