HomeMy WebLinkAboutMiscellaneous - 25 WINDSOR LANE 4/30/2018I
Location
v
No. Date
TOWN OF NORTH ANDOVER
f ? • • L9
' Certificate of Occupancy $
Building/Frame Permit Fee $
s�cMus
Foundation Permit Fee $
Check # /A&
18130
Other Permit Fee
TOTAL
1
�y
�'� Building Inspector
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.TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT WA
RENOVATEOA DEMOLISH AONS OR TWO FAMQ.Y DWEi.LIIQG
BUWING PERMIT NUMBER:
DATE ISSUED:
SIGNATURE:
Buil '
rofBuildings
SECTION I - SM INFORKMON
1.1 Propedy Ad4rem
a
%
1.2 Map and Puod Nnmbw..
z o0
Map Number Patod Numbr
.1.3 Zminghdbrmatim:
Zm iq DidrW Use
1.4 Rq mtyDmm*=
I Lot Ara F 8
1.6 BUILDING SETBACKS ft
Front Yard
Side Yard Rear Yard
ReVired Provide
ReVired Provided Provided
1.7 WSW sapplyKo"aa S4)
PA& 0 p*mc 0 zoo
13 PbodZoeeEdametioa 1.8 S--VDLpoWSs'Aeos
ouWbFbMZ so 0 mmio4il 0 Oasi -Diq"d Sy" m 0
SECTION 2 - PROPERTY OWNERSHIPIAUTHORIM AGENT
21 ;r e,
Name (Print)
(�rn CO-kra-c-�- :
_
Address for
I
Signature
Tdcoone
2.2 Owner of Reoord:
Name Print
Address for Service:
S' tura
Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 sod Construction Supervise
Licensed Construction Supervisor:
Addrm
Sigastum
Telephone
Not Applicable
LiceaseNumber
> Daft
3.2 Regijaad Homo Improvement Contractor
Not Ap%p]6u2b/le 0
puny Name
l 6-9
[ Y . r.
Rc&fttion W mbar
7,_ 13
`Fxp
Addrems
L.
mfm Date
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SECTION d - WORKERS COMPENSATION (KG.L C 152 S 25c(A
Workers Compensation Insurance affidavit mu completed and submitted widi this application. Failure to prmdde this affidavit will result
in the denial of the issuance *film it.
Signed affidavit Attached Yes ...... No...... A
SECTIONS ' ofProposed
Work ebbec afl
New Construction, 0
Existing Building 0 Repair(s)
rinions(s) Hoff 0
Accessory Bldg. 0
Demolition 0 Other
0 Specify
Brief Description ofOe7lPmposod Work
r r
lj-
1, —,l
!',e .
SECTION 6 - ESTIMATED CONSTRUCTION COSTS .
Item Estimated Cost (Dollar) to be
ORFS STs;D�4I.XfZ
CowleW by
1. Building
(a) Budding Permit Fee
Mul Tier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
I Building Permit fee (a) x (b)
4 Mechanical LKVAQ
S Fireprotection,
6 Total 1+2+3+4+5 `'
I Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
T.
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUHDING PERMIT
I,
as Owner/Authorized Agent of subject property
Hereby authorize
to act on r
My behalf, in all matters relative to work authorized by this building permit application.
Si lure of Owner
Date
SECTION 7b OWNERIAUTH0RIZED AGENT DECLARATION
1, Z,
,as (honer/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 bel• f
ffPrint
Nam
O
- I
Si atone of Owhter/ t
Date
0.OF STORIES
Sim
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS Or
2ND3
SPAN
DIIv1ENSIONS OF -SUM
DMNSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION
THICKNESS
SIZE OF FOOTING
X
MATERIAL OF CHIMNEY
1S BUILDING ON SOLD OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS. LINE
` The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Please Print
Name:
Location:
City Phone
Qam a homeowner performing all work myself.
F -1I am a sole proprietor and have no one working in any capacity
am an employer pr idinng� workers' compensation f/l my e�m'plloyees worrking on this job.
anv name- // i 64J �/N"'i x, \ » <—/
Address 1331 h E'o` n<:�S f
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 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.
I do herby certify undeptW ains and penalties of perjury Coat tpe information provided above is true and correct.
h
Print name 2_ clt4 IA % e S Phone #�
v l`
Official use only do not write in this area to be completed by city or town official' ❑ Building Dept j
❑Check if immediate response is required Building Dept p Licensing Board
p Selectman's Office
Contact person: Phone #: 0 Health Department
11 Other
FORM WORKMAN'S COMPENSATION
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Please Print
Name:
Location:
City Phone
F-1
am a homeowner performing all work myself.
01 am a sole proprietor and have no one working in any capacity
F-1 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 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.
I do herby certify under the pains and penalties of perjury that the infofmadon provided above is true and correct.
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OF THE TOTAL CONTRACT PRIOi; tp THE ACTUAL COST OF ANY NMVML DR e+'.x,.IImmw WNIOH HAS 70 KE MCIAL OMERED OAS CUST, h! MACE NJHICH f.r tp
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YOU MAY CANCS_ 749 AOA :MCNT IP IT HAS BEEN BIOtM I}Y A PARTY THERETO AT A !"LAOC OTHEM. THAN AN ADORM OF THE SELLER,
+VHIOH MAY BE MS MAIN Or, NE OR BRANCH THEREOF PNOVIOBD YOU NOTIFY THE SELLrR IN WRITING AT HIS MAIN OPTIOE CIR {i13ANI;) EY
ORpINAVY MAIL POSTED, BY I'FIEdRAM SENT OR W D UVt99Y. NOT LATER THAN M DNMMT OF 714E THM0 %1SiNEGS DAFT]IlOW*0 THE
TONING OF Ti!6 AORIMVEN
3Y !!"0MVG BELOW, YOU Al: TIOWLEDGF TWAT YOU OWN Tt♦; ABOVE FROPeRTY AND THAT YOV AGREE TO ALL OF TW. TL°RMS OF THIS
DO -TRACT. YOU ALSO AOKI, tM.EbOtt THAT YOU HAYS RFCEJVED A FULLY COMPfzTEO COPY Of TwS CONTRACT AND TWO COMPLVW
C00W OF THE NOTICE OF C PCELLATJC1N ANO TMAT YOU HAVE WIN ORALLY INFORIAR15 OF YOUR FIGHT 70 CAANCF,I„
00 NOT SM tM CONTRACT tF TWit ARE ANY BIANK BMOM
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NO ICE OF CANrIELLATION -(,> _ CATs (TWAY's)
'DU MAY CANCEL THIS TRAM ACTION,''WITHOUT ANY FENALTY OR O@UCATION, IMTMN THREE BUKtNEBS PAYS FROM THE ABOVE DATE.
P YOU CANCEL, ANY PROF RTY TRAOEO !N, ANY FAYMEMt'F IAAUE 9Y YOU UNDER TrG CONTRACT OR SALC, AND ANY Nc®OTIASLC
NSTRUMENT EY.ECUTED M YCU WILL ES RCTURNED WITWIN 10 "NESS DAYS COLLOLYING RECEIPT EY THE $ELLER GF YOUR
)A!NOELL ATR1N NOT", AND NY SECUN*C INTF_RESTAF911ING CUT OFTHr TgNNSACTION VA" PE CANCEMD.
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Y'.RITT6ll Td01'4^Fr
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ItO1Jl;ir'T OF:
bnTe (IttiN6. � 10 t'RL;pT •a et(c uoArA
1,15M 6Y CANCEL THIO ""I, IACTION.
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Board of Building Reg bla ions and. Staadards
One Ashburton Place - Room 130.1
Boston., Massachusetts U21.U�
Home Impro�°em�ent Contractor Registration
Replswtloni 104088
Type. Pdvate Corporation
Exatmtlon: 711312006
NEW ENGLAND SASH, INC
Kevin Wells .�
1331 Grafton Street
Worcester, MA 01604
Update Address and return card. Mark reason for Bhang
Address Renewal Employment Lost Card
)PS-CA1 0 SON, W04-0,1001218
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Board of Building Regulattens end Standards Licenae or registration valid for ludividul roe only:
HOME iMIPROVEMENTZONTRACTOR before the expiration date. tf"found return to:
R"MIANon. 104098 Board oflutiding Regulations and Standards
Expiration': '7113/2006 One Ashburton .Place Rin 1301
Type:Private Corporation
Boston, Ma.'02108
NEW ENGLAND $ASH lNC
Kevin Wells,
1331 Gratton Street-ye°-s...� ,•r,,.- /L�v",,/
Worcester, MAL Q1604 Admlaiatrator ��� Not valid 'witheat^#igtla[tirc ��
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N° 47:,7
Date.ex
TOWN OF NORTH ANDOVER
' PERMIT FOR PLUMBING
This certifies that ...f /t /.1 ! ifl � ...............
has permission to perform ... 4 /. 7 ........................
plumbing in the buildings of .. !.................. .
at.....? . �` !�. �.t. 1.`�.............. North Andover, Mass.
Fee... y..... Lic. No........` .. ..............................
PLUMBING INSPECTOR
Check #
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Print or Type) //
n ly/D ass. Date � Permit # /�?
Building Location c-% lA/ ��OF_ZZOJOwner's Name 6U4 1Oit'�
Type of Occupancy Residential
New ❑ Renovation ❑
Replacement N Plans Submitted: Yes ❑ No ❑
FIXTURES
Installing Company Name Heritage Htg. &Plg. CO. Inc. Check one: Certificate
Address 35 Pleasant Street [B Corporation 714
Stoneham, Ma 02180 [] Partnership
Business Telephone 781 — 4 3 8 — 7 7 7 6_ (1 Firm/Co. _
Name of Licensed Plumber Gordon Switzer
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes ® No ❑
If you have checkedrtes, please indicate the type coverage by checking the appropriate box.
A liability Insurance policy IN 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 ❑
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 the permit issued for this appiication will be in compliance with all
pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By
Title
Signature of—Licensed Plumber—
Type
lum erType of Uconse: Master [$ Journeyman ❑
City/Town 8 3 2 2
APPRTO
OVEDTINCE US ONL) License Number__
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SUB-BSMT.
BASEMENT
1ST FLOOR
2ND FLOOR
3RD FLOOR
4TH FLOOR
STH FLOOR
6TH FLOOR
7TH FLOOR
8TH FLOOR
Installing Company Name Heritage Htg. &Plg. CO. Inc. Check one: Certificate
Address 35 Pleasant Street [B Corporation 714
Stoneham, Ma 02180 [] Partnership
Business Telephone 781 — 4 3 8 — 7 7 7 6_ (1 Firm/Co. _
Name of Licensed Plumber Gordon Switzer
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes ® No ❑
If you have checkedrtes, please indicate the type coverage by checking the appropriate box.
A liability Insurance policy IN 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 ❑
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 the permit issued for this appiication will be in compliance with all
pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By
Title
Signature of—Licensed Plumber—
Type
lum erType of Uconse: Master [$ Journeyman ❑
City/Town 8 3 2 2
APPRTO
OVEDTINCE US ONL) License Number__
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