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HomeMy WebLinkAboutMiscellaneous - 26 HEMLOCK STREET 4/30/2018T 10 57 2 Date .... L1... V11 ....... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING Lr,�J-ek/,T, rf has permission to perform ... plumbing in the uildings of.....4c................................................................... 2- w`� °c--�(— ,North Andover, Mass. at...................................................................... Fee. � v..-...... Lic. No3 ....... M......................................................................... PLUMBING INSPECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK b 1 CITY 0 _ _11 MA DATE [ - ���`: PERMIT # JOBSITE ADDRESS OWNER'S NAME S-kAJUA. I POWNER ADDRESS TEL x'15'! FAX j TYPE OR OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL © RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: ® REPLACEMENT: 0 PLANS SUBMITTED: YES ® NO FIXTURES Z FLOOR --e BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM _._.._J i t j ! ! T _! ! _I ..- ..._._! t f f DEDICATED GAS/OILISAND SYSTEM € v.._ ! f _ __.-. ! -_ _ _L J I .. __.__..! -__ _._,I .n i DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM f ._ I I __ i _ _. ! _ _._ _ . { I __... - I -_.... I f ( .... . I t DEDICATED WATER RECYCLE SYSTEM __1 _i —..! DISHWASHER DRINKING FOUNTAIN ..___.-_l FOOD DISPOSER _.A ._._ _._J .__._ _ j==== FLOOR/AREA DRAIN i _.._ ._l € J _._ _i [ J _..__J INTERCEPTOR (INTERIOR) i _ I _ -1 KITCHEN SINK �(_ _.._ ! I I ! __ J _____J ____! __..._.1 ____i --- ___J LAVATORY (! .__._. _► ! ROOF DRAIN SHOWER STALL _( J _I ._-_ ( 1 SERVICE / MOP SINK 1 J _ I _--- . I ._. l _ _.! ,_..._I___ -- TOILET ! ___..... f ____._f _i URINAL ._..__I ._..._._i _---' WASHING MACHINE CONNECTION , WATER HEATER ALL TYPES WATER PIPING OTHER _.___ - _ � INSURANCE COVERAGE: 1 h :�J��.La current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO 01 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ZJ OTHER TYPE OF INDEMNITY 0 BOND 0 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 0 AGENT 10 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate tote best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will b in co li ce 'hall i ent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAMEDi1r1 _ LICENSE # - yy . SIGNATURE MP 0 JP 9 CORPORATION D# j PARTNERSHIP 0# LLC COMPANY NAME O o��.,�1 S'' I-� _ ADDRESS '3 bS}- CITY I Awc4 6,___..__...._� STATE (vL(t�- ZIP j}&73 TEL �j M �if20 �lZ FAX .._ – – CELL -- -- EMAIL Q1NLL N -----_ --------....._... 'n Z V1 ❑ iii LU R I a f'�' _ , . C, The Commonwealth of Massachusetts Department of lndustrigl Accldiiks Office of Invesfigations 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers, _Applicant Information j /� Please Print Les`ibiv Name (Business/Organization/indiividud): JDh 0& Please Address: �>o Vcn5 PC&_ 43 J'`- City/Stade/Zip: m 0- Phone #: 1_46�Z® Z2 . 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 lilted the sub -contractors 2. Q�l am a sole proprietor or partner- listed on the attached sheet. ship and1ave 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 insurancerequired.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing. repairs or additions 12. ❑ Roof repairs 13.❑ Other *Any applicautthat checks box#1 mustalso fill outthe section below showing their workers' compensation policy information. t 'Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that cheA this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy anal job site information. Insurance Company Policy # or S elf -ins. Lic. #: Expiration Date:, Job Site Address: City/State/Zip: Attach a copy of the workers' compensation p olicy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL e. 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. I do herebyrte u der tiie pai enaitie J that the information provided above is true and correct. ��� _ ( G na+P• 1, /(0-� Vhr%na :U• U ! -N— qw -6 l v;?, Official use only. Do not write in tills area, to be completed by city or town official. C'ty 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 Pers Phone #: e 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 ofpublic 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 -contractors) 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: Tho Commoumalthof.A/I.assarhUS3 S De,partme,ut o£.Industrial Accidents Office dInvesupt iom 600 Washiugtou Stxo-t Boston} MA. 021 It Tel, # 617-7-2,7-4.900 et 406 or. 1-877- fASSAFB Revised 5-26-05 Fax # 617-727-7749 WWmMass,govaa Date ..... ........... ............................... WN OF NORTH ANDOVER AIT FOR GAS INSTALLATION ,ibis certifies that. .01.t 01" !f /J-0 �j (0e-�j .. has permission for gas installation ).0 .. .✓z ................................................ in the buildings of. (a ................................................................................ at ...........`� ;North Andover, Mass. 2 4....,....w` ..................................... Fee...'N. — Lic. No. �-�..9` ............ ................................................................. GASINSPECTOR Check # 2 t, -Z- 9797 I\ •` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK WCITY �!`r��� G-1 vP� MA DATE /��lv "/� I� PERMIT # 1 I�� JOBSITE ADDRE6Co�. -� OWNER'S NAME GOWNER ADDRESS 7 i © S>F" TE & FAX YPENOT OCCUPANCYTYPE COMMERCIAL EDUCATIONAL �( RESIDENTIALff CLEARLY NEW:3 RENOVATION: D REPLACEMENT: El PLANS SUBMITTED: YES 0 NO APPLIANCES Z FLOORS- BSM 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER-- -- ------ -- CONVERSION BURNER COOK STOVE .: ! _ _ _ i-=�� 1 .. ...... _� DIRECT VENT HEATER DRYER h.- . - ._ -- .. _ __. FIREPLACE FRYOLATORI FURNACE. J -. . GENERATORI- GRILLE INFRARED HEATER LABORATORY COCKS [- i� L _.._ `- -� _ _IVB _ ---_ 1—.=- C-- MAKEUP AIR UNIT _.- _..l�_- . �• _ _..v -_.� �-- 1__- OVEN - POOL HEATER - ROOM / SPACE HEATER T I I ROOF TOP UNIT TEST UNIT HEATER_ UNVENTED ROOM HEATER _ WATER HEATER OTHER -r INSURANCE COVERAGE � have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 6] NO Ej IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ] OTHER TYPE INDEMNITY ® BOND F 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 0 AGENT 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 accurate to the best of m ge and that all plumbing work and installations performed under the permit issued for this application will be in c mplia a w' II Pe ' rovi ' t Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME LICENSE # 32��+y SIGNATURE MP El MGF Ejl JP [N JGF LPGI ® CORPORATION []# PARTNERSHIPDI#E:L— I LLC E]# COMPANY NAME: -If - �2► rteADDRESS CITY STATE �Z�-ZIP B!1/3_JTEL - T70 Z FAX��� CELL_ EMAIL L. POCOu_N t- ado •CctM __ _ _ z z 0 H U W a o El z O � W ❑ F- W O w O W x cn � 7 Q w CO O w (� w � CO o a a a U J H M a a U) w x w LL H °z z� 0 H U a G� 0 �\� — O, . in 7T»{! : . . .. y...ƒ. 4 <f \�� M. (,nl, . Date. "1J :a`/...... °•° TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .. Jr. :,...4-11 � ? ® has permission for gas installation ... f IP �4 .lX-I f.7......... . in the buildings of ,00. -/ .............................. ,at :........ North Andover, Mass. Fee. .31, .�.` Lic. No. L `.% . r.... ... ........ ASINSPECTOR Check # 1 )' MMSSACHUSEnS UNIFORM (Type or print) NORTH ANDOVER, MASSACHUSETTS FOR PERNIlTTODO GAS HUNG Date % —1 ,3 —o y Building Locations [Q l-eld Of I11C 5 4 Permit # _eL-1 -5i V Amount $ C Owner's Name New Renovation ❑ Replacement Plans Submitted (Print or type)Cy_/J w/1/O w %/� Fin Checkone: Certificate Installing Company Name !lJJ�� �J 11 Corp. Address5 %yl`'� El Partner. Business Telephone r Firm/Co. c Name of Licensed Plumber or Gas Fitter J G INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 13 Noo If you have checked yes, please indicate the type coverage by checking theappropriate box. Liability insurance policy 0 . 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: Signature of Owner or Owner's Agent Owner t-,._,.1.. ----•-, -••-, ••-�• -• �- .•• . -- . ...............u.,.,., . „a.1= auu,1ullcu kUl clncrcu) in avove appucanon 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 State Gas Code and Chapter 142 of the General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) .-Signature of Licensed Plumber Or Gas Fitter Plumber • 1:2�§- Gas Fitter Icense Number Master Journeyman Location 6. No. Date �/' Z -"� NORT1y TOWN OF NORTH ANDOVER •. • OA F3? Certificate Occupancy of $ .o,. ---•.s• s'ACNUS Building/Frame Permit Fee $ .� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 1 ►549/2 '— Building Insp66or TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVAT& OR DEMOLISH A ONE OR TWO FAMILY DWELLING . ,.t BUILDING PERMIT NUMBER: �3� DATE ISSUED: d SIGNATURE: Building Commissioner/I for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: L,-2(, k--mLoc K ST 1.2 Assessors Map and Parcel Number: � � L-� Map Number Parcel Number 2 j -D O ` / t /Z �,4 0' " r 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Requir=ed' Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ 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 Name (Print) Address for Service � G Signature U Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Not Applicable 0 License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone 0%9 9 ;c Q I� Z M 90 O Mn ic M r r s Z a SECTION 4 - WORKERS COMPENSATION (M.G.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 au applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition R— Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: (� f o' X17- Fpec-)c/o 7" o /40 s A C &.'V T 6. e t c lc % f �{ SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY 1. Building (a) Building Permit Fee Multi Tier 2 Electrical (b) Estimated Total Cost of Construction �f 3 Plumbin& Building Permit fee (a) x obi L I ••� 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 �/df a o, e Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, 1 Ig , as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relativeto work au rized by this building permit application. -Signature of Owner— (5 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 Print Name Signature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TD KERS is 2ND 3RD 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 FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary Boards and Departments having jurisdiction have been obtain da 'This does not 'reliets ve the applicant and/or landowner from compliance with any applicable or requirements. _-------"°°APPLIGANT FILLS OUT THIS SECTION********************** APPLICANT �TL y `tJ [r -C: LOCATION: Assessor's Map Number SUBDIVISION STREETpc s PHONE -J)` 110,Sb -6 S5� PARCEL � ! LOT (S) ST. NUMBER ****************************************OFFICIAL USE TOWN CONjFfVA G COMMENTS TOWN PLANNER COMMENTS FOOD INSPECTOR -HEALTH SEPTIC INSPECTOR -HEALTH COMME DATE APPROV15D DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTO Revised 9197 jm DATE D. Robert Nicetta Building Commissioner (97,8) 688-9545 .:(978) 688-9542 Fax Town of North Andover Building Department 27 Charles -Street .. North Andover, MA. 01845 HOMEOWNER UCENSE EXEMPTION Please print DATE Lf A 62— JOB LOCATION 2- , Number Street "HOMEOWNER 'S-FC-Q,b-K) Le-6oqL_ Name PRESENT MAILING ADDRESS -EU I f, City' Town I � S - -(A (J 7 Home Phone S - map lot Work- -Phone 0 / S . Zip Code • The current exemption for "homeownersPwas extended to include ,ipwner-c=pied:dwellings of two units or I ess and to allow such homeowners to .engage an individual,W.'hire who. does. not possess a1icense, provided that the owner acts as supervisor (State Buildn g Code Section 108.3 5. 1) .DEFINITION OF HOMEWOWNER- Person(s), who owns a parcel of land on which he(she resides or intends. to reside, on which there is, or it intended to be, a one or two family dwelling, attached or detached structures ac- cessory to such use and/or farm- structures. A person who consbix:ts more than one home in a two-year period shall not be'considered a hoineowner. The undersigned "homea"er" assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned "homeowner" certifies that helshe understands the Town of No. Andover Building Department minimum inspection procedures and requirements and that he/she vhll comply with said procedures and requirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFICIAL a,' a A 4 I 77'::u v��lFt4 SaA . . .. `d ? 3 ..e• 4.J_t.i. 1� . a..a , .. : k �'La �'� . 'A.ia .S:k+u� isi� �'$v-ct �..... >.. ,. . i . � .. NO ter. r - r� — ? x - tv Is 77'::u v��lFt4 SaA . . .. `d ? 3 ..e• 4.J_t.i. 1� . a..a , .. : k �'La �'� . 'A.ia .S:k+u� isi� �'$v-ct �..... >.. ,. . i . � .. r 0 z CSA v u � cnU o w -o C � 00 C2 CE G U id w ° p�� to iC w W C� id w x d C7 7 iC w z w w cn o cn O 0 co yy O V V Z CD d O CO) G C Cn LLJ U) w W IrW LLJ U) c c CO c o c C3 � c.) c) VJ � CLc a) C V: o: y � 1 Ea 1 m \�C:F^ CD v �E_"T l� : 0 m \ 0 S m c E mm cm 3 " m H m CO C • y A O 1= �Cm : E m y V m t oc `` - p QI c c p Q N �_ Cp :yCt o cc a c ~ Q y m C m c O = ~ m 0Ne w ~ N m W C m v_.. �N 2 W A �a= Cp p F- H =r- m 'o9CH Z O w VCJm -Cm 0-0 Vi a o0z .0` h O 4-.-am� O 0 co yy O V V Z CD d O CO) G C Cn LLJ U) w W IrW LLJ U) Location No. �3oti Date NORT►TOWN OF NORTH ANDOVER Certificate of Occupancy $ Mut��' Building/Frame Permit Fee $ ACs Foundation Permit Fee $ Other Permit Fee $ TOTAL $ '357 Check # 176876//-/"---- Building Inspeetos TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATEz OR DEMOLI■SSHHy�A ONE OR TWO FAMILY DWELLING 'S 6:. J BUILDING PERMIT NUMBER: a DATE ISSUED: SIGNATURE: Building Commissioner/Inspector of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property //Address: ',�. �/ / W c-1 � 1.2 Assessors Map and Parcel Number: f c Q e � C::)O _31 L -c t Od0 o. a Map Number Parcel Number i� A` n / ✓d� 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 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT " "1,0t 1 C DistfiCt: Ye,s Nn 2.1 Owner of Record L,, - � 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 Incensed Construction Supervisor: 1 Lkgsed Construction Supervisor: Address Signature Telephone Not Applicable License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature _ Telephone M z FA, 0 z M 90 0 M z Q C� 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 .......0 No ....... ❑ SECTION 5 Description of Proposed Work check a0 a 8cable New Construction ❑ 1 Existing Building ❑ 1 Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ 1 Other ❑ Specify Brief Description of Proposed Work: S I SECTION 6 - F.STTMATF.n CnNv.TRrtCTTnN CncTQ Item Estimated Cost (Dollar) to be OFFICIAL"USE ONLY Completed by permit applicant 1. Building 51' egDU (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing3 S oa Building Permit fee (a) X (b) _ O'er 4 Mechanical HVAC 2_)-06 5 Fire Protection 6 Total 1+2+3+4+5 0 0.' a Check Number .+.+.....+.. ... .. i.a.a��v aai_Zts lLvliq 1 V DL' l,VDL1' 1r.1r.0 WIMA OWNNEERR'S�\\AGENT �OR CONTRACTOR APPLIES FOR BUILDING PERMIT .. O / Hereby authorize_ My behalf_jtnall matters to work Signature of Owner V — SECTION 7b OWNER/AUTHORIZED AGENT as caner Authorized Agent of subject property to act on by this building permit application. /l 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 Print Name of NO. OF STORIES BASEMENT OR SLAB SIZE OF FLOOR T VIBERS ISI SPAN DDAENSIONS OF SILLS DINIENSIONS OF POSTS DMIENSIONS OF GIRDERS HEIGHT OF FOUNDATION _ SIZE OF FOOTING MATERIAL OF CHIly1NEY _ 1S BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Date SIZE 2' _ THICKNESS X M CA iii m m m x m mm y d t=/l c. Z y CL FS, _ C � � C d= H aCO C) go CDCL O c� �d CD CD o CD C O CO y CO C A I cn cn n O cn C 0 op. c W�10 m -4 s =_wao N = 70 W Mm O m y C7 geiCL 3 m Z o� = n -• n m = homy o y S1 3E ?m ; m 7 32. 7 m C p N CA a 2 na a : h K 02 0 CS W Sas m 'cam = ? __. ti Ott CD U o� m o c =r o O o - m 6 4 O w: WimCD 0: � N s %r dd n� "I 0 om. �q C/) cntd z ro IW o z n r T ^� 7d 7d 7d 0 Imi 0 c TOWN OF NORTH ANDOVER AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application MGL c. 142 A requires that the "reconstruction, alteration, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units ... or to structures which are adjacent to such residence or building" be done by registered contractors, with certain exception, along with other requirements. Type of Work: Est. Cost Address of Work �� t65� L cy-- S /U • �� �� �/Cy- Owner Name: % CUC:ri L--e---(s /9 L_ Date of Permit Application: -CSC I ��Z I hereby certify that: Registration is not required for the following reason(s) Work excluded by law Job under $1,000 Building not owner -occupied Owner pulling own permit Other (specify) Notice is hereby given that: For office Use Only Pemit No. Date OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FIND UNER MGL c. 142A. Signed under penalties of perjury: I hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. OR: Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property: 40(_T-0�1�93��=Z � Date Owner Name 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: Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector Location a 6 W, ," /c, K 5 No. -1-/ q1Z Date NORTN TOWN OF NORTH ANDOVER f �,y ' Certificate of Occupancy $ Building/Frame /Frame Permit Fee $ S s�CHust 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL___-- rv1/0 Check # 17305-3S3131-1-( l i Ez59 il�� Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE,OR DEMOLISH A ONE OR TWO FAMILY DWELLING r�'dr ilii i3�ei�ll r.3� BUILDING PERMIT NUMBER: DATE ISSUED: a 3 SIGNATURE: C Building Commissioner/I for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: _r 6/ [/P��? Lock Y. 1.2L Assessors Map and Parcel Number: l q - 31 Map Number Parcel Number %1 % /���® ✓� �/� , 1.3 Zoning Information:/ Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide R 'redProvided Provided -ReqLlired 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Intion: Public 0 Private ❑ Zone Outside Flood Zone 0 1.8 Sewerage Disposal System: Municipal 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record 5+cve �L -7- 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: .of Licensed Construction Supervisor: Address Signature Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor am -j lkdRo��, Not Applicable ❑ (� Q / ! 1 7O Company Nam / AddreASS/ .b�i/1%11.U2h ������3i�-? Registration Number �y Expiration Date Si nature Telephone v rn O Z rn 90 O ic r v rn r z 0 u 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. W C ;�l Cp — Signed affidavit Attached Yes .......0 No ....... 0 SECTION 5 Description of Proposed Work(check au applicable) New Construction ❑ Existing Building V Repair(s) ❑ Alterations(s) 11 Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: S74 r �,6 A Pr fi D-�— I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I Item Estimated Cost (Dollar) to be m leted by permit applicant OFFICIAL DISE ONLY 1. Building t��0(a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 PlumbinE Building Permit fee (a) x (b) S �- 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 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 I, 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 Print Name Signature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINMERS 1ST 2 ND 3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS f (EIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE P -'J.4 �\ Board of Building Regulations and Sland ae.as 1 Licenst> or registration valid for individul use only, I HOME"IMPROVEMENT CONTRACTOR�; before;�the expiration date. If found return to: Registration 1BoardLOf BuildingRegulations and Standards g •109198 Expiration 9/412004 One Ashburton Place Rm 1301 ;Type lttiividual Bostont Ma. 02108 ALBERT FOLIRNI�,R Ai4ert Fournier 16`8 Maple Street C/ -c °�;r►�l.�-� Methuen -MA -01844• Administrator _ _.i1 } Not valid without signature AL FOURNIER 168 MAPLE ST METHUEN, MA 01844 TEL. 683-5127 �i Family Roofers & Painters MOBILE EXTERIOR PAINTING - CARPENTRY - ROOFING 50 -341-1583 REE ESTIMATES j� A e 4-1-- 7— --- Af---5 0o"te'e:- ON ACCEPTANCE WHEN STARTED HALF COMPLETE BALAN4 WHEN COMPLETE ALL CHECKS TO ALBERT FOURNIER 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: LLS IJGG 8d� Pe11?aM, /J. /�, (Location of Faci Signature of Permit Applicant 7-03 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector C= C � — CD CO)CD C'7 n Z y CL O �� r = CO O CZ =• CO) at -0 C) n CD o p CD o CC CL CTG =r "C d CD CD O CCD 3 C CCD C—D. CO CO) O I O CD C C s� o d 2 O �• to O Q N d0SCD y CL col m c-) Z =r -c y '�•� O� .d► m E - CL T CL -0 O O O y O H o m o m a �O �. n o ZO•o!9 O c O .� O � CA a. d acro C/)m c�•o o m c CD C d C o�y�: A' d co): L c• d : o cr Cn WE Fit N C•�O cn yCD . � O VJ y V, O cs CD OO o es z CO)orlbFIL . �d CD A CD ,...� C T N Abn d �Z o 1=01 �€ o CD f' N �t H 09 C I� 3 ., ° o d p o z y g o n z O p o Z � � p' j.o o X o a a z c- z � C n 0 d o x 9 �t H 09 C I� 3