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HomeMy WebLinkAboutMiscellaneous - 218 MASSACHUSETTS AVENUE 4/30/2018Locati=�;7;M No. ,40RTPI 0 CHUS Check # 14 5 6 121 Date 2 �*,/ TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee TOTAL J-11-1 Building Inspect -Sr/ TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER0 DATE ISSUED: SIGNATURE: Building Commissionerfl for of din9S Date SECTION 1- SITE INFORMATION 1.1 (Property Address: < 1.2 Assessors Map and Parcel Map Number Number: 0 47 Parcel Numbrer 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area (sf) Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided R aired Provided 1 1.7 Water Supply M.G.L.C.40. 54) Public ❑ Private ❑ 1.5. Flood Zone Information: Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record E �4 a tf Name (Print) Address for Service: Signature Telephone ,2.2 Owner of Record: Name Print Address for Service: Signature Tele hone SECTION 3 - CONSTRUCTION SERVICES 3.1 censed Construct' n Supervisor: Not Applicable ❑ ro�� G�/(S Cd�S�\ •.� ?Cr 7 Licensed Cc truction Supervisor: /� License Num6er A dress -7d-- G Expi ation Date v Signature- Telephone 3.2 Registered Ho a Improvement Contractor Not Applicable ❑ Company Name ?70 Registration Number Address Expiration Date Signature Telephone SECTION 4 - WORKERS COMPENSATION (AG.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 rmit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work(check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Sr*cikq f 6, ,A. ` `� Brief Des 'ption of Proposed Work: `'' `• "�''� --7 G SECTION - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be tFFI13A1r USEENLY, k Completed by permit a licant 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 d" 5 Fire Protection 6 Total 1+2+3+4+5) Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 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 permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 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 F- 1'rint Name Signature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 ST 2 ND3 PD 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 m m m m VJ VJ 0 m y d C � d 'v O CD C7 Z y CFD O 'O. CL r c CL =' y � o CD O v MQ O Q Er CD O CD C CD y � CL v � O cc CD v CO) O 1 Z CD O O CD C CD ;re cn 0 cn e C ?� O CO ..y C CT dSo 10 Q m CD .+ C O d Ott• N �a m 02 CD * _i o e� N O =rm CD o :CD ki C2 0 Z�• CO) a CL ~'� C '* O O H O 0 O. m N ."i• CZ =, cr CD N y� O OCD Im CO) � O m U2 O C) w O CD O : N .�► : : , •a 0 CD 0W CD .% N : d Wim: dd: 5 'o o.'o• Cl) y O Co: o ~" 0 . CA Cl) m ?I m CIS S cn c -x 7d -X cp 7y � � (� o m O �7 `� ° ~' p'- W old y w A Ctf n r" bb uta x 'ti rl t�f � � p 'k :)r' r CL 0• Gd m 0 � y o Q. n O Q y f" A) M M 0*6 z 0 O C t d k '✓hn. �tyliaiiLci3zUHt�`ZCSI. Q�t/Yl•�,%il.�C,rtudEl�p BOARD) OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS � r 058498 • I Birthdate: 10/21/1966 t Expires: 10721/2001 Tr. no: 6698 Restricted To: 00 I SCOTT C GEORGOULIS I 96 ARLINGTON AVE.. DRACUT, MA 01826 Administrator NONE IIPROVENENT CONTRACTOR z Registration: I1781O EXpiratior 12112/2002 Type: Private Corporatio -GEORGOULIS CONSTRUCTION, r I SCOTT GEORGOULIS b ARLINGTON AVE )MINIsTRAMR ORACUT NA 01826 vrrrce OT invesUgaxions Boston, Mass. 62111 A; Workers' Compensation Insurance Affidavit Please Print /2"7 qi�'> _ q (-J t �U� -�� %L y `f Phone am a homeowner performing all work myself. al 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. 62el le( -5 Phone # Comyany name: Address C; fid. Phone # Insurance Go Policy # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of `7fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. r I do herby cerfdy und3f the pains and penalties of perjury that the information provided above is true and correct Signature Print name , Cy Official use only do not write in this area to be completed by city or town official' ❑Check if immediate response is required Building Dept Contact person:_ Phone #. FORM WORKMAN'S COMPENSATION late-�a/ — hone # ?-l" ���'�- 9ddo E Building Dept E] Licensing Board p Selectman's Office Ej Health Department 0 Other N2 2 129 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...... ......... . ......................................... . .................................... has permission to ......... ................ wiring in the building of ... .......... t at.:��?g .................................................................. . North Andover, Mass. 9 -- Fee—& . . ...... Lic. .............................................................. ELEcTRICAL INSPECTOR 11/09/98 15:03 35-00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Rough ServiceFin �t 9�a e�:hr UJa111nn1n111caltli of AsIllsa chtlott�to office use only Deportment of Public Stfetr Permit No.----• _ BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:001 'f✓/ occupancy &tee Checkrtl -_— 5- ^` � 3/90 heave blank) APPLICATION FOR PERMIT T PERFORM ELECTRICAL WORK All work M Fre performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 Irl EASE PRINT IN INK OR TYPE All INFORMA .t, - II _ Cit or Town of e, K' Date_--_.—>©—7�F ---- to the Inspectnr of Wires, y The undersigned. applies for a permit to perform file eleciricaltwork described below. Lncatinn (Sireet 6 Number) Owner or Tenant Owner's Address -- `-------- — Is fills permit in conjunction with a building permit: Yes Nolu (Check Approprfa B I ✓� rmpnse of Building _ _ _----•--_—_-- _-----111i1i1y AuItizali No. �---_-.---------- Existing Service Amps __- /_ J—L ! o_ Volts Overhead llndgrd l—�J No. of Meters New Service __ '� Amps —,/ �` `� Veils Overhead l `J Llndgrd t —! No. of Meters Nunrher of reeders and An+paeity I oration and Nature of Proposed Electrical Workje--��- ------ — - ---- OTI IFR: INS( TRANCE COVERAGE: Pursuant to the requirements of Massachusttes General Laws I have a current Liability Insurance Policy Including Completed Operations Coverage or its substantial equivalent. YES El NO C 1 I have submitted valid proof of same to this office. YES (A NO 1.1 If you have checked YES, pleaseIndicate the type of coverage by checking the appropriate box. INgTRANCE E] 00ND 0 OTHER❑ tPlease Spetifyl -- ---- (Fxplratinn Date) tolotated Value of Electrical Work f G J Work In Start -&//—/— Inspection Date Requested: Rough !�~ Z_ _ Final Signed under the penalties of perjury: _, FIRM NAME rl- O� c��%�/Lois- eG — LIC. NO. Aq?%� Licensee �O f �L° Signature .� ` LIC. NO. r Address % i C by %�'�yr Bus. Tel. No( All. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required by Massachusetts Gene raI aws, anMmy ure on Ihls permit application waives this requ rement.�i Dr Agent (Please check one) "0 TelephoPERMIT FEE (Signature No. f/1�y ---- (Signature of Owner or Agent) - tvint No. of Lighting Outlets No. of Ilot lube No. of Transformers KVA — No. of I.Witting rixtures Above Swimming Pool gind. n - ❑ gind. ElGenerators KVA r No. o Emergency .ig Alng No. of Receptacle Outlets No. of OI) Burners Batte Units No. of Switch Outlets No. of Gas Burners ota FIRE ALARMS No. of Zones No. of Deter tlon and - No. of Ranges No. of Air Conditioners eat Total Tons TotalNo. Initiating Devices of Sounding Devices No. of Dis losals No. of Pumps Tons KW No. of Sep Cootained DetedinnfSnunding Devices No. of Dishwashers S acelArea I leating KW Municipal lor-al❑ Connectins 0011ler No. of Dryers Ileatin Devices KW -- No. of Water Healers KW o. of No. of Ballasts Low Voltage Wiring —Signs No. I lydro Massage tubs No of Motors Total I IP OTI IFR: INS( TRANCE COVERAGE: Pursuant to the requirements of Massachusttes General Laws I have a current Liability Insurance Policy Including Completed Operations Coverage or its substantial equivalent. YES El NO C 1 I have submitted valid proof of same to this office. YES (A NO 1.1 If you have checked YES, pleaseIndicate the type of coverage by checking the appropriate box. INgTRANCE E] 00ND 0 OTHER❑ tPlease Spetifyl -- ---- (Fxplratinn Date) tolotated Value of Electrical Work f G J Work In Start -&//—/— Inspection Date Requested: Rough !�~ Z_ _ Final Signed under the penalties of perjury: _, FIRM NAME rl- O� c��%�/Lois- eG — LIC. NO. Aq?%� Licensee �O f �L° Signature .� ` LIC. NO. r Address % i C by %�'�yr Bus. Tel. No( All. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required by Massachusetts Gene raI aws, anMmy ure on Ihls permit application waives this requ rement.�i Dr Agent (Please check one) "0 TelephoPERMIT FEE (Signature No. f/1�y ---- (Signature of Owner or Agent)