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Location
N o.. Date
01 j0RT#j TOWN OF NORTH ANDOVER
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Certificate of Occupancy $
Building/Frame Permit Fee $
CHU
Foundation Permit Fee $
Other Permit Fee $ C7
TOTAL $
Check #
121
--.Building Ins e5r",,—
PC
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Ox.,.. '.7py.,
BUILDING PERMIT NUMBER: DATE ISSUED:
SIGNATURE: �-----
Buil —Commissiondaps
kEtor of Buildings Da �? ?e
SECTION 1- SITE INFORMATION t
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
Map Number Parcel Number
1.3 Zoning Information:
1.4 Property Dimensions:
Zonis District Proposed Use
Lot Areas Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Required Provide Required Provided
Required Provided
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information:
Zone Outside Flood Zone 0
1.8 Sewerage Disposal System:
Municipal ❑ On Site Disposal System 0
Public ❑ Private ❑
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1//Owner of Record
Mame (Print) Address for Service
/ Q /
,signature Telephone
2.2 Owner of Record:
Name Print Address for Service: y
Si na a Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable ❑
41�/$/ 6315p�—
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7,7
Licensed Construction Supervisor:
l/
License Number
�� �� ���
��,/� J~
Address
�� 03
- �p��
Expiration Date
<
Signa re Lelephone�
3.2 Registered Home Improvement Contractor
Not Applicable ❑
Company Name
Registration Number
X7/cy"p—
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7� � �T �✓
Address
Expiration Date
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Si natu v---- Telephone
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SECTION 4 - WORKERS COMPENSATION (NLG.L C 152 6 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 ❑
Existing Building ❑ Repair(s) ❑
Alterations(s) . -
Addition ❑
,tlter 11 pec
Accessory Bldg. ❑ Demolition❑vA
00"
Brief Description of Proposed Work:
---
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed b permit applicant
CiFFIGIAL,USE
�N
ONLY
�
1. Building
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) x (b)
CT,
4 Mechanical HVAC
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
1, as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf, in all matte srelative to work authorizJd by this building permit application.
Signature of Owner Date
SECTION 7b WNER/AUT IZED AGENT DECLARATION
1, as Owner/Authorized Agent of subject
property _ , r
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
Print Name
Signature of Owner/A ent Date
sus
._.., ..i i W R.,� SIZE ,.,..-.,... .. w,
NO. OF STORIES
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 1 2 3
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
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13OARD.0F BUILDING REGULATIONS
is License• CONSTRUCTION SUPERVISOR
l Nurnber~'CS 034200
Tr. no: 4398
Restricted 00; , '_
NORMAN; GAY
70' JEFFERSON, ST' G `+
N ANDOVER, MA 01"845 Administrator
Chimneys
Siding
Mass Toll_Free
1 -800 -WAIT -4 -US
(924-8487)
®NE R04O F
Residential & Commercial Roofing All Types Of
CHIMNEYS POINTED -REBUILT -CAPPED Expert Masonry Work
* Roof Leaks Experts * Licensed & Insured
Locally Owned & Operated Since 1976 em " : License #034200
s
IKO® Czee Woem or Sohn i� We Work Year Round
Proposal Submitted To
Phone
Date
Street
Job Name / •/
City, State & Zip Code
Job Location
Job Phone
We Propose hereby to furnish and labor in accordance specifications below, for the sum of-
/with
lac'! 7/ 4
d4i Dollars
All material is guaranteed to be as specified. All work to be completed in a workmanlike Authorized
manner according to standard practices. Any alteration or deviation from specifications be- Signature:
low involving extra costs will be executed only upon written orders, and will become an -
extra charge over and above the estimate. All agreements contingent upon strikes, accidents NOTE: This proposal . ay be
or delays beyond our control, Owner to carry fire, tornado and other necessary insurance. �.
Our workers are fully covered by Workmen's Compensation Insurance. withdrawn by us if not acc pied within days,
We hereby submit specifications and estimates for:
Znstall 3 feet "Eave Seal"
of special ice and water barrier protection along all bottom edges of roof
and top to bottom in each valley. Lf xcaof_is_stlap{�ed, we will apply conventional ice and water shield
- - ---
( ) ft. high in the same locations previously described and tar will cover the
,_paper �- will
,.Gemain,iaag.bare-&cood. Any rotted or damaged boards will be replaced at
or (`�) per sheet of plywood.
Install heavy gauge aluminum drip edges along every edge surface of each roofline.
!
� Cover IKO 25
entire roof (s) with year all asphalt, non -fiberglass, premium grade shingles
(Color of choice).
] Replace boots
all pipe where possible.
U Seal flashings Geo
all with clear -Cel sealant. No black tar unless r
g ss p evlously applied.
Remove all work-related debris.
dcontractor warrants roof against all leaks due to defects in
g his workmanship for 12 years under
normal circumstances.
Local
b/
current references and proof of workman's compensation insurance gladlygiven. y
❑ Remarks: ��✓%`d 'l G�l, � r Gir�✓c�cr� l lay,1,101
,.�1,d �i�^,�r'' .�ci�L � ,�-�'�" t.� Q.C.= r Q .,��"'✓ 1 r.�,�r� .�'G�.�' �.�c,�''
Acceptance of Proposal - The above priced, specifications
and conditions are satisfactory and are hereby accepted.
You are authorized to do the work as specified. Payment Signature:
will be made as outlined above.
Date of Acceptance: Signature:
ADate . ............................
&ORT"
TOWN OF NORTH ANDOVER
_6 0
0
PERMIT FOR WIRING
IL
Ss
CHU
This certifies that ... ...... j ... 2 .... ........ ...... ... A77n ...............
has permission to form . .......................
67
wiringinthebuil ingo��,., .....................................................
North Andover, Mass.
............................... .. . ... .. ......... .. .....
Fee..,0.1 ....... Lic. N . ...... .. .... - .. ........... . ....... .........................
ELECTRICAL INSPECTOR
Check #
5199
TRE COMNIOAMEALTHOFMASSACHUS'ETTS Office Use only
�1
DEPARTNIFVTOFPUBLICSAFETY / Permit No. �Wi
BOARDOFFIREPREVEMONREGUTA770NS527CAIIZI2.-OO ^0-1.
APPLICATIONFOR PERMIT TO
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE?
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION)
Town of North Andover
Occupancy & Fees Checked .�
PERFORMELECTRICAL WORK
IASSACHUSSTS ELECTRICAL CODE, 527 CMR 12: 00
To the Inspector of iW1res:
The undersigned applies for a permit to perform the electrical work described'below. %
Location (Street & Number) � q— W � ve- pe C L."
112,1
Owner or Tenant
f et/
Owner's Address
Is this permit in conjunction with a building permit: Yes M No (Check Appropriate Box)
Purpose of Building
Existing Service _
New Service 1
Number of Feeders and Ampacit;
Utility Authorization No. 0.
Underground M No. of Meters
Underground r--1 No. of Meters
Location and Nature of Proposed Electrical Work
No. of Lighting Outlets
No. of Hot Tubs
No. of Transformers
Total
KVA
No. of Lighting Fixtures
Swimming Pool
Above
Below
Generators
KVA
round
ground
No. of Receptacle Outlets
No. of Oil Burners
No. of Emergency Lighting Battery Units
No. of Switch Outlets
No. of Gas Burners
'of Ranges
No. of Air Cond.
Total
FIRE ALARMS
No. of Zones ��
Tons
/ No cf Disposals
No. of Heat
Total
Total
No. of Detection and
Pumps
Tons
KW
Initiating Devices
���
No. of Dishwashers
Space Area Heating
KW
Ng. of Sounding Devices
No of•Self Contained
���
De'tection/Sounding Devices
No. of Dryers
Heating Devices
KW
Loca'I Municipal
71
Otte
Connections
No. of Water Heaters KW
No. of
No. of
Signs
Bailasis
No. d-Iydro Massage Tubs
No. of Motors
Total HP
)THFR
stnanceCovaageL Ptua=tothe iegimwrr is of Nb%ac nxZ Gerirallaws
iaveaamutiLiabflitylnstuancePbhcyinchxbngComp]fire Covaageoritsmbsl m a aWwalat YES NO
tawsubrivedvalidploofefsametothe0ffice. YES r7p IfyouhawdedodYES,pleaseuxkalethe typeofcoverage by
ecIg thebox 1.—J
ISURANCE BOND MHIFR (Please Specify)
Date
I ;v
ensee Signature
Eskrnle,d Vahie cfEkarical Wodc $
Rough Fugal
Lam=`% f C IicenseNo. d -. 5'
BusinessTallo.
dim. %� & - to k, 3 . 1-/ 1/t1 Alt Tet No.
di\ER'S INSURANCE WAIVER; I am aware that dr -License does nothave the in%iiance cow age orits substantial equivalent as m4med by Massachusetts General Laws
that my signatre on this penrit applicalion waives this Rgnrelnent
ease check one) Owner ® Agent
Telephone No. PERMIT FEE $
Signature ot Uwner orgen
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation insurance Affidavit
Name Please Print
Name:
Location:
Cit ry Phone #
I am a homeowner performing all work myself.
I 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.
Company name:
Address
City: Phone #:
Insurance. Co. _ - Policv #
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.wellas_civil.penaltiesin.-theform ofa..STOP WORK_ORDER..and_a.fine.of_(.$1D0.00.)_aidayagainst..me. I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
i do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature
Print name Phone
Official use only do not write in this area to be completed by city or town official'
City or Town Permit/Licensing
O Building Dept
❑Check if immediate response is required Licensing Board
Selectman's Office
Contact person: Phone #. F, Health Department
Other