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Location
No.
Date
%ORTh TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ Z'
CHU
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
16206 -Building Inspec
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
w .� '� k\y�4Y`'',.n' ��? � .,. .. n ,x �...:"' Mi�.. �. .. „. ,. �� �+ tiF��,�,- k��� � tt` aC. �➢h j ��:'ia. �§y BUILDING PERMIT NUMBER: ` DATE ISSUED:
SIGNATURE:
Building Co ------ oner/I ctor of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
17 n1 U� S -
1.2 Assessors Map and Parcel Number:
�,l 0%6 ti. 6-00H .000
00.E
Map Number Parcel Number
1.3 Zoning Information:
R-4
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Areas Fronts e 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 Sewerage Disposal System:
Municipal ❑ On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
n0emavn05
Name (Print)
Address for Service:
6 0916 9 IF
Signat#re
Telephone
2.2 Owner of Record:
V
Name Print
Address for Service:
Signature
Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construct on Supervisor:
_D "V,60��'Tr
Licensed Construction Supervisor:
Address
Sigfature
NAjd veY
% Q 7? Ll 5
Telephone
Not Applicable ❑
O
License Number
! V /"1 ®� 3
Expirationate
3.2 Registered Home Improvement Contractor
0, (s jltwo
Not Applicable ❑
/ 2 U / ��
Company Name
���
Registration Number
Expiration Dae
Address
up
—4&
Si nature
Telephone
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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 applicable)
New Construction 0 Existing Building ❑ Repair(s) ❑ Alterations(s) EK Addition ❑
Accessory Bldg. ❑ Demolition 0 Other 0 Specify If ni' F -Or
Brief Description of Proposed Work:
Vino Roovv�
1 �J i3 -Qcti, -�-
I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I
Qoorv► 15 e urr�,rl I f/ rt Ft'K i4eo( Roan),
Item
Estimated Cost (Dollar) to be
Completed by pernut applicant
,; kf "} OFFICIAL USE ONLIe` `
_ dT V7? n'
1. Building
600i), 0d
(a) Building Permit Fee
Multiplier
2 Electrical
3 W. Q D QO
(b) Estimated Total Cost of
Construction
3 Plumbin
00 • d0
Building Permit fee tel X (b)
4 Mechanical (HVAC)
5 Fire Protection
100,00
6 Total 1+2+3+4+5
043 A 6
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf, in all matters relative to work authorized by this building pennit application.
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
I, a ,64-�' 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 r
U;
Print Name 1 `/d
Signature of Own(?1/A ent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB ST RD
SIZE OF FLOOR TIMBERS 1 2 3
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DD�ENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL, OF CHRANEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
r FORM U - LOT RELEASE FORM )AJ(0J*( L6, u.,4 -
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 or requirements.
*****************************APPLICANT FILLS OUT THIS SECTION******�****************
APPLICANT
LOCATION: Assessor's Map Number.
SUBDIVISION
STREET ✓�-o C,w-�
PHONE
PARCEL
LOT (S)
ST. NUMBER vim/
************************************OFFICIAL USE ONLY*******************************
RECOMMENDATIONS OF TOWN AGENTS:
CONSERVATION ADMINISTRATOR DATE APPROVED
DATE REJECTED
COMM
TOWN PLANNER
COM
DATE APPROVED
DATE REJECTED
FOOD INSPECTOR -HEALTH DATE APPROVED
DATE REJECTED
SEPTIC INSPECTOR -HEALTH DATE APPROVED
DATE REJECTED
COMM
PUBLIC WORKS - SEWER/WATER CONNECTIONS
C
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTO
Revised 9197 jm
I
TE
F'7U
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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:
a 1 7 Nv55 ,Q ►�
(Location of Facility)
Signature of Permit Applicant
�3 acid ?
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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Name
The Commonwealth of Massachusetts -
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Please Print
Print
City ly WAC/-tz- Phone #
I am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
CI am an employer providing workers' compensation for my employees working on this job.
Company name: ' f
Address d e[ VY N
Z- kv7 (/ 57
T? )- 3-vj? 7 *27Qole,10_a.-dl
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 we11_as_civil.penattiesin-theinrm-f-a_STDP WORK_ORDFR and_afore._cif.-($1110.DD)-aAay.againstme I
understand that a copy of this statem t may be forwarded to the Office of Investigations of the DIA for coverage verification.
/ do hereby certify under the r »allies of perjury that the informatm provided above is true and correct037.
Signature Date
Print name �f �I Pbone.#`�
Official use only do not write in this area to be completed by city or town official'
City or Town Permit/Licensing
Building Dept
E]Check if immediate response is required []
Licensing Board
E]
Selectman's Office
Contact person: Phone #: El
Health Department
Ei
Other
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148 Main St. Bldg. A
North Andover, MA 01845
Tel: 978-688-5422
Fax: 978-688-5717
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INVESTMENT PROPERTIES
FLOOR PLAN
BASEMENT RENOVATION
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148 Main St. Bldg. A
North Andover, MA 01845
Tel: 978-688-5422
Fax: 978-688-5717
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Date. . Q ........
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that
has permission for gas installation ............................
in the buildings of. 7 �� -!�� ................
at ..... 7 ..12M J. -C . North Andover, Mass.
Fee.,:>?,"-.q'�� Lic. No. ..........................
GAS INSPECTOR
Check# / 7 V 5
4193
MASSACHUSETTS UNIFORM APPLICATON FOR PERAUr TO DO GAS FITTING
(Type or print) Date
NORTH ANDOVER, MASSACHUSETTS
/� fir"
Building Locations 7 en,Ss /i 111-1. Permit #
• /`1
Amount $
i^� rJUUt � Yom' S * Owner's Name
New Renovation ❑ Replacement ❑ .
Plans Submitted ❑
(Print or type)/))1(/
� v P � � �-��� J `AA ,Q �C oCne: Certificate Installing Company
Name bY` /v ❑ o p.
Address 1 ��— S�� L:Z� �. ❑ Partner.
Business Telephone 5' 7e e%I' Co.
Name of Licensed Plumber or Gas Fitter /9
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes No❑
If you have checked ye—s .please indicate the type coverage by checking the appropriate box.
Liability insurance policy [3--' 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.
ch. Ar nnP-
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 above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts S %e Qas Code and, Chapter 142 of the General Laws.
(OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
❑ Plumber / �-p �—
❑ Gas Fitter License Number
❑ Master
M,k6rneyman
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(Print or type)/))1(/
� v P � � �-��� J `AA ,Q �C oCne: Certificate Installing Company
Name bY` /v ❑ o p.
Address 1 ��— S�� L:Z� �. ❑ Partner.
Business Telephone 5' 7e e%I' Co.
Name of Licensed Plumber or Gas Fitter /9
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes No❑
If you have checked ye—s .please indicate the type coverage by checking the appropriate box.
Liability insurance policy [3--' 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.
ch. Ar nnP-
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 above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts S %e Qas Code and, Chapter 142 of the General Laws.
(OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
❑ Plumber / �-p �—
❑ Gas Fitter License Number
❑ Master
M,k6rneyman
Date.
TOWN OF NORTH ANDOVER
0
PERMIT FOR GAS INSTALLATION
This certifies that . Ile ..... Ij?'/ /-/
....................
has permission for gas installation .
in the buildings of ... 0-1�-- dc.—. '-'. t., t. .....................
at ... 14-lAf.f .............. North Andover, Mass.
�7D
Fee.,
7. Lic. No.. . � . ..... . .....
GIIN, S'PECTOR
Check # �/- ) ) ('
4 0 6" 0
27
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
Ala. And weir Mass. Date 'i — 12 — y 2 Permit #_v -v
Building Location .217 M S Ave.. Owner's Name P -4ee— M en 0 U oS
Type of
New Renovation ❑ Replacement rj Plans Submitted: Yes❑ No ❑
Installing Company Name Heritage Htq . &plg . Co. Inc. Check one: Certificate
Address 35 pleasant Street M Corporation 714
Stoneham, MA 02180 ❑ Partnership
Business Telephone 7 1-438-7776
Name of Licensed Plumber or Gas Fitter Gordon Switzer
❑ Firm/Co.
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes EX No ❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy ® 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:
Owner❑ Agent ❑
Signature of Owner or Owner's Agent
i hereby certify 'that all of the details and information I have submitted (or entered) in above application are trus 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 compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
By T e of Licenser
Plumber Sign5lure o cf Lr ense8 Plumber,,97 Gas itter
Title Gasfitter 8322
Master License Number
City/Town Journeyman
APPROVED (OFFICE USE ONLY
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SUB—BSMT.
BASEMENT
1ST FLOOR
2ND FLOOR
I
3RD FLOOR
4TH FLOOR
STH FLOOR
6TH FLOOR
7THFLOOR
8TH FLOOR
Installing Company Name Heritage Htq . &plg . Co. Inc. Check one: Certificate
Address 35 pleasant Street M Corporation 714
Stoneham, MA 02180 ❑ Partnership
Business Telephone 7 1-438-7776
Name of Licensed Plumber or Gas Fitter Gordon Switzer
❑ Firm/Co.
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes EX No ❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy ® 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:
Owner❑ Agent ❑
Signature of Owner or Owner's Agent
i hereby certify 'that all of the details and information I have submitted (or entered) in above application are trus 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 compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
By T e of Licenser
Plumber Sign5lure o cf Lr ense8 Plumber,,97 Gas itter
Title Gasfitter 8322
Master License Number
City/Town Journeyman
APPROVED (OFFICE USE ONLY
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Date. �/-. n<-. �� ;�
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that . ... F lvz�� ..........
has permission to perform EN .. ....
plumbing in the buildings of . L, �'t , 3
.......................
at. ............. -North,Andover, Mass.
Fee.6. '? ..... Lic. No/-�.,�.) . ...... .........
I i PLUMBING INOECTOR
Che6k # v
5580
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Date
Building on Locati1 7 r���$j• %9 ✓�� Owners Name m r itl vQ n/ U S Permit
/ �
Amount
/ � 4 12 O(AACIAType of Occupancy `j "14 LL 1
New 0-- Renovation Replacement ® Plans Submitted Yes No
FIXT-11RES
`I
111'
.-�........-�-.-.�-.-....
(Print'or type) Check one:
Installing Company Name 9 /4V IO 4 L=7-Pn►ti�f�� ® Corp.
Partner.
Q— m/Co
Name of Licensed Plumber: y
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policyEl Other type of''inderrinity Bond
Certificate
Insurance Waiver: I, the undersigned, have been made" aware thai the licensee of this application does not have any one of the above
three insurance
Signature Owner 1:1 Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massac S to Plu Cod ,and Chapter 142 of the General Laws.
By Signature of Licenseaum er
Type of Plumbing License
Title . p S
City/Town icense . um er Master ® Journeyman
APPROVED (OFFICE USE ONLY
Date .......
f,,ORT
0,
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ...... ......... . ................
has permission to perform ...... If 4
.........
v.�*vin-the building of .......
. .......................
at . .................... INA Andove I s.
Lic. No.o.,"I.I.3W ..... .... ..
Fee.,� .... ....... . ............ ........
Check # x ICAL IN CTOR
4468
�ornnsonturaflh o� %�aoe�itterw '
For Office Us
.1Je
rc•��/� �c77 (Rev. 11/gg)
rParin"d o1 }irr �enricrd Permit Number:
BOARD OF FIRE PREVENTION -REGULATIONS occupancy & Fee
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
(ALL WORK TO BE PERFORMED WITH THE MASSACHUSETTS ELECTRICAL CODE 527 CMR 12:00)
PLEASE PRINT IN INK OR TYPE ALL INFORMATION V-19-03
A� Date:_
City or Town of: (��h N D 4V� �
By this application the undersigned gives notice of his or her intention to perform the electrical work described below. To the Inspector of wires:
Location: (Street & Number)_ 5� AVE
Owner or T
TnAL,- k
Owner's Address:
Is this permit In conjunction with a Building Permit? es ❑ No ❑
(Check Appropriate Box)
Purpose. of Building: Utility Authorization #:
Existing Service: Amps _/ _Volts Overhead ❑
Underground. ❑ # of Meters
New Service: Amps / Volts Overhead ❑
Underground.❑ # of Meters:
Dumber of Feeders and Ampacity:
Location and Nature of Proposed Electrical
No. of Recessed Fixtures
No. Of Lighting Outlets
No. of Lighting Fixtures
No. of Receptacle Outlets
No. of Switches
rNo. of Ranges
No. of Waste Disposals
No. of Dishwashers
No. of Dryers
No. of Water Heaters
# of Hydro Massage Tubs
No, of Cell.•Susp. (Paddle) Fens
No, of Hot Tubs
e m e oyT
.. I No. of Transformers
Swimming Pool: Above ground o In Ground o
No. of 011 Burners _
No. of Gas Burners
No. of Air Conditioners TOTAL TONS:
Heat Pump Totals:
Number: TONS: KW:
Spscs /Area Heating: KW
Heating Appliances SOMIS l[ KW
Generators
Total KVA
KVA
# of Emergency Lighting Battery Units
Fire Alarms # of Zones
# of Detection & Initiating Devices
# of Sounding Devices:
# of Self Contained
Detection/Sounding Devices
Local o Munictoal Connection o Other o
Security Systems:
No. of Devices or Equivalent
Data Wiring, No. of Devices or Equivalent:
Telecommunications Wiring: No of Devices or
Equivalent:
KW I No, of Signs: .# of Ballasts'— n
OTHER;
I No. of Motors Total HP
2
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical.Wbrk may Issue unless the licensee provides proof of liability insurance
including 'completed operation' coverage or its substantial equi/val'I. The undersigned certifies that such coverage Is In for , and has exhibited roof of same to the permit
issuing office. CHECK ONE: INSURANCE BOND o
OTHER O Please specify:1,�
Estimated Value of Electrical Work S"I tI-SD0 (When required by municipal policy)
WorktoStart: ��•� 1 tp zool
I certify, under the pains and penaitles of er u that the InfoInspectirmation on hlsons to be a requested application is true aIn accordance tnd comh MEC plete.
Firm
end upon completion.
STA'7 EL n16 E (..«c.. -t A t �, 66- p l ry� pp p
Firm Neme:X N 4 JJ � n L'
Licensee: LIC. # 017
Signature:
' (If applicable, enter "exem�pt" In the license number line) /
Addr�ss:ie ('111/1 ST A AM`i•�EUeiy Bus. Tel.# I �p 2'
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liabllily Insurance coverage
waive this requirement. I am the (check one) Owner o OR Agent o
Signature of Owner/Agent: Telephone #
LIC. #
r f �
�, .1. •
law. By my signature below, I hereby
Date.../�--
.......... .........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that . . ..... . .. ....... ............... ...... : ............................
-Y
has permission to perforrn--� .... .. ... . ....................................
wiring in the building of ....... r— ....................................................
at ............................................ ................ . North Andover, Mass.
UY/
Fee ... Lic.No./).,k!-.4§J(./*` .... ..................
R
Check #
7456
P-\ Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No. _
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (ME ), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: o'lo / 7
City or Town of: NORTH ANDOVER To the Insp cto of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) zP19
Owner or Tenant � �' tzyls Telephone No.CPIV 1
Owner's Address . VI
Is this permit in conjunction with a buildin permit? Yes ❑ No. (Check Appropriate�Box)
Purpose of Building C9 / ``�Z,� fG Utility Authorization No. e77G�
Existing Service 00 Amps *7e 0Volts Overhead.® Undgrd ❑ No. of Meters
New Service Amps H,6 /A& Volts Overhead Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Completion of the following table may be waived by the Inspector of Wires.
No. of Recessed Luminaires
No. of Ceil: 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- El
o. o Emergency Lighting
rnd. rnd.
Batter Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection an
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
g
No. of Waste Disposers
Heat Pump
Number.
Tons
KW
No. o -
Se Contained
Totals:
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municippi ❑ Other
Connection
No. of Dryers
Heating Appliances Kir
Security Systems:
No. of Devices or Equivalent
No. o Water KW
o. o No. of
Data Wiring:
Heaters
Signs Ballasts
No. of Devices or E uivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecom nr Whrmg:
afDevices
No. of Devices or Ea uivalent
OTHER:
Estimated Value of Electrical Work:
Attach additional detail if desired, or as required by the Inspector of Wires.
(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,M BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: 07 LIC. NO.:
Licensee: Signature. )VL? ' LIC. NO.:/�13&63—
(If applicable, enj - exempt" in the license umber line.) Bus. Tel. No.:
Address: 73 410' MA/ `l' 7 Alt. Tel. No.:
*Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: 1 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.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/E I ectri cians/P lumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): t,j%&/i/'' Z:5�<
Address: 0e/l,lejE' C yof
Phone #:
Cit /State/Zi 039 �
Y P� /y�/t , l7 r
Are you an employer? Check the appropriate box:
I. ❑ I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).*
2.�KI am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
have hired the sub -contractors
listed on the attached sheet. t
These sub -contractors have
workers' comp. insurance.
❑ 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):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
I OgElectrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
*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 than hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #:
Job Site Address:
Expiration Date:
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 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-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under•thhee pains and penalties of perjury that the information provided aboveis true and correct.
Siynature:. %'`- 6*%� Date:// "17
Phone #:
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone #:
Location
No. Date
TOWN OF NORTH ANDOVER
2
. 40.
Certificate of Occupancy $
44S Building/Frame Permit Fee $
CHU
Foundation Permit Fee $ e-411
Other Permit Fee $
e-0
TOTAL
Check #
5 619 il6ing Inspe,.Xr
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO COhtTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
_, �' •4 P yam'^ �}. "a 3scaw qy} �.
BUILDING PERMIT NUMBS RDATE ISSUED:
SIGNATURE: Ing
BuilTnj Commissionerfinspector of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
Map Number Parcel Number
1.3 Zoning Information:
Zoning Dis1rid Proposed Use
1.4 Property Dimensions:
Lot Areas Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Required Provide ReTfired Provided
Required Provided
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information:
Public ❑ Private 0 Zone Outside Flood Zone ❑
1.8 Sewerage Disposal System:
Municipal 0 On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
P,e4v- YNwha i`�—
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 Supervisor: r
C o0 /
Licensed Construction Supe isor:
Address
Signature Telephone
Not Applicable ❑
/E D, I
License Number
Expiration Date
3.2 Registered Home Improvement Contractor
bn� V (to
Not Applicable ❑
m
Company Name 1
Address
Registration Number
(
Expiration Date
Signature Telephone
Ma
M
M
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aaaalz
O
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90
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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 ....... 0 10
SECTION 5 Description of Proposed Work check all applicable)
New Construction ❑ Existing Building 0 Repair(s) Alterations(sq) ❑ Addition ❑
`°111
Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify'"" ti3O \ 0& "a
Brief Description of Proposed Work:
0 V/15
P Cgbtqll
SF.CTION 6 - ESTIMATED CnNCTRTTCTTnN CnCTC
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
-,__, OFFI,CIAL�USE ONLY
1. Building
®�
V
(a) Building Permit Fee
Multiplier
2 Electrical
r0 oil Q9
J
(b) Estimated Total Cost of
Construction
3 Plumbin
0
Building Permit fee (e) X (b)
4 Mechanical (HVAC)
--
5 Fire Protection
6 Total 1+2+3+4+5
5 d
Check Number
JEUTION 7a UWNEK AUTHORIZATION TO BE COMPLETED WHEN
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 pennit application.
Signature of Owner
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
Date
1, 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
a (`S 6d 2!:_t (oil
Name
of
Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 1 2 3
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
I-tiIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHRvINEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUMDING CONNECTED TO NATURAL GAS LINE
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#I' BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 001821
Birthdate: 10/02/1959
#� Expires: 10/02/2003 Tr. no: 5959
Restricted: 00
DAVID P GULEZIAN
428 PLEASANT STS —+
N ANDOVER, MA 01845
Administrator
}
- ��ie 1°am�nzoouveci/,� .a���caaoac�izcaelid
Board of Building -Regulations and Standaids
HOME,IMPROVEMENTCONTRACTOR j
Registration: 120199
Expiration .-11%1/03
Type Individual
DAVID'GULEZIAN ,
DAVID GULEZIAN-
428 PLEASANT ST
y
-NORTH ANDOVER, MA 01845 Administrator
_.4...
` North Andover Building Department
I✓
DEBRIS DISPOSAL FORM
Tel: 978--688-9
In accordance with the provision of MGL c 40 S 54, a condition of Building Permi
Number is that the debris resulting from this work shall be 1
disposed of in a properly licensed solid- waste disposal facility as defined b
c11,S150A. by MGL
The debris will be disposed of in:
2 / ro64.5
(Location of Facility)
Signature of Permit Applicant
Date
NOTE: Demolition permit from tl?e Town of North Andover must be obtained for
this project through the Office of the Building Inspector
AQW& ,ERTIFICATE OF UABILITY INSURANCE 0@f��/ 0�:
raaour�� T"M.Q CATE UM AS t n to 3t1f+Dt�11MTt
ase to :1= A %im OMY Atm CONFF NO ROW" UMM TML G99MME
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D@ti41i6Ef1T 1 R$a pm To Wi 'l4 Tl41Si.CERlk a MAY BE msuip >ft
�$ 5uaar s TO Atl 773E tam. IMMUS101,4 a AND CONN M oP
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Location ;71 1) . I �
No. 3M
Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
2"
Building/Frame Permit Fee $
Foundfition Permit Fee
X-MdapParmit Piza
.It I K
PAID By -tiewer-Connection Fee
ater Connection Fee
VA I
-- r TOTAL $ Z
go. Andover Collector 6aA
Je�e— Building Inspector
Div. Public Works
PERMIT Nt"',. APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS.
_r.
a
PAGE 1
MAP a4C-
\
LOT NO.
I
2 RECORD OF OWNERSHIP DATE
BOOK 'PAGE
ZONE
SUB DIV. LOT NO.—I
LOCA N � 7 � f-0- �1 f/
/�C4Fj;r /, rY
PURPOSE OF BUILDING
CSC,
OW 'S NAME
NO. OF STORIES �7/C SIZE
f•`
ER'S ADDRESS l� /�
J
BASEMENT OR SLAB
RCHITECT'S NAME
SIZE OF FLOOR TIMBERS IST 2ND D
UILDER'S NAME C--+;tj—lrle V C.•�
SPAN
DISTANCE TO NEAREST BUILDING
DIMENSIONS OF SILLS
DISTANCE FROM STREET
POSTS
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 TO REQUIREMENTS
F 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 fy�
DATE FI D Q1""6191 6� �` 56
SIGF4ATURE OF OWNER OFtAUTHORIZED AGENT OWNER
/' CONTR. TEL.
FEE �T 4
l
PERMIT WANT
3 PROPERTY INFORMATION
LAND COST
EST. BLDG. COST �l/.�I _LPJ
EST. BLDG. COST PER SQ. FT.
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
BOARD OF HEALTH
PLANNING BOARD
BOARD OF SELECTMEN
d4ODN-
BUILDING INSPECTOR
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Date.
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
Nz�
This certifies that P-"", -------
has permission to perform
.. ...........
plumbing in the buildings of . ........
at. ......
: . ......... North Andover, Mass.
Fee �5. Lic. No..
...... . ............
Check # --Pj Um PECTOR
5278
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Location
Owner
Z�l7 414ss4CfiS11M( 'eVC�'
New 1:1 Renovation �� Replacement
FIXTURES
Date t 0 Z --
r'`" Permit
� Amount & �
Plans Submitted Yes 1:1 No ❑
(Print or type) Check one: Certificate
Installing Company Name_ /1 &-eR V,fi,/1-t'j 1-3 Corp.
ddress 36 # Y C z T, YZ e' r a Partner.
'" 7t'S
Flusmess Telephone afirm/Co.
Name of Licensed Plumber:
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy 0-0�— Other type of indemnity 0 Bond ❑
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner ❑ Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations perfo e under Permit Issued for this application will be in
compliance with all pertinent provisions of the Mas chusetts tate P d Chapter 142 of the General Laws.
By igna u Icen ea FlumDou
Type of Plumbing License
Title S- U S^�
City/Town ricense NumSer Master ❑ Journeyman
APPROVED (OFFICE USE ONLY LJ