HomeMy WebLinkAboutMiscellaneous - 26 HERRICK ROAD 4/30/2018a _
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3856
S
HORTM
°'<�•° •�" TOWN OF NORTH ANDOVER
'11 ' PERMIT FOR PLUMBING
',SSACNUS��
This certifies th �•/
has permission to perform _ �,� ...
. - .�
plumbing in the uilding sof
..... ..• • • North Andover, Mass.
Fee Lic. No. :f sl .
PLUMBING INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
(Type or Print)
NORTH ANDOVER
Building Location
r /�//�
,Mass.
Owners Name
New D Renovation 1] ' Replacement
Idt
I
L.
i.�lw7iil.
J
(Print or Type) II Check one: Certificate
Installing Company Name ) k.) �( k ❑ Corp.
Address 3 S L t 4--144L (,r Partner.
�a-4 C1 Firm/Co.
Business Telephone- 2 J:2 a Sl �-
Name of Licensed Plumber: EK ,PQ I,yl, Pj -Y- 1 Aj
Insurance Coverage: Indicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy IXOther type of indemnity E] Bond ❑
Insurance Waiver: 1, the u1ndersigned, have been made aware,that the licensee of i
this application does not have any one of the above three insurance coverages. "
Signature of owner/agent of property Owner ❑ Agent�� ❑ ',
I bemby certify 44at all of U.ie details and idoieation I ha.c sutomkicd lot camcd) in aMsyt appikalias ere Iwe aT�Pwafd to dee best of of
kmwkdgic and "all plambing work and inslaltaaions l•cu(oinacd undcr rcrarit I«ucd (of this applicaliow wilt be in eaMspliassq.itll W PatM�t «`,
tisigas of"Ma&"ascus Static Plumbing Codc and Cluptcr 142 of Uic (:cncsal UWL , ,r
By
Title•
City/Town:
A0DPr)VFr) 7oFFtcF use oNt_YI
Signature of Licensed Plumber
Tv a of Plumbing License
License Number %master ❑ JourneywM'
Location
No. -
Date 722�—�
4
A
"°R*"
TOWN OF NORTH ANDOVE§
„
Certificate of Occupancy $
Building/Frame Permit Fee $
JACHUS t
Foundation Permit Fee $
..
O
Other Permit Fee $
Sewer Connection Fee $_
Water Connection Fee $
0
TOTAL
wilding Inspector
C 3 IS
Div. Public Works
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IV 03Wa0383d 38 Ol AdOM
141
9.ON 3NOHd
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0103111Aen-ivsodoad
7dSOd02Ed
NORTH ANDOVER BUILDING DEPARTMENT
400 Osgood Street
Tel: 978-688-9545
Fax: 978-688-9542
BUSINESS FORM FOR TOWN CLERK
DATE: ///,//�
ADDRESS:
C
ZONING DISTRICT: /
TYPE OF BUSINESS:
NO
BUILDING LAYOUT PROVIDED: YES NO
AVAILABLE PARKING SPACES: Zp5 J`klu C "k—
lie
ZONING BY LAW USAGE: YES.2 NO
/P /l
BUILDING INSPECTOR SIGNATURE
Revved 11.5.04
BWPMS FORM FOR TOWN CLERK
A
Location -a
No. ,-'41( Date
NORTo, TOWN OF NORTH ANDOVER
41
F A
s , ; Certificate of Occupancy $
b ro
°
3 Building/Frame Permit Fee $
,S�CNUSE
•
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ n'
Check #
178'19
Building Inspectq
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAI RENOVAT& OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER:�(/ DATE ISSUED: l l n r /
(6u-c�
SIGNATURE: 'v /N
Building Commissioner for of Buildings Date
SECTION 1- SITE INFORMATION
Property Address:
1.2 Assessors Map and Parcel Number:
^1.1
OboiA op 15'
Map Number Parcel Number
1.3 Zoning Information:
1.4 Property Dimensions:
Zoning District Proposed Use
Lot Area s Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Required ovide Required Provided
Required Provided
r54)
1.7 Water Supply M.G.L.C.40. 1.5. blood Zone Information:
Zone Outside Flood Zone
1.8 Sewyrage Disposal System:
Municipal 1t�? On Site Disposal System ❑
Public Private ❑
SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT
UiStrict: os NO
2.1 Owner of Record
a e (Print) Address for Service
Signature Telephone
SJQ J�Q
2.2 Owner of Record: ~
Name Print Address for Service:
Signature Tele hone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable ❑
Licensed Construction Superviso .
License Number
y^J a�
r
15 -
ddress
�`
U" S-335-
ZQ (a tU
Expiration Date
Signature Telephone
3.`2 Registered Home Improvement Contractor
Not Applicable ❑
Company Name
Registration Number
�
w
r
Address
k
�b
Expiration Date
SS ature Telephone
Ma
M
M
z
O
SECTION 4 - WORKERS COMPENSATION 0
Workers Compensation Insurance affidavit must be cwm.
in the denial of the issuance of the uIlding permit.
Signed affidavit Attached Yes ....... No ....... 0
SECTION 5 Description of Proposed Work chat
New Construction ❑ 1 Existing Building ❑
Accessory Bldg. ❑ 1 Demolition
Brief Description of Proposed Work:
M
G.L. C 152 § 25c(6)
eted and submitted with this application. Failure to provide this affidavit will result
all appHcable
Repair(s) ❑ Alterations(s) ❑ Addition
❑ 1 Other 0 Specify
I UrTION 6 - F.STTMATF.n r0NST112TirT1nN rnCTC I
Item
Estimated Cost (Dollar) to be
Completed b permit applicant
OFFICIAL USE ONLY
1. Building
�l y v
(a) Building Permit Fee
Multiplier
SPAN
2 Electrical
DBAENSIONS OF SQLS
(b) Estimated Total Cost of
Construction
DIMENSIONS OF POSTS
3 Plumbing
----__
Building Permit fee (a) x (b)
—
4 Mechanical HVAC
SIZE OF FOOTING
5 Fire Protection
MATERIAL OF CHININEY
6 Total 1+2+3+4+5)
0 V 0
Check Number
Vnl\L'll AV JL"UX iGA'11V1\ 1V 111: l.VMrLh 1tLP WH r4
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, ��•-� .�v-� as Owner/Authorized Agent of subject property
by authorize_ ,.► �A to act on
pn. %ifflmatters relative to work authbrizOby this building permit application.
Signature of'Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
as Owner/Authorized Agent of subject
property u C!
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
of
NO. OF STORIES
BASEMENT OR SLAB
SIZE OF FLOOR TRV BERS
'bt4 Y2 1
SPAN
1
DBAENSIONS OF SQLS
— 2�-
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
v
HEIGHT OF FOUNDATION
SIZE OF FOOTING
MATERIAL OF CHININEY
IS BUILDING ON SOLID OR FILLED
LAND
IS BUILDING CONNECTED TO NATURAL
GAS LIN
to -6I bN
Date
SIZE ` )L'
THICKNESS U"
� X t
v L��
4
ti
P -M
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 or requirements.
******APPLICANT FILLS OUT THIS SECTION*********************** I
APPLICANT (`,. L, � PHONE LCL -_53?r
LOCATION: Assessor's Map Number PARCEL
SUBDIVISION LOT (S)
STREET ST. NUMBER
COM
**********OFFICIAL USE ONLY*******************y�*****�t�t********
OF
SERVATION ADMINISTRATOR DATE APPROVED
DATE REJECTED
TOWN PLANNER DATE APPROVED _
DATE REJECTED
COMMENTS
FOOD INSPECTOR -HEALTH
SEPTIC INSPECTOR -HEAL
COMMENTS.
DATE APPROVED
DATE REJECTED
t�A-TE�or?RnVED
DATE REJECTED
PUBLIC WORKS - SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE
Revised 9197 jm
0
North Andover Building Department
DEBRIS DISPOSAL FORM
Tel: 978-688-9545
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:
/�,ll-o `�,oUS� c
n of Facility)
V " Signature of P4rmi ptlicant
I L �, u
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
0
I
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Name - Please Print
City t jr, /J,_� &,*.^ Phone # U LS 3 3 �
I am a homeowner performing all work myself.
0 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.
--- ` / A \ .-. .
k
I ME
Citv t�./v, U LV Ll Phone
�.la
Comoanv name:
Address
City: Phone #•
Insurance Co. Policv #
vw
Future 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 vire➢_as.civil.,penaltiesin The lbrmda.STOP WORK_ORDER..and..afine .of.($100,00)-riay 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 ceily and a sins and p� allies o�pery'ury tha anon provided above is true and correct.
Signature Date
Print name ��'<,�, ,.� M ,.,,,�L.,�
Phone # 60- 5--3-3
Official use only do not write in this area to be completed by city or town official'
City or Town Permit/Licensin
❑ Building Dept
❑Check if immediate response is required ❑ Licensing Board
E] Selectman's Office
Contact person: Phone #. ❑ Health Department
❑ Other
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PLAN OF LAND
IN
NORTH ANDOVER, MASS.
PREPARED FOR
ELIZABETH QUINN
SCALE. 1"= 20' DATE.812012004 SEE ASSESSORS MAP 60'A, PARCEL 15.
1011212004 THE ZONING DISTRICT IS R3.
Scott L. Giles P.L.S.
MA