HomeMy WebLinkAboutMiscellaneous - 26 PEMBROOK ROAD 4/30/20188 72 1
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Date.
-� f NOR71y, TOWN OF NORTH ANDOVER
3? �. "' . , • hoc
PERMIT FOR PLUMBING
,SSACHUSE�
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This certifies that ..�Q . �....... ...... .
has permission to perform ...'tl�!...:..¢^...�!��
plumbing in the build'ngs of
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at a. .Q%Cn... ?i't. Coo.!-........... North dovex,Mass.
e .-C) ..��: Lic. No. E-54 .. .... /1`/1,......2F/R�
PLUMBING INSPE
Check #
FIXTI IRFS
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
City/Town: 4/e474 .9lvd6G 4IF4 , MA. Date: Oo `9 1 ILa Permit#
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Building location: cQ6 foe"? is lqoa' Owners Name: S74 )0 1116111"--
Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential®'
Type
New: ❑ Alteration: ❑ Renovation: ❑ Replacement: E�r Plans Submitted: Yes ❑ No ❑
FIXTI IRFS
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 checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy 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
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
Owner ❑ Agent ❑
nature of Owner or Owner's
hereby certify that all of the d
submitted (or
are true and accurate to the best of my
Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with an
Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By Type of License: _ A� szc— �—
Title 21lumber Signature of Licensed Plumber
Cityrrown Gaster License Number: bc�'9S_� —_
APPROVED (OFFICE USE ONLY) ❑Journeyman
DEDICATED
SYSTEMS
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2ND FLOOR
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Check One Only Certificate #
Installing Company Name:JW-6M i" /O P? 006 >2- t►,
❑ Corporation
Address: /WO 9 dc %jn City/Town: F * r:r4WAI State: &14.
❑ Partnership
Business Tel: i'i&f — /— -�dur3 Fax: 99,P457-004// j.Firrn/Company
Name of Licensed Plumber: e / O?a
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 checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy 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
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
Owner ❑ Agent ❑
nature of Owner or Owner's
hereby certify that all of the d
submitted (or
are true and accurate to the best of my
Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with an
Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By Type of License: _ A� szc— �—
Title 21lumber Signature of Licensed Plumber
Cityrrown Gaster License Number: bc�'9S_� —_
APPROVED (OFFICE USE ONLY) ❑Journeyman
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UN
LocationfO� /
No. G Date' r oG
NORTIy TOWN OF NORTH ANDOVER
3? • . • OA
►O' 9
Certificate of Occupancy $
CMUS t<� Building/Frame Permit Fee $
J�
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
17380
Building Inspe o
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FA,gMILY DWELLING
A ..,
y 3 .i. .? _6' yy�� J 1z�N 3'`.4r�A'� 3?a''+' §""s e 7^zp �,.etiF�ny=
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BUILDING PERMIT NUMBER: DATE ISSUED:
- D
s
SIGNATURE:
Building Commissioner/I for of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
q Z
Vap Number Parcel Number
1.3 Zoning Information:
1.4 Property Dimensions:
Zoning District Proposed Use
Lot Areas Fronts ft
1.6 BUILDING SETBACKS 11
Front Yard Side Yard
Rear Yard
Required Provide ReqWred Provided
Recmired Provided
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information:
1.8 Sewerage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone ❑
Municipal ❑ On Site Disposal System ❑
SECTION 2 -PROPERTY OWNERSHIP AUTHORIZED AGEN -
t o v l . 1. „
,_ ( t,, 3 110�._
2.1 Owner of Record
Name (Print) Address for Service:
r'
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Si ature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Lices/ed Construction Supervisor:
Not Applicable ❑
�lt �`v G% E
Licensed Construction Supervisor:
License Number
Address '
Expiration Date
Signature Telephone
3.2 Registered Home Improvement Contractor
Not Applicable ❑
Company Name
Registration Number
Address
Expiration Date
Signature Telephone
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SECTION 4 - WORKERS COMPENSATION (AG.L C 152 S 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 it.
Signed affidavit Attached Yes .......❑ No ....... ❑
SECTION 5 Description of Proposed Work(check all
applicable)
New Construction ®
Exic" Buildoig
Repair(s) ❑
Alterations(ts).=, ❑
Addition ❑
Accessory Bldg. ❑
Demolition ❑
Other ❑ Specify
Brief Description of Proposed Work:
/ A
TS f CcJ
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by pennit applicant
QFFICIAL USE ONLY
1: Building
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (e) x (b)
y �I
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5)
C9 -,161&
Check Number
SECTION 7a O QRTZAUON TO BE COMPLETED WHEN
OWNERS OR CONTRACTOR IPPLIES FOR BUILDING PEII A
%GEN/T
I, `�� le (�N°� as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf, in al relati thorized by this building permit application.
j,pr o �
Signl6e of dwner Date
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
i
Print Name
Sip -nature of Owner/Agent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TINMERS IST 2ND 3
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING x
MATERIAL OF CHEVINEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
G
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
c 11, S 150 A.
The debris will be disposed of in:
(Location of Facility)
Signa ure 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
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Name Please Print
Name:�"�''lt/
Location Cz-�P--�c..�
City //Z/ A.�a le Phone # J?Zje- Z _ 3 t 2�
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.
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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 WORK_ORDER..and_a fine -of .(.$1D0..00)_aslay.against_me. I
understand that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification. .
1 do hereby certify under the pains an�lper�ities o,gpff"e information provided above is true and correct.
Signatu
Print
Date D 6 —/"7>
Phone.# ed3-
Official use only do not write in this area to be completed by city or town official'
City or Town Permit/Licensing
❑
Building Dept
❑Check If immediate response is required ❑
Licensing Board
❑
Selectman's Office
Contact person: Phone #. ❑
Health Department
❑
Other
A. V/ 041t/I17.0'!LU/P.ILGiiL O� /(/�g4�(LGLcigeua,
Board o[ Building Regulations and Standards
V HOME IMPROVEMENT CONTRACTOR
Registration: 114134
Expiration: 8/6/2005
Type: DBA r
i
Salem Vinyl, Siding, & Windows
GLENN COTE
46 HERRICK CIRCLE,,`„ -,fir.✓
PELHAM, NH 03076 Administrator
�ize T�JO�!I7/ht6'IZCl/CILG[IL 6�✓!/lad6ll!,itl[6P,�.6 i. i
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number d;S`i 035152 S
9;
Birthdate: 08131/1948 i
S
Expires:'Ai3/31@005 Tr. no: 11803
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