HomeMy WebLinkAboutMiscellaneous - 240 HICKORY HILL ROAD 4/30/2018Date!�l. ��/ o ... .. .
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TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that .�� ../� u'` { ... �� 14 , , .. , .. .
has permission for gas installation ... y -e
.,.. 1.
in the buildings of . 7. . , ... .
at.. ....... , North Andover, Mass.
Fee SSI SS . Lic. No.. .(?.. .... .. .
GASINSPECTOR
Check # t.
I� •`
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY 0. 0,1) �� _ _ MA DATE PERMIT#
JOBSITE ADDRESSVL_L,OWNER'S NAME Fp
GOWNER
-Al
ADDRESS ,�y,�-1 T,e TEL —^--__ _ FAX
TYPE OR
PRINT
OCCUPANCY TYPE COMMERCIAL EDUCATIONALRESIDENTIAL Pj`
11
CLEARLY
NEW: El RENOVATION: REPLACEMENT: R2' PLANS SUBMITTED: YES Q NO0
APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER-
CONVERSION BURNER
COOK STOVE _ .. I _ _ I !
DIRECT VENT HEATER _ .- „-
DRYER
FIREPLACE
_ _ 111111
FRYOLATOR J .= I f .
FURNACE
GENERATOR-
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER _ 1 -1 r.._ .. .a _ ._ I __I
ROOM I SPACE HEATER---
ROOF TOP UNIT
TEST
UNIT HEATER - ---- .- _ __._ _..._ 1
UNVENTED ROOM HEATER - - , _ f l-^ ( - i I _ I
WATER HEATER
OTHER
-
INSURANCE COVERAGE
have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES 40 �-I
1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [ OTHER TYPE INDEMNITY E] BOND
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER E-] AGENT ,�[-__fJ
SIGNATURE OF OWNER OR AGENT
hereby certify that all of the details and information I have submitted or entered regarding this application are true and a curate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compli ce th all P rtinent pr ision o he
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME (,; �,(� ' _ S T �_yr�-�LICENSE# - b 3. ._� NATUREUURERO�REEII
^-
MP 0 MGF [� JP [:]J JGF [-]I LPGI CORPORATION Z#'= PARTNERSHIP 0# LLC [-]#
COMPANY NAME: _2 ��_! _.__.___I ADDRESS I _R? L) t1 off- ---
CITY4�? < _[it/c� r1-•-_ . STATE' ZIP ITEL 7_ GIo OZz! _ __(
FAX CEL
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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/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip:
Phone #:
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet. #
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. F1 Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.0 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 then hire outside contractors must submit a new affidavit indicating such.
#Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and 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. #: 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 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 may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
F Flo hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
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 #:
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 hire,
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 enterprise, and including the legal representatives of a deceased employer, or the
receiver 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 be 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 not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) 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
Please 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 certificate(s) 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
Industrial Accidents. 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 their
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
that 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. A new 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05
Fax # 617-727-7749
www.mass,gov/dia
�- NORT"
O S
,'is CHUSEt
This certifies that .'.
has permission to perform
Date//?
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
L��f ..............................
plumbing in the buildings of .......................
at .. ��. �fE?.../. t°!.� .0 ... ` .! .. North Andover, Mass.
Fee. 1. Lic. No.. ".'.� ! ..........�
PLUMBING INSPECTOR
Check # I X
5057
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print) ,� 3
NORTH ANDOVER, MASSACHUSETTS '
Date
Building Location e 6 jtGOwners Name -57-CV G (r) Permit #
k / A Amount
Type of Occupancy 1/J S i cY CA-iTi,119 �
New 1:1 Renovation 01-*' Replacement 1:1 Plans Submitted Yes 1:1 No 0
M 01 Kly
1111'
,41
(Print or type)j / Check one:
Installing Company Name 1� � C F f ,�,% 11 Corp.
Address /� C��t-ALN ��6'� Partner
Name of Licensed Plumber:
Insurance Coverage: Indic,
Liability insurance policy
Lj Firm/Co.
•ance coverage by checking the appropriate box:
Other type of indemnity ❑ Bond ❑
Certificate
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 performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Mas ' usetts State PlumMg Code d Cha r 142 oft e General Laws.
BY M4
ure o7 1-icenscu riumDer
Type of Plutbing License
Title �
City/Town License Number Master 0-l" Journeyman ❑
APPROVED (OFFICE USE ONLY
N2 3479 Date.e..... ..... :.e!......
0:, TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ....................................
......................................
has permission to perform .... ....................................................................
wiring in the building of ........ . ...... hez
............................................
at .......... /'� ... � ..................... . North Andover, Mass.
Fee... .............. Lic. No�.'.'j . .......... ..............................................
ELECTRICALINSPECTOR
Check #
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
TBE COMMONWE+ <1 UH OFMASSACHUSE77S Office Use only
DEPARTA&WOFPUBLICS4FETY Permit No. &Y;7 9P
BOARD OF FIRE PREVEMONRBGUIA77ONS 527 CM 12Q0
Occupancy &Fees Checked
APPLICATIONFOR PERMIT TO PERFORM ELECTRICAL WORK
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date -.Z Z- 16 rl O f
Town of North Andover
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number) 0 k4 I CX -0
Owner or Tenant
Owner's Address SA—k C�
To the Inspector of Wires:
Is this permit in conjunction with a building permit: Yes [2 --No (Check Appropriate Box)
Purpose of Building ,vim Utility Authorization No.
Existing Service Amps / Volts Overhead Underground No. of Meters
New Service Amps / Volts . Overhead Underground No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work Lt)i Z� 5
No. of Lighting Outlets
No. of Hot Tubs
No. of Transformers
Total
KVA
No. of Lighting Fixtures
Swimming Pool Above
Below
Generators
kVA
t A
_1
round
round
No. of Receptacle Outlets
No. of Oil Burners
No. of Emergency Lighting Battery Units
No. of Switch Outlets
I
_
No. of Gas Bumers
FIRE ALARMS
No. of Zones
No. of Ranges
No. of Air Cond. Total
Tons �. S
No. of Detection and
No. of Disposals
No. of Heat Total Total
I
Pum s Tons
KW
Initiating Devices
No. of Sounding Devices
No. of Dishwashers
Space Area Heating KW
No. of Self Contained
Detection/Sounding Devices
Local Municipal
Other
No. of Dryers
Heating Devices KW
Connections.
No. of Water Heaters KW
No. of No. of
Signs Bailasis
No. Hydro Massage Tubs
1
No. of Motors Total HP
OTHER•
IrmuanoeCoW1agu RM"10
¢IbavrraomattLmbikyLmm=PUicyinchdTComplele ComWorzwbstariUcc uvalent YES. NO
Ihawg bmktadvandptoofofsametodr,Office. YES F)whavedmAwdYES, pleaseit thetypeofoovaageby
4- bo EI
g x
'4INSURANCELJ BOND OTHER
WQklDSW / L
101MTJ1./_ Ul0
(Spm)
F mDate
( EstmatadVahleof octicalWoik $
Rough
Fnal
Lio wNo.
BusitmTeLNo.
Addtes L .4 -V LL 00 ,, S 1 j DI ti , —q 03 -5 Alt Tel. No.
OWJNER' S INSUFANCE WAIVER, Iamaware that the lioemedoes nothavethe msttrancecovaageoritssubstarlIalegtuvakaastecl red byMassaduTttsGataalLam
and that mysignahueon this permit application waives thistegturearte t
(Please check one) Owner 1:3 Agent
Telephone No. PERMIT FEE $ ��4�_
igna ure ot Owner or Agent
19
I
No 1994
Date.... f ......................1r
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
��
This certifies that ............................................................... ...................
has permission to perform
...:..............
wiring in the building of. ........:. .. ..................................................
at ....L......K�� .:.:..... ............ '.......... , North Andover, Mass.
Fee..` ................ Lic. No.............................................................................
ELEcmcAL INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
08/09/1995 18:46 5089701177 FIELDING ELECTRIC PAGE 02
I
9-Y& S-�s�s 1A&W
The Commonwealth of. Massachuseus office uqe ck, ''
Permit No.
Department of Public Safety
BOARD OF FIRE PREMMON REGULATIONS S27 CMR 1= Date Issued:
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
AJA umk Ie bK fenw ad In occardance rlth the 04araaaha5901 Eltetot>•► Code. S27 CMR 12:00
(PIX"E PR= IN I= OR 2'!P£ ALL WFODU =ON) Date i I ` 19
City or Town of . At4tve(L 20 the Iaapeetor of Sures:
The undersigned applies for s pmic to petfam the electrical varx described below.
ri/
Lowoare
�(Stat i *wsbar) LID tqlc e P/,
Owner or Tananc 4 A�-k(..dL,
c.
owne�'•s Address � '7It�
V ,CAry
Is Ibis Permit is eosiumcioo with a building pvsmit: Yes a No ❑ (Ofeek Appropriate Sou)t
Purpose of Building
. �� Utility Authortutiaa No. /V /'#
Tsisting Service 49'C-0 Zo 1 2 yo velts Owst►aad ❑ Undgrd [a- No. of haters��
Neb�S_rvicee _Amps / Yaks OverUiAd ❑ vadasd ❑ No. of Raters`
Number of Fooders sed Aepacii7
Ieeacion and Nature of Proposed Electrical Bork U ` 4 N t `j
No. of Lighting Outlets No. of Rat Iubs Imo. of Iransforsi rs
TWAl �
fie. of Ligntin` rtsttras Svueing Pool A.bew �
d. : � Geearatpss [TA �
No. of #aceptaels outlets 10of 1 No. of oil gushers �- la er Fmergaecr Liguiciai
SatcY 1lnits ,
No. of Switch outlets
No. of Gas Burners
FIM ALAWS No. of Zo:tes
No. of Rangesfin,
of Air Cased. local
06- of Detection and
Initiating Devices
No. of Disposals
Ne. of =a ZotalIs
No. of Sounding Devices
No. of Dishwashers
-�
$pace/Area Heaeing
No. of Self Contained {`—
betaecionlSounding Devices
No. of Dryers
�,
Nearing psviees f
Local ❑ CConneccion❑othsr
No. of Water Haaters
- ►
No, of Aa. of
Siena dallascs
Inv voltage
W
No. Hydro Neonate Tubs
f
No. of motors Total
RIM. P
i..._
I1ISORANCE COVZRA=: �pwvuant to the rsquirownts of Masadmattt Ga mril Laws
I hava a currentL1 ill Insurance, Policy iaeluding Co Misteo operatims Coverage or its substenclAl
equivalent. 1= Ur (3 1 Iwe su0aitted valid Proof of am" to this office. YISe NO Q
If you bane theekad yo, please indicate the t7pa of coverage by checking the appropriate box.
I1MPANCE a' BOND ❑ OEM O (P14Ase Specify+)
k"piratl9n Lata/
Estimated Value of Electrical Work S . 60 —
:fork to Start �� Impaction Dace Requested: A4usls1f
Final W rl�l Col(
Signed under chs penalties of r Wr7:
FM NAM � c dry E/Cc 2 rc Care_
Licensee Signature LIC. NO (E) tom%
Address 1 o C_' ^. 7U Zi (&A3 ) bus' 97'g �S 1 if
lit. Iel. No.
09=15 Iii=URANCB WArM-. I as avert that the Licansea does not have the insurance, coverage or Lds suo-
ftantial equivalent as required by HassocAmmetca General Laws, , Mo that ry Sumanwe on Cala pereit
application waives this requiresent. Owner Agent 011easq check ane) Permit Fee:
relephane No. Receipt
Sig stura of Owner or Agsatl
Location
moo. c�23 Date
�ORT� TOWN OF NORTH ANDOVER
Of i••o ,�1h
.. 9
Certificate of Occupancy $
Building/Frame Permit Fee $ �� 2'
sACMUS
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
v
Check #
L 1��
151 16G Building Inspector
DOV
DEPARTMENT _
&PLACATION TO CONSTRUCT REPAIR_ RENOVATI+ OR IDERTOT.TSH_A..ONR.OR. TWn.FAMii:V hikUY: .rNs` „
F .
SECTION 4 - WORKERS COMPENSATION (IVI G I C 152 § 25c(6)
. r.
Workers Compensation Insurance affidavit must be completed and submitted with this applicatron. Failure to provide this affidavit will result
in the denial of -the issuance of•the building permit. -
Si ned affidavit Attached Yes p , No;... ❑
SE'CTIONF 5 Desert tide' bf Pro "osed Wtirk check allJipp, cabie n
New Consti'ucttoii X Existing Building ❑ Repai(s) ❑ Alterafions(s) 0 Addition X1
Accessory Bldg. ❑ ,Demolition. ❑ ° .Other ❑ Specify '
'�X,
Brief Description of Proposed Work:
r KOFdS6X) uiooD -eR Ami' 6ARA66' d U-bR60AA &DD) Tiranl
SECTION 6 - ESTU4ATED CONSTRUCTION•COSTS'
Item Estimated Cost (Dollar) to be fig:
Com leted by permit applicant
1
1. Building (a) Building Pen cut Fee -�
2-6 ivlulti lies ,
2 Electrical (b)- E961fiated To Cost of S —
.:. M 3��. • Construction / � .. ,..
3 _Plumb�n 34n 60 .,Buildmg::Pernut fee (a) :x. (b)
4 Mechanical HVAC 3 d
1049._-918
5 Fie Protection:
6 Total 1+2+3+4+5 1 SZO . Check Iuniber
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUnDING PE°RAUT
a
�I, .y� eVP ✓1 a"V as Owner/Authorized Agent of subject property.
Hereby authorize % d d Al a S --D. ZCU kd ful, to act on
My behalf, ii a 1 matters relativ to work a rued by this building permit application
Signature of Owner Date I C� I CU 1
°SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
as Owner/Authorized Agent of subject
property
aHereby
nd gelideclare that the statements and information on the foregoing application are true .and.:ateurate, to the best of my knowledge
L a j
Print N me
d[ '
ure of Owner/Agent Date. -
NO. OF STORIES L SIZE
BASEMENT OR SLAB SLAB ,
SIZE OF FLOOR TIMBERS 1 sr 2 �� / j� 43
SPAN
DINIENSIONS.:OF SILLS
DR NSIONS OF POSTS 3 k/2, �� S L A -
DRVIENSIONS OF GIRDERS L.r
HEIGHT OF FOUNDATION tP (F Rb roti (i THICKNESS /U
SIZE OF FOOTING ri X r�
KRTERIAL OF CHIN iNEY WA
[ISBU
ILDING CONNECTED TO NATURAL.GA$ LINE
Ii
FORM U. -
LOT RELEASE FORM r a���
I INSTRUCTION
� S. 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 c6AA L PHONE 7-687
LOCATION: Assessor's Map Number (01? PARCEL %3b
SUBDIVISION y i C/►'voco 1�f�G{GK LOT (S)_
STREET C/�e r j �Q ST. NUMBER
**********************************,t****OFFICIAL USE
AONLY***********************************
AGENTS:
ADMINISTRATOR DATE APPROVED
DATE REJECTED
COMM
COMMENTS
D INSPECTOR -HEALTH
SEPTIC INSPECTOR -HEALTH
COMMENTS4
?
UA It REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED l
DATE REJECTED
PUBLIC WORKS - SEWERIWATER CONNECTIONS Al
DRIVEWAY PERMIT_ W A
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTO
Revised 9\97 I'm
i
DATE
0
�RdPoSED FOUNDATION PLAN
LOCATED /N NO_ ANDD
SCALE /"I*. -4o' DATE: R /22 /94
Scott L. Giles RL. S.
50 Deer Meadow Rood
North Andover, Mass.
59,4.
LOT 40
2/, 873 S.F.
:h
IST FO / IVD
EX V
t y
33,
JCC,
O L=//2.36'
HICKORY HILL ROA D
/ CERT/FY THAT OFFSETS SHOWN ARE FOR THE USE
THE OFFSETS OF THE SU/L DING /NSPEC TOR ONLY
SHOWN COMPLY AND SUCH USE /S FOR THE
WITH THE ZONING DE TE OF ZONING
BY LAWS OF CONFORM/T Y OR NON- CONFORM/TY
x .
No. ANDOVERMe WHEN CONSTRUCTED.
WHEN. BU/LT.
otjkLiH
fie -�omvnzoauoeall�i o�✓�%aaaae�u,�oelta ��
BOARD OF BUILDING REGULATIONS
£ ` License: CONSTRUCTION SUPERVISOR .
Number: CS 055417
Birthdate: 04/05/1960
x Expires: 04/05/2002 Tr. no: 21877
Restricted To: 00
THOMAS D ZAHORUIKO�
185 HICKORY HILL RD
N ANDOVER, MA 01845 Administrator
✓lie �anvrreoou�s � /%/�aaaae�%%%aell
DEPARTMENT OF PUBLIC SAFETY
License: HOISTING ENGINEER LICENSE
r. Number: HE 065667
Birthdate: 04/05/1960
Exp ir'es: 04/05,/2002 Tr, no: 19273
Restricted To: -;26
THOMAS D ZAHORUIKO
185 HICKORY HILL RD
N ANDOVER, MA 01845 Acting Commissioner
.. �re voo�zo�zoou�sP.al/�, o� , ��iueac���oseCt
Board of Building Regulations and Standards
HOME !MPROVEMENT CONTRACTOR
O) Registration: 107679
Expiration: 8/5/02
Type: INDIVIDUAL
THOMAS DAVID ZAHORUIKO
Thomas Zahoruiko
185 Hickory Hill Road p _-
North Andover, MA 01845 Administrator
The Commonwealth of Massachusetts
.Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
workers' Compensation Insurance Affidavit
Name
Name: el � %!. zet �0 /
Location: / I /`l
aI am a homeownef performing all work myself.
I am a sole proprietor and have no one working in any capacity
Please Print
-6 F,
I am an employer providing workers' compensation for my employees working on this job.
Company name:
Address
City:. Phone #.
Insurance Co. . Policy:#
Company:name
Address .
CiWf Phone..#
t-pourato secure coverage as reyulrea-`unoer becuon z- or 75L leaa'wine lmposmon or enminal.penames or,a:tine up to s9,50E
and/or one years' irnpns.6nment-as_i OIJ-as_cial_penalties.� -SIQP W-ORK ORE)ER-and_aiin6.At�$IIlO�_a-dayagainsime.
understand that a copy of this statement may, be forwarded't the ce of tnvestigations of the DIA for coverage ver cation.
l do hereby certify under the pains and penalties of pequ that a information provided above is'true and correct. %
Signature: Date
Print name Phone.#(72E-4F7-Z��S`"
Official use only do not write in this area to be completed by city or town official'
City or Town Permit/Licensinq
C7 Building Dept
❑Check if immediate response is required 0 Licensing. Board
0 Selectman's Office
Contact person: Phone A Health Department
Other
TARA LEIGH DEVELOPMENT, LLC
185 Hickory Hill Road, North Andover, MA 01845
978-687-2635 fax 978-689-2310
Constr. Spvsr. # 055417
HIC # 107679
Fed. ID #04-3516982
Agreement for Construction Services
October 24, 2001
Parties, Contact Addresses, Telephone Numbers:
Client: Steve and Heidi Chaff Contractor: Tara Leigh Development, LLC
240 Hickory Hill Rd. 185 Hickory Hill Road
North Andover, MA 01845 North Andover, MA 01845
978-794-2595 978-687-2635
Location of Work: 240 Hickory Hill Rd., N. Andover, MA
Description of Work to be Completed: Addition/expansion; see attached Scope of Work/Plans
Attachments: Scope of Work
Plans
Limited Warranty
Proposed Work Schedule: Proposed Start Date October 29, 2001
(foundation installation may begin prior, as weather conditions allow)
Proposed Completion Date December 31, 2001
Payment Schedule: At Time of Agreement 20% $18,304.00
Completed Frame 20% $18,304.00
Roof, Windows Complete 20% $18,304.00
Siding, Rough Mechanicals,
Insulation, Drywall 20% $18,304.00
Completed 20% $18,304.00
Total as Proposed 100% $91,520.00
1
TARA LEIGH DEVELOPMENT, LLC
185 Hickory Hill Road, North Andover, MA 01845
978-687-2635 fax 978-689-2310
Permits: By this Agreement, Client acknowledges its authority and authorizes the Contractor to apply for and
acquire all necessary construction -related permits (From time to time there are additional permits and
approvals required prior to building permits, which have not been provided for in this Agreement. These
may include Special Permits, Conservation Commission Conditions, Planning Board Approval, or Zoning
Variances, among others, and these are not included, if necessary). Unless specified in attached Scope
of Work, costs of permits, as well as any costs for application or documentation required to apply will
be passed through to Client, over and above the terms of this Agreement, for reimbursement. Client
acknowledges that no work can begin until all necessary permits are in hand, and that Contractor will
use good and reasonable efforts to acquire the necessary permits, but Contractor does not control the
timely issuance of said permits. Client agrees to endorse all applications as required to facilitate
permitting.
All work and schedules, as well as that of any subcontractors, will be subject to all applicable permits
being available on a timely basis, and will be performed by licensed and insured professionals whenever
required.
General Conditions & Definitions:
1. This Agreement constitutes the entire agreement.
2. Any changes are to be documented in writing and signed by all parties. Any changes will be paid for at
the time of the change request, prior to the changed work being undertaken. TLD, LLC reserves
the right to not accept specific requests for changes if and when acceptance of those change
requests adversely affects integrity of work product or schedule.
3. Additional work will be billed at the rate of $42.00 per hour for licensed labor, $28.00 per hour for
common labor unless otherwise agreed.
4. Work sites will be left in equivalent condition to those existing prior to contracted work; unless
specifically agreed, no existing site conditions will be improved.
5. Any specific work hours which are restricted by local statute, agreement or association, and which
adversely affect contractors' normal work schedule will cause completion time to be extended
accordingly.
6. Completion time will be extended due to any delayed inspection services, beyond those specified by
the current Massachusetts State Building Code.
7. Contract will be considered Substantially Complete when all work has been initially completed; repairs
and warranty are beyond the scope of Substantial Completion and final payment will not be
withheld due to repairs and warranty items.
8. Non-payment or delayed payment according to the Payment Schedule will result in work stoppage for
the duration of any payment delays, and completion time extended accordingly.
9. Late payment will result in a finance charge applied to the entire balance due at an annual rate of 18%.
10. Only those work items specified in the "Scope of Work" and "Plans" are included in this contract, and
this specifically excludes any items not specified, such as upgrades to electric service, water
service, furnace/boiler, or other unspecified systems.
2
TARA LEIGH DEVELOPMENT, LLC
185 Hickory Hill Road, North Andover, MA 01845
978-687-2635 fax 978-689-2310
Scope of Work
Construct an addition/extension per attached plans and specifications (including 3 -car garage, mudroom, master
bedroom suite, new fourth bedroom) including all demolition, cleanup, disposal, site stabilization and redressing.
Demolish and dispose existing garage
All materials and specifications to match as closely as possible/available with the existing structure,
including 2x6 wall frame, plywood sheathing, Andersen windows, plaster finish, stain -grade trim/doors
R-19 walls, R-30 ceiling, R-30 floor, 10" thick poured concrete foundation, 4" thick concrete slab
Electrical to include wiring for CATV, telephone, wiring for ceiling fan in MBR.
HVAC to be extended from existing circuits.
Wall paint color choice, (2) coats, standard finishes.
(3) 9' x 7'6" woodgrain garage doors with openers
Repave driveway
Extend brick walkway to mudroom entry
Cut -through, reframe, wire, plaster, trim, paint second floor access area, replace carpet in new study
Bath cabinets Schrock Select or equivalent
Allowances:
Carpet $20.00 per yard materials and labor
(including master bedroom, closets, upper hallway, reworked bedroom)
Plumbing fixtures
(sink/counter/faucet, jacuzzi/faucet, shower/faucet, toilet) $2,200.00
Tile $1,500.00 materials and labor
TARA LEIGH DEVELOPMENT, LLC
185 Hickory Hill Road, North Andover, MA 01845
978-687-2635 fax 978-689-2310
Additional Conditions for Residential/Home Improvement Contracts ONLY:
1. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
2. All home improvement contractors and subcontractors shall be registered, and any inquiries about a
contractor or subcontractor relating to a registration should be directed to:
Director, Home Improvement Contractor Registration
One Ashburton Place, Room 1301
Boston, MA 02108
Tel. (617) 727-8598
3. Client is entitled to a three-day right of cancellation under MGL c.93, ss48; MGL c. 140D, ss 10 or
MGL c. 255D ss14, as may be applicable.
4. Client is entitled to owner's rights and warranties under the provisions of 780 CMR R6 and MGL c.
142A.
5. Unless otherwise specified or notified, there is no lien or security interest given on the residence as a
consequence of this contract.
6. Any and all necessary construction -related permits are necessary for work to commence.
7. It is the obligation of the contractor to obtain such permits as the owner's agent.
8. Any owners who secure their own construction -related permits or deal with unregistered contractors
shall be excluded from access to the Guaranty Fund.
9.The contractor and homeowner hereby mutually agree in advance that in the event the contractor has a
dispute concerning this contract, the contractor may submit such dispute to a private arbitration service
which has been approved by the Office of Consumer Affairs and Business Regulations and the consumer
shall be required to submit to such arbitration as provided in MGL. c. 142A.
Owner
Contractor
This Agreement is available to contract only at the time of presentation.
Agreed this day of October , 2001, by:
Client Contractor
4
f4AScheck COMPLIANCE REPORT
Massachusetts Energy Code
MAScheck Software Version 2.0
CITY: Lawrence
STATE: Massachusetts
HDD: 6235
CONSTRUCTION TYPE: 1 or 2 family, detached
HEATING SYSTEM TYPE: Other (Non -Electric Resistance)
DATE: 10-24-2001
DATE OF PLANS: 10/20/01
TITLE: Chaff Addition
PROJECT INFORMATION:
240 Hickory Hill Road
North Andover, MA 01845
COMPANY INFORMATION:
Tara Leigh Development LLC
185 Hickory Hill Road
North Andover, MA 01845
COMPLIANCE: PASSES
Required UA = 187
Your Home = 140
Permit #
Checked by/Date
Area or Insul Sheath Glazing/Door
Perimeter R -Value R -Value U -Value UA
CEILINGS 692 30.0 0.0 24
WALLS: Wood Frame, 16" O.C. 994 19.0 3.0 54
GLAZING: Windows or Doors 91 0.350 32
DOORS 21 0.350 7
FLOORS: Over Unconditioned Space 692 30.0 23
COMPLIANCE STATEMENT: The proposed building design represented in these
documents is consistent with the building plans, specifications, and other
calculations submitted with the permit application. The proposed building
has been designed to meet the requirements of the Massachusetts Energy Code.
The heating load for this building, and the cooling load if appropriate
has been determined using the applicable Standard Design Conditions found
in the Code. The HVAC equipment selected to heat or cool the building
shall be no greater than 125% of the des' n load as specified in
sections 780CMR 1310 and J4.4
U� d
Builder/Designer Date—
a
MAScheck INSPECTION CHECKLIST
Massachusetts Energy Code
MAScheck Software Version 2.0
Chaff Addition
DATE: 10-24-2001
Bldg.
Dept.
Use
CEILINGS:
1. R-30
Comments/Locati
WALLS:
1. Wood Frame, 16" O.C., R-19 + R-3
Comments/Location
WINDOWS AND GLASS DOORS:
1. U -value: 0.35
For windows without labeled U -values, describe features:
# Panes Frame Type Thermal Break? [ ] Yes [ ] No
Comments/Location
DOORS:
1. U -value: 0.35
Comments/Locati
FLOORS:
1. Over Unconditioned Space, R-30
Comments/Location
AIR LEAKAGE:
Joints, penetrations, and all other such openings in the building
envelope that are sources of air leakage must be sealed. Recessed
lights must be type IC rated and installed with no penetrations
or installed inside an appropriate air -tight assembly with a 0.5"
clearance from combustible materials and 3" clearance from insulation.
VAPOR RETARDER:
Required on the warm -in -winter side of all non -vented framed
ceilings, walls, and floors.
MATERIALS IDENTIFICATION:
Materials and equipment must be identified so that compliance can
be determined. Manufacturer manuals for all installed heating
and cooling equipment and service water heating equipment must be
provided. Insulation R -values and glazing U -values must be clearly
marked on the building plans or specifications.
DUCT INSULATION:
Ducts in unconditioned spaces must be insulated to R-5.
Ducts outside the building must be insulated to R-8.0.
DUCT CONSTRUCTION:
All ducts must be sealed with mastic and fibrous backing tape.
Pressure -sensitive tape may be used for fibrous ducts. The HVAC
system must provide a means for balancing air and water systems.
TEMPERATURE CONTROLS:
[ ] Thermostats are required for each separate HVAC system. A manual
or automatic means to partially restrict or shut off the heating
and/or cooling input to each zone or floor shall be provided.
HVAC EQUIPMENT SIZING:
[ ] Rated output capacity of the heating/cooling system is
not greater than 1250 of the design load as specified
in sections 780CMR 1310 and J4.4.
MISC REQUIREMENTS:
[ ] Refer to 780 CMR, Appendix J for requirements relating to swimming
pools, HVAC piping conveying fluids above 120 F or chilled fluids
below 55 F, and circulating hot water systems.
----NOTES TO FIELD (Building Department Use Only)-------------------------
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TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $�•
Foundation Permit Fee $
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Sewer Connection Fee $
Water Connection Fee $
TOTAL $ 130
Building Inspector
Div. Public Works
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7:
KEEN CONSTRUCTION CO.
A_- 21 HEWITT AVENUE
NORTH ANDOVER. MA 01845
Tel: (978) 691-5201
Fax: (978) 682-3231
Submitted i
U C J
To: l Q .....t.�_r i ...�/ i7
1461
PROPOSAL
All home improvement contractors and subcontractors
engaged in home improvement contracting, unless
.specifically exempt from registration by Provisions of
Chapter 142A of the general laws, must be registered with
the Commonwealth of Massachusetts. Inquiries about
--- - registration and status should be made to the Director,
Home Improvement Contract Registration, One Ashburton
Place, Room 1301, Boston, MA 02108 (617) 727-8598.
Owners who secure their own construction related
permits or deal with unregistered contractors will
be excluded from the Guaranty Fund Provision of
MGL c. 142A.
PHONE ].DATE REGISTRATION NO. F.I.D. N0.
MA. H.I.C. 108383 04-325-8052
i�
C/S = Customer Supplied S + I = Supply + Install _ �y
We hereby submit
•fir: j: ii/c
and estimates for work to be performed and materials to be used:
r
( I
._..i.. _r..' l /! :i l l_I..!_l.r;.._.!f_.._cL.t_.i.A. l L.'"..:_ !_...i . _.
Construction related permits:
......-................................................................................................................................ _......... .. ... .........,
WORK SCHEDULE
Contractor will not begin_ the work or order the materials before the third day following the signing of this Agreement, unless specified here in writing. Contractor will begin the work on or
about J ' - (date). Barring delay caused by circumstances beyond Contractor's control, the work will be completed by / - / E (date). The Owner hereby
acknow edges and agrees that the scheduling dates are approximate and that such delays that are not avoidable by the Contractor shall not be considered as violations of this Agreement.
WARRANTY
The Contractor warrants that the work furnished hereunder shall be free from defects in materials and workmanship for a period of ! t l r L following completion and shall
comply with the requirements of this Agreement. In the event any defect in workmanship or materials, or damage caused by the Contractor, his subcontractors, employees or agents, is
discovered within one year after completion of any job, including cleanup, the Contractor shall, at his own expense, forthwith remedy, repair, correct, replace, or cause to be remedied,
repaired. or replaced, such damage or such defect in materials or workmanship.The foregoing warranties shall survive any inspection performed in connection with the agreed-upon work.
We Propose hereby to furnish material and labor - complete in accordance with above specifications, for the sum of :
- / �- , , / �✓ / %1C , " !int e -- -- —
Payment to bemade s follows
�C�
($ •` +"- �' ) upon signing Contract; C/C -t / l .l
($ /.,/upon completion of a .j/J1•
% ($ �t^T` �) upon completion of
of shall be made forthwith upon,",' it fit' 't {,
($
completion of •wock,urlderitxl�.cenicact- ,� I , ��- T'
Notice: No ag`ree�ent for hb42' ir)tprdve'mi6nt- �Acting work shall require a
> down payment (advance deposit) of more than one-third of the total contract price
or the total amount of all deposits or payments which the contractor must make, in
advance, to order and/or otherwise obtain delivery of special order materials and
equipment, whichever amount is greater.
dollars ($ Z � e-, C, C, _)
KENNETH B. KEEN
Name of Contractor / Designated Registrant
21 HEWITT AVE.
Street Address
N. ANDOVER, MA 01845
City / State
(978) 691-5201 (978) 682-3231
Phone Fax .
Name of Salesman
Author-zed5ignature'
Note: This proposal may be withdrawn by us it not accepted within days.
Acceptance Of Proposal - I have read both sides of this document and all attached documents and accept the prices, specifications and conditions stated.
I understand that upon signing, this proposal becomes a binding contract. You are authorized to do the work as specified. Payment will be made as outlined above.
You, the Buyer, may cancel this transaction at any time prior to midnight of the third business day after the date of
this transaction. Cancellation must be done in writing.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
Signature
Date J
Date
IMPORTANT INFORMATION ON BACK ►
f
._J__../.J
j
.... ..... ...../...i
1.
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_._ t_
r
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._..i.. _r..' l /! :i l l_I..!_l.r;.._.!f_.._cL.t_.i.A. l L.'"..:_ !_...i . _.
Construction related permits:
......-................................................................................................................................ _......... .. ... .........,
WORK SCHEDULE
Contractor will not begin_ the work or order the materials before the third day following the signing of this Agreement, unless specified here in writing. Contractor will begin the work on or
about J ' - (date). Barring delay caused by circumstances beyond Contractor's control, the work will be completed by / - / E (date). The Owner hereby
acknow edges and agrees that the scheduling dates are approximate and that such delays that are not avoidable by the Contractor shall not be considered as violations of this Agreement.
WARRANTY
The Contractor warrants that the work furnished hereunder shall be free from defects in materials and workmanship for a period of ! t l r L following completion and shall
comply with the requirements of this Agreement. In the event any defect in workmanship or materials, or damage caused by the Contractor, his subcontractors, employees or agents, is
discovered within one year after completion of any job, including cleanup, the Contractor shall, at his own expense, forthwith remedy, repair, correct, replace, or cause to be remedied,
repaired. or replaced, such damage or such defect in materials or workmanship.The foregoing warranties shall survive any inspection performed in connection with the agreed-upon work.
We Propose hereby to furnish material and labor - complete in accordance with above specifications, for the sum of :
- / �- , , / �✓ / %1C , " !int e -- -- —
Payment to bemade s follows
�C�
($ •` +"- �' ) upon signing Contract; C/C -t / l .l
($ /.,/upon completion of a .j/J1•
% ($ �t^T` �) upon completion of
of shall be made forthwith upon,",' it fit' 't {,
($
completion of •wock,urlderitxl�.cenicact- ,� I , ��- T'
Notice: No ag`ree�ent for hb42' ir)tprdve'mi6nt- �Acting work shall require a
> down payment (advance deposit) of more than one-third of the total contract price
or the total amount of all deposits or payments which the contractor must make, in
advance, to order and/or otherwise obtain delivery of special order materials and
equipment, whichever amount is greater.
dollars ($ Z � e-, C, C, _)
KENNETH B. KEEN
Name of Contractor / Designated Registrant
21 HEWITT AVE.
Street Address
N. ANDOVER, MA 01845
City / State
(978) 691-5201 (978) 682-3231
Phone Fax .
Name of Salesman
Author-zed5ignature'
Note: This proposal may be withdrawn by us it not accepted within days.
Acceptance Of Proposal - I have read both sides of this document and all attached documents and accept the prices, specifications and conditions stated.
I understand that upon signing, this proposal becomes a binding contract. You are authorized to do the work as specified. Payment will be made as outlined above.
You, the Buyer, may cancel this transaction at any time prior to midnight of the third business day after the date of
this transaction. Cancellation must be done in writing.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
Signature
Date J
Date
IMPORTANT INFORMATION ON BACK ►
ooejs /,z,, -f '. -j
cim
insurance en_
Failure to secure coverage as required under Section 25A of MGL 152 ern lead to the imposition of criminal penalties of a fine 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 of5100.00 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.
1 do hereby certify under the
of perjury that the information provided above is true and correct.
Signature_(QiL/,e / Date /O ` 7 :21
Print name I�ENAJ E th • JetEE ...�.. .. ....... _.._ . _.._. _..Phone #"S71O
official use only do not write in this area to be completed by city or town official ,:.:.....- ..:_.. -
city or town:
❑ check if immediate response is required
contact person:
(revised 3/95 PIA)
permit/license # -Building Department
❑Liceiisingloard
❑Selectmen's Office
❑Health Department
phone #; -Other
r__-
'The Commonwealth of Massachusetts
If
,_.
Department of Industrial Accidents `
0/iieeelloyestigatiens
--�.
600 Washingt
a on Street
a -c+
~—,
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
ooejs /,z,, -f '. -j
cim
insurance en_
Failure to secure coverage as required under Section 25A of MGL 152 ern lead to the imposition of criminal penalties of a fine 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 of5100.00 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.
1 do hereby certify under the
of perjury that the information provided above is true and correct.
Signature_(QiL/,e / Date /O ` 7 :21
Print name I�ENAJ E th • JetEE ...�.. .. ....... _.._ . _.._. _..Phone #"S71O
official use only do not write in this area to be completed by city or town official ,:.:.....- ..:_.. -
city or town:
❑ check if immediate response is required
contact person:
(revised 3/95 PIA)
permit/license # -Building Department
❑Liceiisingloard
❑Selectmen's Office
❑Health Department
phone #; -Other
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s. T Office Use Only (�
;� MAR 2. 1 1996 Permit No. 7 3 '
lryP �IIYITIriIIItiUPj�(1IB1`#B . _ .. Occupancy�blank)
(leIge"rtmettt of Public *afttp
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Ward -
Area
-. .
APPLICATION FOR PERMIT TO, PERFORM ` ELECTRICAL •WORK
All work to be performed in accordance with the Massachusetts Electrical- Code. 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INF rooveag
ATIQN) Date 3City or Town of %v1) Rn4 To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work de]s
Location (Street & Number) /• / D #-1 Gp/
1�l
Owner or Tenant
Owner's Address
!s this permit in conjunction with a building permit:
Purpose of Building
Existing Service Amps _J Volts
New Service Amps J Volts
Yes ❑ No ❑ (Check Appropriate Box)
Utility Authorization No.
Overhead ❑ . Undgmd ❑
Overhead ❑ Undgrnd ❑
No. of Meters
No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work -Install a t i on of alarm system
No. of Lighting Outlets
No. of Hot Tubs
No. of Transformers Total
kVA
No. of Lighting Fixtures
Above In -
Swimming Pool
. gmd. ❑ gmd. ❑
Generators - rIWA
No. of Receptacle Outlets
No. of Oil Bumers
No. of Emergency Lighting
Battery Units
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS No. of Zones
No. of Detection and
Initiating Devices
No. of Sounding Devices
No. of Self Contained
Detection/Sounding Devices
Local Municipal ❑Other
❑ Connection
No. of Ranges
No. of Air Cond. Total
tons
No. of Disposals
No. of Heat Total Total
Pumps Tons KW
No. of Dishwashers
Space/Area Heating KW
No. of Dryers
Heating Devices KW
No. of .Vater Heaters KMJ
No. of No. of
Signs Ballasts
oltage
—Wiring
No. Hydro Massage Tubs
No. of Motors Total HP
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General laws 1 have a current Liability Insurance Policy includ-
ing Completed Operations Coverage or its substantial equivalent. YES O NO O 1 have submitted valid proof of same to the Office.
YES O NO O If you have checked YES. please indicate the type of coverage by checking the appropriate box.
INSURANCE X% BOND O OTHER O (Please Specify)
OD (Expiration Date)
Estimated Value of Electrics Work S r' J r
Work to Start 3 Inspection Date Requested: Rough Final
Signed under the Penalties of Perjury:
FIRM NAME LIC. NO. 1 2 1
r
Licensee Signature LIC. NO.
Bus. Tet. No. 617-431-5800
Address 60 William 8t./Wellesley, MA 02181 Alt. Tel. No.6I'T-d' — �7
OWNERVS INSURANCE WAIVER: 1 am aware that the Licensee does riot have the insurance coverage or its substantial equivalent as re-
quired by Massachusetts General laws. and that my signature on this permit application waives this requirement Owner ... Agent
(Please check one)
Telephone No. PERMrr FEES
i . i�:' i' ..: iui�t=+:..: H:•mi7 (atOnatrrre of Owner or ADerrt) ...: c .. .
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Date ..
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b d NORTH. _
^•'14,a TOWN OF NORTH ANDOVER
3r ;end d°- OL
° PERMIT FOR WIRING
il 1 9
,SSACHU -
} This certifies that ... �... l .. ...............:...........
has-permission to perform ........ H.Q.R.w.........� S ...S n
......................................
wiring in the building of ....., .&
at :.... �f r C �r t ................................. /!.... , North Andover, Mass.
..... .
Fee :..............
✓ �.... Lic. No./.. .?1.. .............................................................
r ELECTRICAL INSPECTOR .
cn-
0A/ 6% 14:37 35.40 PAID
r
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File
- - ti
V
Location f1^
No. Date
1,
a
*Oft,o TOWN OF NORTH ANDOVERe
o:cam=...,•tic �
p Certificate of Occupancy $
ti
Building/Frame Permit Fee $
ld tion Permit Fee $ _
" ermit Fee $� --�
Sewer Connection Fee $
oti
Water Connection Fee $
TOTAL $
S�F
Building Inspector
gq p �.r� Div. Public Works
N2 O 4
TOWN OF NORTH ANDOVER
Certificate of Occupancy
$
Building/Frame Permit Fee
$
Foundation Permit Fee
$
00
Other Permit Fee
$
Sewer Connection Fee
$
-8-
Water Connection Fee
$
TOTAL
12
SO 718 Div. Public Works
..v,.,i,,...F: �,;qa.. r.,�,•-`*w'rvr:�,rk�:�-+..+ri,,.:r�5+`,1t"�'j5�-s'y,.^—�"=-:.
Location�or
No. Date
f
TOWN OF NORTH ANDOVER
Certificate of Occupancy
$
Building/Frame Permit Fee
$
Foundation Permit Fee
$
w cv
Other Permit Fee .
$
Sewer Connection Fee
$
Water Connection Fee
$
TOTAL
$
�� o
1. l� 21% 9
8025
Lj
qV
Building Inspector
150.00 PAID
Div. Public Works
A 7-
Z4eLS
440
Location
No. 3
' Date 3'2-9¢
TOWN. OF NORTH ANDOVER
�O
a�a° r••
.. p
.t r ` 4
Certificatesof Occupancy $
.
x
Building/Frame Permit Fee $
�'+s "'°'•�� _
SACH
Foundation Permit Fee $
Other Permit Fee $.
AC 637
Sewer Connection Fee a $
�a 33,E
water Connection Fee $ /4-co
TOTAL $�
,(�"'
'w 08/194 09:54
,.�, ildi g Inspector
�f►p�j,; - AA. �/_,,�
6935
Div 1:5 1fc works
PER.Ifr!T'NO.� 34+7 APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS.
V PAGE 1
MAP K-40. E
LOT NO.
2 RECORD OF OWNERSHIP IDATE
BOOK
:PAGE
ZONE R�
SUB DIV. LOT NO.
v
a A �i> J (�
t}lO (
LOCATION �ai
PURPOSE O UIiL"DIING ftp
&
OWNER'S NAME ��/VipY7 7� 1
NO. OF STORIES SIZE fa lz
�J
C �7 �
a
OWNER'S ADDRESS G 11
BASEMENT OR SLAB �•.,
ARCHITECT'S NAME�.
Tk'7J
SIZE OF FLOOR TIMBERS IST �2ND'i•�/
l //
3RD
BUILDER'S NAME
SPAN
DISTANCE TO NEAREST BUILDING
DIMENSIONS OF SILLS�7�i'T
DISTANCE FROM STREET
--
POSTS
DISTANCE FROM LOT LINES — SIDES ,. REAR 7 C l�
`3)
GIRDERS�j 17 I� IiC
% /F
AREA OF LOT : FRONTAGE
/
//V THICKNESS
HEIGHT OF FOUNDATION
/
IS BUILDING NEW ` -
SIZE OF FOOTING X /z)
Cd
IS BUILDING ADDITION p
MATERIAL OF CHIMNEY �C�7
IS BUILDING ALTERATION
IS BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE pp
Y
IS BUILDING CONNECTED TO TOWN WATER
BOARD OF APPEALS ACTION. IF ANYif
�'Ci
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
nt�I2C z 2.5 3 47
PERMIT FOR FOUNDATION ONLY
REGULATED BY PARA. 114.8,5. B.C.
,5LECTRIC ME, EPS MUST BE ON OUTSIDE OF BUILDING
i ATTACHED GARAGES MUST CONFORM TO STATE FIRE (R��EA�GTTULA
P(,ANS MUST BE FILED AND APPROVED BY BUILDING ItlWBP
DATE FILED ' � 1 7 11
FEE PAID
SIGPQtTGRE OF OWNER O ORIZED AGENT PERMIT FOR FRAME/BUILDING
FEE " 7/40 DATE. 8 0 4
FEE PAID.
PERMIT GRANTED
O 19 T/f
OWNER TEL.
CONTR. TEL. 3t
lm FDA ffl ! o� � CONTR. LIC. #�/ j
yDUE FRAME PERMIT $ 9110�--
-� sncMo
'�IS AUG i 01994
3 PROPERTY INFORMATION
LAND COST O ipv ev
EST. BLDGi
EST. BLDG. COST ! �` ^7
8
o - OD
EST. BLDG. COST PER FT.R SQ. BEST. BLDG. COST PER SQ.
EST. BLDG. COST PER ROOM J�
SEPTIC PERMIT NO. 'k1 V
4 APPROVED BY
BOARD OF HEALTH
PLANNING BOARD
BOARD OF SELECTMEN
4 Iew, I�oo BUILDING INSPECTOR
B078 --
J
i
BUILDING RECORD
1 OCCUPANCY 12
SINGLE FAMILY s�oRIEs
LY OTHIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT: AND DISTANCE FROM
MULTI. FAMIFFICES - _- LOT LINES AND EXACT DIMENSIONS, OF BUILDINGS. %•WITM `PORC•HES. GA -
APARTMENTS -,.-.RAGES. ETC. SUPERIMPOSED. THIS R.EPLACES.PLOT PLAN.
CONSTRUCTION --
2 ' FOUNDATION I 8 INTERIOR FINISH -
CONCRETE t✓'�I d 2 _13 "
CONCRETE BL K. PINE
BRICK OR STONE HARDW D —
PIERS PLASTER
DRY VJAII � -
UNFIN. --
3 BASEMENT I "
AREA FULL FIN:.. BMT AREA
'L FIN.- ATTIC AREA -
NO BMT FIRE PLACES
HEAD ROOM MODERN KITCHEN
4 WALLS 9; FLOORS
CLAPBOARDS B 1 2 3
DROP SIDING CONCRETE �_ --
WOOD SHINGLES -EARTH
ASPHALT SIDING HARDW D —
ASBESTOS SIDING COMLACN _
VERT. SIDING ASPH. TILE •1` .-- .��
STUCCO ON MASONRY'
STUCCO ON FRAME -"•� ^ ti {
BRICK ON,MASONRY :�ApTIC STIRS . 8 FLOOR
BRICK ON. FRAME-. I �,.a ' 1•
CONC. OR 61 DER-BCK.
STONE,ON MASONRY WIRING ] & ,;{'I T ((S,i; j�j.= �jo-4
STONE ON FRAME .l v t �.a�'Iv�e (yv
SUPERIOR I� POOR RAf;i i,f;a 0: S IA..iI'�l ,
ADEQUATE I NONE }
5 ROOF 10 PLUMBING _
GABLE 1,y I HIP BATH (3 FIX.) 7
I
GAMBREL MANSARD TOILET RM. 12 FIX.) cirri 3n.�,.�..._.�,..._.,...,..r_.._ lT
FLAT SHED WATER CLOSET _
ASPHALT SHINGLES LAVATORY
WOOD $HINGES KITCHEN SINK J
SLATE NO PLUMBING _ --
TAR & GRAVEL STALL SHOWER - - -
ROLL ROOFING MODERN FIXTURES �- I• j` q,�j 9 �
TILE FLOOR '���}`�•.��''$:--J1�'i I`'St[�t �^'�.F� �Si f/;,F �t
TILE DADO '''j \• `
6 FRAMING I 11HEATING _ _'.>o.•aait i - ' •t
WOOD JOIST PIPELESS FURNACE '
FORCED HOT AIR FURN.
TIMBEk BM COLS. J STEAM
STEEL BMS. HOT W'T'R OR VAPOR
WOOD RAFTER _ AIR CONDITIONING .
RADIANT H'T'G
UNIT HEATERS
7 NO. OF ROOMS GAS �}�
OIL 331 AV 27,11¢
B'M'T 2ndELECTRIC q� +y£ {^g
1s 1 3rd NO HEATING _ ., t ,�. _ - t TIM3rd IMAIP ,0
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pRolpoSEb ';ITE PLAID
L07 yo -t tcKozy HIL -t- KOAD
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110 " p
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*-rE
FORM U - LOT RELEASE 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.
****************A/pplican/t� fills out this section*****************
APPLICANT: Zl 140-S L/, AQ yaL 0 Phone _�F i `
LOCATION: Assessor's Map IN/umber- Parcel
Subdivision ( , clke4vJ 1
I, Lot(s)
Street ! Cd / 1 / QT St. Number 2�
*******
*****************Official Use Only************************
RECO DATIORS OF TOWN AGENTS:
Date Approved
Conservation Administrator Date Rejected
Comments
1,4 C 0
Town Planner
Comments
Health Agent
Comments
Public Works - sewer/water connections ,
- driveway permit
Date Approved
Date Rejected
Date Approved
Date Rejected
:31-z- Fl:�e
Fire Department
/06r
Received by Building Inspector
t Date
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CERTIFIED FOUNDA TION PLAN
LOCATED /N N O_ ANDO VER, MA,
SCALE: /". 40' DATE: Al 9194
Scott L. Gi/es R. L. S.
50 Deer Meadow Road
North Andover, Mass.
5ga4.
O L=//2.36'
HICKORY HILL ROAD
/ CERT/FY THAT OFFSETS SHOWN ARE FOR THE USE
THE OFFSETS OF THE SU/L DING /NSPEC TOR ONLY �o�v►Ep�1H
SHOWN COMPLY AND SUCH USE /S FOR THE s rr
WITH THE ZONING DETERMINATION OFZONING FS
BY LAWS OF CONFORM/ T Y OR NON- CONFORM/T Y , ��; '39�a Q
NO, ANDOVERII�a WHEN CONSTRUCTED.qT rR cOP`�JG
WHEN BU/L T.
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KAREN H.P. NELSON
Director
BUILDING
CONSERVATION
HEALTH
PLANNING
NORTq
7
r,..., Town of
D
NORTH ANDOVER
hie ��e 49 , 1
s^OM 5� DIVISION OF
PLANNING & COMMUNITY DEVELOPMENT
CHIMNEY APPLICATION AND PERMIT
DATE J - q 1-1 _
LOCATION J"o 9 -0 /tom li �n L •'/ r
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OWNER'S NAME -
BUILDER'S NAME f aT 14-0.
MASON'S NAME- cA T'L I� C� 1�
MASON'S ADDRESSrc i\, v , I � / n,
120 Maizi Street, 01845
(508)682-6483
PERMIT #
MASON'S TELEPHONE �� `,�� "� L
MATERIAL OF CHIMNEY
INTERIOR CHIMNEY Cl EXTERIOR CHIMNEY Ar) l�I4
NUMBER AND SIZE OF FLUES
THICKNESS OF HEARTH /C3
Will chimney or fireplace conform to requirements of the code and
have rules and regulations been received:
DATE o z, 4G/
i
SIGNATURE OF MASON fCPNTR. LIC. #
EST. CONSTRUCTION COST/CONTRACT PRICE d�
PERMIT GRANTED q / A — 9 t/ FEE uv
ROBERT NICETTA, BUILDING INSPECTOR
INSPECTED
REMARKS
SOLID BRICK REQUIRED
THIS PERMIT MUST BE DISPLAYED ON THE PREMISES
CERTIFICATE OF USE & OCCUPANCY
Building Permit Number 344
�. 01-11 SEMEM..
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 240 HICKORY HILL ROAD - Lot #40
MAY BE OCCUPIED AS SINGLE FAMILY DWELLING W/2 CAR IN ACCORDANCE
GARAGE
WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND
SUCH OTHER REGULATIONS AS MAY APPLY.
CERTIFICATE ISSUED TO Tara Leigh Dev. Corp.
LE -5 Hickory Hill Rd.
ADDRF5,q�Nor2Lh Andover
Bui! i g inspecto
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