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Home My WebLink AboutMiscellaneous - 26 STONECLEAVE ROAD 4/30/2018Po CO --f m 0 ;<n P 0 0 , -'I / Lo(,,ation,--V(.O' No. //Y Date ,40RTjj TOWN OF NORTH ANDOVER .0 0 4 Certificate of Occupancy $ Building/Frame Permit Fee $ CHUS Foundation Permit Fee $ Other Permit. Fee $ TOTAL $ Check # 2 4 Building Inspector Permit NO: Date Issued: / ' BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received I - IMPORTANT: Applicant must complete all items on this va2e I LOCA Print Fa.Te TWJ TZ "IN Y Print 'MAP NO: —PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Re54T—"6,==, Non- Residential New Building "!O—ne family �,Zlo Addition or more family Industrial Alteration No. of units: Commercial ,kRepair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed'District Water/Sewer I I I OWNER: Name Address: CONTRACTOR Nam Address: DESCRIPTION OF WDRK TO B Type or Print Clearly) A — I Supervisor's Construction License: Exp. Date: Home Improvement Date: ARCH ITECT/ENG IN EER Phone: Address: Reg. No. FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000-00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.:_ NOTE: Persons contracting with unregistered contractors do not have accesslo't-4Aajontyfund nature Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private (septic tank, etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATEAPPROVED PLANNING & DEVELOPMENT COMMENTS DATE REJECTED DATEAPPROVED CONSERVATION COMMENTS DATE REJECTED DATEAPPROVED HEALTH COMMENTS 4 Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Commen Conservation Decision:— Comments Water & Sewer Connection/signature & Date Driveway Permit Located at 384 Osgood Street I I I FIRE DEPARTMENT - Temp Dumpster on site yes no_ Located at 124 Main Street Fire Departme n*t signature/date COMMENTS Dimension Number of Stories: — Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes MGL Chapter 166 Section 2 1 A —F and G min.$100-$l 000 fine No NOTES and DATA – (For department use) Q Notified for pickup - Date .......... . ................ . ....................... . ..... . ....... . ....... . ...................................... . .............. . . . .... ... . . . ................................. . . .. . ...................................................... . . . . . . . ........ . ..................................... . ........ . . . Doc.Building Permit Revised 2007 Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISFO-SAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Private (septic tank, etc. Tobacco Sales Food Packaging/Sales Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATEAPPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION DATE REJECTED DATEAPPROVED COMMENTS HEALTH DATE RE . JECTED DATEAPPROVED COMMENTS Zoning Board of Appe . als: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/s ---Qriveway Permit----. Located at 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes Located at 124 Main Street no Fire Departmen't signature/date COMMENTS Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits • Building Permit Application • Workers Comp Affidavit • Photo Copy Of H.I.C. And/Or C.S.L. Licenses • Copy of Contract Ei Floor Plan Or Proposed Interior Work D Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks • BuildingPermit Application • Certified Surveyed Plot Plan • Workers Comp Affidavit • Photo Copy of H.I.C. And C.S.L. Licenses • Copy Of Contract Li Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) • Mass check Energy Compliance Report (If Applicable) • Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Ei Building Permit Application Ei Certified Proposed Plot Plan Li Photo of H.I.C. And C.S.L. Licenses Ei Workers Comp Affidavit Li Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (if Applicable) Lj Copy of Contract zi Mass check Energy Compliance Report L3 Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building apptication Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 Location,_; No. Q� A Date %3- , �-504- ,,, TOWN OF NORTH ANDOVER -Aiffiidh'�21 Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 190,11 Building fnspectQ� $M4 0 "Cl 0 F=4 04 t 0 2 0 �E E Cf) Cf) 0 �-4 u w r-4 z 5 or. 1 a a x r- u co x z —co 21 u w ow 1.4 u W 92 Cf) —co Cd z F4 ZW 0 Z cf) 0 -C/) 4w 0 "t �j 73 4�W4 S, � � UJ CLC CF E s 0 CD 4* c CD v C3 0 Q cm 45 co 0 CLC.) b� 0 C-33 m z vo-=o IRS CD 4� CO) Cue cc m e E c.2 = c03 CJ CO C.) CIO CL CD cc CL.,. co 2� E Z M is 'as cm cm, cm 0 PQ CD z 0 C/) C/) z u C/) C/) 0 u 4.4 co E <2 'u co u 0 z 47 CD ca cm UJ CLC CF E s 0 CD 4* c CD v C3 0 Q cm 45 co 0 CLC.) b� 0 C-33 m z vo-=o IRS CD 4� CO) Cue cc m e E c.2 = c03 CJ CO C.) CIO CL CD cc CL.,. co 2� E Z M is 'as cm cm, cm 0 PQ CD z 0 C/) C/) z u C/) C/) 0 u 4.4 co E co z CD ca cm ca CD ca ow cc 0 m: cm< ca *-0 C cc cp ca Z ts CD 0 C.3 CO3 cc CL C43 w w 0 19 LLI w ce LLI ul (1) 11-18—'08 12:58 FROM—THD PRODUCTION 5087569009 lrj,"44 T-857 P001/001 F-049 A6- lliv-sat-huseti% Puhl hafm Rc_i-jjI;jji,jjjt jod Standard's constructio- n Supervisor License Oceftse: CS 101433 Restricted 10, 00 SERGIO SANTOS 11 HAwK,,iys $TREET NO I SOMERVILLE. MA 0214.3 lOiQu L X/l/k DATE (mm/on/yvy) ACORD, CERTIFICATE OF LIABILITY INSURANCE.: 1 02/26/08 PRODUCER 1-404-995-3 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Marsh USA, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICAT� HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTENU Oil ,-iomedepat.cer"trequestC-marsh�com ALTER THE COVERAGE AFFORDED BY THE POLICIES SELOW. 3475*Piecimont Rd NE, Suite 1200 .ktlanta, GA 30305 (212) 948-090, INSURED H ome Deoct U.S.A Inc The Home Deoct, Inc. 1455 Pace3 �erry Raad aulldLng C-8 Atlanta, GA 30339 :NSURERS AFFORDING COVERAGE N 11 IC 9 INSURER A: stead Ea3 t ins cc 26337 INSURER8iZurich A�merican ins cc LIMITS INSUPERC�IllinOis Kati Ins Co 2 3 a Il INSURER 0- Americarl Home Assur Cc 19 340 INSURERE:New Hampshire Lns.Co 2 3 a il COVERAGES .THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICYP.ERiOO INDICATED. NOTWIFIN 101('W.It� ANY REOUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUE0 OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERIVIS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DO I LrR �N S R C rYPEOF(NSURANCS POLICY NUMBER POUCYEFFECTIVE DATE (MMIOO/YYI POLICY EXPIRATION DATE IMMIOQIYYI LIMITS A CENERAL LIABILITY IPR 3757 608-02 03/01/08 03/01/09 EACH OCCURRENCE . S 4,000, 00o MERCiAL GENERAL LIABILITY CLAIMS MA OCCUR f—CO 01 LIMITS OF POLICY ARE EXCESS "OF SIR: $1,000,000 PER DCC11 OAMAGGTOR NT E ence) $ 1, 000, 000 PREMISES (Ea oc7u(T MED EXP (Any one pefson) s EXCLUDED PERSONAL &ADV INJUR1i S 4 000, 000. GENERALAGGREGATE $ 4 , 000, Ou GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMPIOP AGG S 4 , 000, 000 7X POLICY F-I PRO- 7] JECT F LOC B AUTOMOBILE X LIABILITY ANYAUTO BAP 2938863-05 03/01/08 03/01/09 COM81NEO SINGLE LIMIT 1, 000, 000 (Ga acciden(I BOOILYINJURY S (Perpersonl ALL OWNED AUTOS SCHEDULED AUTOS. BOOILYINJURY (Per accident) HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE (per accia() X SELF INSURED AUTO PH-YSICAL DA -RAGE GARAGE LIABILITY AUTO ONLY - EA ACCIDENT S OTHER'THAN EAACC S ANYAUTO AU TO ONLY: AGG S k -XCESSIUMBRELLA LIABILITY IPR.37S7 608-02 03/01/08 03/()1/09 EACH OCCURRENCE $ 5, 000,000 X OCCUR 0 CLAIMS MADE AGGREGATE 000 '0 11 DEOUCT18LE S RETENTION WORKERS CCMPENSATION AND EMPLOYERS' LIABILITY ANY P . POPRIETOR/PARTNERIEXECUTIVE 1928757 (FL) 1928756 (CA) 03/01/0B 03/01/08 03/01/09 03101109 X OC S TA TIU OTH. TW RY LIM T�T I I FR E L. EACH ACCIDENT $ l,OOO,U00 E.L. DISEASE - EA EMPLOYEE S 1,000,000 0 FFICEPWAEMBER EXCLUDED7 1928755(AOS) 03/01/08 03101109 Hyes. describe under E.L. DISEASE - POLICY LIMIT S I , 0 0 0_, OQO SPECIAL PROVISIONS belo- OTHER TX Employers Excess TNS -,C45197967 (TX) 03/01/08 03/01/09 urrence/sIR 2SM/2M Workars Compensation 1928759 (QSI) 03/di/08 03/01/09 [cc iqorkers Compenqation 1928758 (ICY, MO, NY, WI) 03/01/08 03/01 SCRIPTION OF OPERATIONS f LOCATIONS/ VEHICLES/ EXCLUSIONS ADDED BY ENDORSEMEN r t SPECIAL PROVIS[OtIS OR EVIDENCE ONLY 'RTIFICATE HOLDER CANCELLATION SHOULD ANYOF THE ABOVE 0 ESC RIB ED POI.ICIE9 BE CA14C EILLEO BEFORE TI IE EXPIRA flou HOME DEPOT, INC. DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 OAYS WRITTH! NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO 00 50 jIALL 3 P. -.CES FERRl R:)- N.11. BUILDING C-3 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPOtI THE INSURER, ITS A(,C!ITS OP. REPRESENTATIVES A�,ITA,.GA 30339 AUTHORIZED REPRESENTATIVE USA ORD 25 (2001/08) d-atkinson (VACORD CORPORATION 1988 8213215 7-- ,7 Board of Building R ekulatiofis and Standards HOME IMP License or registration valid fo ROVtME r individul tj�e on1v NT CONTRAtTOR before the expiration date. If fouud'return to: Registr4i6q,,, 126893., Board of Building Regulations and Standards E One -Ashburton Place Rrn 1301' Xpiratid 10 . . .... . ..... j ype,-�:�� upp '__S ')er�ent C.Ird ]Boston, Ma. 02108 The Home Depol-'i INICHARD FALL .3200 COBB GA GA. 3 ----------- Administrator N ko t vali Without signature The Commonwealth ofAfassachusetts Department ofIndustrial A ccidents Office of In llesfigafioits 600 Washington Street �Bosloli, 1M 02111 WWW.111a5S.001,1dia Workers' Compensation Insurance A.Mdavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please PHLLaith Name (Busine ss/organizat Ion" I nd I vidu a I): 7� Addres s -.— C* ZO Phone 9.- ity/State/Zip__ L6-7,11S_13a Are yo n employer? Check the appropriate box-' I am a employer with J ()D 4. [] I am ageneral contractor and I employees (full and/or part-time).* have hired the sub -contractors 2.0 1 arn a sole proprietor or partner- ship and have no employees working for me in any capacity - [No workers' c.omp. insurance 5. F1 required.] * 3. n I am a homeowner doing all work myself (No workers' comp. insurance required.] t .listed on the attached sheet. These sub -contractors have workers' comp. insurance. We are a corporation and its offlicers have exercised their right of exemption per MGL c. 152, § 1 (4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. EJ New- construction 7- E] Remodeling 8. EJ Demolition 9- Building addition IO.F Electrical repairs or additions I IJ—] P mbing repairs or additions 12.Ell��f repairs 13 g@�Fe r 'Any appli can( that C-hccks box #1 must a] so F1 U out the section below showing their workers' compensation policy information. t Homco��,iicrs who submit this a-fridavit indicating they are. doing aJI work and then hire outside contracto rs must submit a new affidavit indicating such. 'Contractors that check this box must aitachcd &n additional.sh"i.showing the nanie Of the sub-con"ctors and their workers' cornp. policy in format ion. I am an employer th at is providi,*g workers' compensation Insuranceformy eWtoyees. Below is the policy andiob site information. Insurance Company Name: Policy # or Self -ins. Lic. 9: Expira tion Date: Job Site Address: —City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties Ora fine up to $1,500.00 and/or one-year lmprisonme'nt� as well as civil penalties in the forin of a STOP WORK ORDER and a Fine of up to $250-00 a day against the violator. Be advised that a copy ofthis statement may be forwarded to the Office of In vest ig'ations of the DIA for insurance coverage verification. Idohereb.rc ri un e I epa* s*alidpenalfies ofperjun- that the information pro vided abo If "I Signature: Date: lip, DL_ __ U. . I I ) CM Ofji-cial use oaty. Do not write in this area, to be completed bY citi, or town official. City 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 DEC -26-2008 07:22PM FROM -HOME DEPOT 3401 +603-437-4212 T-791 P-001 F-689 Sold, Furnished and Installed by: Branch Name: Boston Date; 12 /& 2009' THD At -Home Services, Inc. d/b/a The Home Depot At -Home Services Branch Number: 345A Greenwood Street, 'Unit 2, Worc=w, MA 01607 Toll Free (800) 657-5182; Fax (508) 756-8823 nNorth 33 <29iE!5 Fcd*ral ID 0 75�)698460; ME Lic # C 02431); kI Cont. IJC# 16427 CT Lic # 565522, MA Home Improvement Contractor RLT, # 126893 Installation Address: 7-6 ZZ� �Z-glaq Notnf A400ig MA 01—f -As- — City State zip Purchssws)- Phone. Home Phone- 14AC Cell Phone: 1 ['7711 6T2-024-1 1071 71-7-0d If Rom Address: (If different ftom Installation Address) City State Zip E-mail Address (to receive project communications and Home Depot updates): W -N I DO NOT wish to receive any marketing emails from The Home Depot .2 -1 -ec"66 Laflon: Undersigned ("Customee� the owners of the property located at the above installation address, agrees To buy, "Xt7 - -4, deliver and arrange for the installaTion C'Installation") of 1 -ID Home scirvices, Inc. ("The Flume DepoC) agrees to furriki all materials described on the below and on the referenced Spec Sheet(s), all of which are incorporated into this Contract by this reference, along with any applicable State Supplement and Payment Summary attachcd hereto and arry Change Orders (collectively, "Contract"); Ob #- ife-1 R.�–1 Praftcts Snee ShLetfsl #: Proiciet Amount 1FR17—f�i.ElSiding []Windows Olmulaiion $ +2_01 +S-�- E)CMUci-5/Covers CIRrittyDoors [3_ 06 '19 2- — - r. Roofing [JSiding U Windows L] Insulation S i M. —,..* — — I ==: - .-g - . — — []Roofing ElSiding [] Windows LJ Insulation $ []Gutters / Covcrs Entry Doors 0 L]ROOFIng Siding Windows [] Insulation $ []Guuem / Covcrs 0EnuY Doors El Minimum 25% Depomt ofCoutract Amount due upon execution ofthis contract. Total Contract Amount $ I Maine Porchmien may not deposit mOre than one4hird ofthe Contract Amount. Customer agrees that, immediately Upon completion of the work for each Product, Customer will execute a Completion Certificate (one fof each Product as defined by an individual Spec Sheet) and pay any balance due. As applicable, each Customer under this Convact agree.; to be jointly and severally obligated and liable hLreundff. The Home Depot reserves; the right to issue a Change Order or terminate this Contract or any individual Product(s) included herein, at its discretion, ifThe Home Depot or its authorized service provider determine,% that it cannot perform hs obligations due to a structural problem with the home, environmental hazards such as moK asbestos or lead pairit. othersafety concerns, pricing errors or because work required lo complete the job was not included in The Contract. Payment Sunimam The Payment Summary # 11. 74Y I'D included as part of this Contract, sets forth the total Contract amount and payments required for ihe deposits and final payments by Product (as applicable), NOTICE TO CUSTOMER You are entitled to a completely filled4n copy of the Contract at the time you sign. Do not sign a Completion Certificate (note: there is one Completion Certificate for each listed Product as defined by individual Spec Sheets) before work an that Product is Complete - In the event of termination of this Contract, Customer agrees to pay The Rome Depot the costs of materials, labor, expenses and services provided by The Home Depot or Authorized Service Provider through the date of termination, plus any other amounts set forth in this Agreement or allowed under applicable law. THE HOME DEPOT MAY WITHHOLD AMOUNTS OWED TO '.fHE HOME DEPOT FROM I'HE DEPOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT LEffITNG THE ROME DEPOT'S OTHER REMIE DIES FOR RECOVERY OF SUCH AMOUNTS. Acce cr agrees and understands that this Agreement is the entire agreement between Customer ,plance and Authorization! Custome and The Homt. Depot with, ..91-d to The Products and Installation services and supersedes all prior discussions and agreernenTs, either oral or written, relating to said Products and Installation. This.A.greement cannot be assigned of amended except by a writing signed by Customer and The Home Depot- Customer acknowledges and agrees that Customer has read, understands, voluntarily accepts the terms ofand has received a copy ofthis Ag=menL ZC-. Date "Cil—y6mert SiffiAure Date nON.- CUSTOMER MAY 'CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELrVEJUNG WRITTEN NOTICE TO THE HOME DEPOT BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER. SIGNING THIS AGREEMENT. THE STATE SUPPLEWNT ATTACHED HERETO CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN .4 CUSTOMER'S STATE. . . NOTICIL ADDITIONAL TERMS AND CONDITIONS ARE STAI 'Submitted by: X#29K PAC=Z�gw- 12 -U-2car Sales Consultant's Signatiffe Date Telephone No. Sales Consultant License No. NIA (a% applicable) K13 ON THE REVERSE SI DE AND ARE PART 017 THISCONTRM�717 10-iAs'nav 8-06-08 C -Sc ; - White- Brancli Fife Yeflv�v- Customer Pink- Sales Consultant 7�0,)� 14ORTH 0 Permit NO: Date Issued: C3 - TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 1-0 &Date Received: 3-7 I IMPORTANT: Avolicant must comnlete all items on this Dage I LOCATION . . 2-6 '�>1bl-JECLE&2P PROPERTY OWNER— Print Print MAP NO.: \ 0�.0 PARCEL: TYPE AND USE OF BUILDING ZONING DISTRICT: HISTORIC DISTRICT YES F1 TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building 11 Addition 0 Alteratioa,,,�� K One family 0 Two or more family No. of units: 0 Industrial VRepai rreplacement 0 Demo�liieml� 0 Assessory Bldg 0 Commercial 0 Moving (relocation) 0 Other 11 Others: 0 Foundation only DESCRIPTION OF WORK TO BE PREFORMED Q - Identification Please Type or Print Clearly) OWNER: Name: Phone: ( zS L4q 7 - Signature Address: CONTRACTOR Name: Phone: -7 5&ci - 'Z�7(p Address: �5 L( Supervisor's Construction License: Exp. Date: Home Improvement License: J—z (.&013 Exp. Date: ARCHITECT/ENGINEER Name: Phone: Address: Reg. No 1& - S - C> (=� FEE SCHEDULE. BULDING PERMIT. S10.00 PER S1000-00 OF THE TOTAL ESTIMA TED COSTBASED OQV S125.00 PER S.F. Total Project Cost :$ S I,q oc> xlO.00=FEE:$ k!69 W Check No.: / vi y Receipt No.:_. 19�9.1,11 Page I of 4 TYPE OF SEWARGE DISPOSAL Tanning/Massage/Body Art Swimming Pools El Public Sewer F1 F1 Tobacco Sales Food Packaging/Sales 11 Well F1 Permanent Dumpster on Site F1 Private (septic tank, etc. NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund Signature of Agent/Owner— C? t-, Cgt,,W4C7- - - Signature of Contractor z Plans Submitted 11 Plans Waived 11 Certified. Plot Plan [I Stamped Plans THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS DATE REJECTED DATE APPROVED F1 11 E]Water Shed Special Permit Site Plan Special Permit Other DATE REJECTED DATE APPROVED El DATE REJECTED DATE APPROVED F1 11 - Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes V —Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer connection signature & date Temp Dumpster on site yes no_ Fire Department signature/date Building Permit Approved and Issued by: Page 2 of 4 Building Setback (ft.) Front Yard Side Yard Rear Yard Required Provided Required Provides Required Provided DIMENSION Number of Stories: Total land area, sq. ft.: NOTES and DATA — (For department use) Page 3 of 4 Total square feet of floor area, based on Exterior dimensions. Doe: INSPECTIONAL SERVICES DEPARTMENT:BPFORM05 Created JMC. Jan.2006 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits u Building Pen -nit Application o Workers Comp Affidavit u Photo Copy Of H.I.C. And/Or C.S.L. Licenses Ej Copy of Contract u Floor Plan Or Proposed Interior Work Addition Or Decks o Building Permit Application Lj Surveyed Plot Plan L3 Workers Comp Affidavit u Photo Copy of H.I.C. And C.S.L. Licenses Li Copy Of Contract u Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) u Mass check Energy Compliance Report (If Applicable) New Construction (Single and Two Family) o Building Permit Application u Certified Proposed Plot Plan u Photo of H.I.C. And C.S.L. Licenses u Workers Comp Affidavit Li Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) u Copy of Contract u Mass check Energy Compliance Report In all cases if a variance or special permit was required the Town Clerks Office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: INSPECTIONAL SERVICES DEPARTMENT: BPFORM05 Page 4 of 4 X 0 6 z A 1% I I ri; W ct Col COD LL LU L.2 C*i 0 o 0 CLC Cc M CD EcC 0 0 CL go E o 0 C.3 0 .10 c .0 Co E (D wo CLC.� CL D 0 (40 0 0 CL 2 CD CA IV 0 r .L*- 0 C� I -- CD Ga m m E c.3 03 L- Q CD cm ID C -0 c 06 0 -F. 0:5 GO m cm cc 0 16.= .= *- CL.I.. 2� E L - co CL M cm CD cc cm cc 0 cm CD z CD C/) z 0 04 u 42 �121 E cr. 0. cn E CD .COD i ca co CD 0 CD L- �— = CL CD i2j" a) — > Cm C:) CD Q 0 CL ca C) CIO CL 012 C.3 Cm Ox IA i W r. 1E LIE 1 0 �2 u x 0 u w 0 u 0 cx u w ZW, Col COD LL LU L.2 C*i 0 o 0 CLC Cc M CD EcC 0 0 CL go E o 0 C.3 0 .10 c .0 Co E (D wo CLC.� CL D 0 (40 0 0 CL 2 CD CA IV 0 r .L*- 0 C� I -- CD Ga m m E c.3 03 L- Q CD cm ID C -0 c 06 0 -F. 0:5 GO m cm cc 0 16.= .= *- CL.I.. 2� E L - co CL M cm CD cc cm cc 0 cm CD z CD C/) z 0 04 u 42 �121 E cr. 0. cn E CD .COD i ca co CD 0 CD L- �— = CL CD i2j" a) — > Cm C:) CD Q 0 CL ca C) CIO CL 012 C.3 Cm Ox IA i W r. CERTIFICATE NUMBER E 'NICE MARS H G, RTIF.I.C.1, ATL -000915907-11 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS MARSH USA, INC. NO RIGHTS UPON THE CERTIFICATE HOLDER OTHER THAN THOSE PROVIDED IN THE ATTN: BRENDA BOOKER (404)995-2594 POLICY. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE MAYA MCQLURE(4Q4)9W32Q6 OR AFFORDED BY THE POLICIES DESCR18ED HEREIN. TAMI ROUSE (404)9W3430 FAX (404)76D- 663 3475. PIEDMONT ROAD, SUITE 1200 COMPANIES AFFORDING COVERAGE ATLANTA, GA 30305 COMPANY 100492-IPUSA-QWA-03/04 A STEADFAST IN$V RANCE COMPANY INSURED COMPANY THD AT - HOME SERVICES INC. B ZURICH AMERICAN INSURANCE COMPANY DBA THE HOME DEPOTAT- HOME SERVICES, INC. COMPANY HOME DEPOT USA, INC. 2455 PACE$ FERRY ROAD NW C NEW HAMPSHIRE INS COMPANY BUILDING C-8 COMPANY ATLANTA,GA 30339 D AMERICAN HOME ASSURANCE COMPANY CQV 1!��. �lb s a la A Usi 0 'y p6riod noted belc.,/. 0 iss -ce 4oe �o!- -J�os'Aqd, IS TO CERTIFY THAT POLICIES OF INSURANCE DESCRIBED HEREIN HAVE BEENISSUED TO THE INSURED NAMED HEREIN FOR THE POLICY PEF OD INDICATED. NOTWITHSTANDING ANY REQUIRBAEbrr, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THE CERTIFICATE MAYBE �''EDORMAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, CONDITIONS AND EXCLUSIONS OF SUCH POLICI,-j. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Co LTR TYPE OF INSURANCE POLICY NUMBER POLICYEFFECTIVE POLICY EXPIRATION LIMIIS DATE(MWDDIYY) DATE(MMIDDlYY) A GENERAL LIABILITY IPR 3757 60&-01 021/01/06 03101/07 GENERAL AGGREGATE $ 4,000,000 X COMMERCIAL GENERAL LIABILITY 'LIM ITS OF POLICY ARE EXCESS' PRODUCTS - COMP/OP AGG $ 4,000,WO —]CLAIMS MADE [X I OCCUR 'OF SIR: $1,000,OW PER OC C PERSONAL &ADV INJURY 4,0 EACH OCCURRENCE OWNER'S & CONTRACTOR'S PROT $ 4,000,000 FIRE DAMAGE (Any one fire) 1,000,wo WED EXP (Anyone person) EXCLUDED B AUTOMOBILE LIABILITY BAP 2938862�03 AQS 03/01/06 03 ,/01107 COMBINED SINGLE LIMIT 1,0001wo X ANYAUTO BODILY INJURY ALL OWNED AUTOS SCHEDULED AUTOS (Per person) BODILY INJURY HIRED AUTOS NON-ONNEDAUTM (Per accident) A ELF-MURED AUTO HYSICAL DAMAGE PROPERTY DAMAGE GARAGE LIABILITY AUTOONLY- EA ACCIDENT $ OTHER THAN AUTO ONLY� ANY AUTO EACH ACCIDENT AGGREGATE EXCESS LIABILITY EACH OCCURRENCE AGGREGATE UMBRELLA FORM OTHER THAN LIMBRELLA FORM WORKERS COMPE SATIONAND 6610,9816 (AZ, ID, MD, VA) 03/01/06 03/01/07 OTH-1 EMPLOYERS! LIABILITY - y ER C 6610995, (AOS) 03/01/06 03,/01/07 EL EACH ACCIDENT $ 1,0w,000 G . F�,� THE PROPRIE'I'm NCL I 6611326 (OR) 03/01/06 03101/07 EL DISEASE -POLICY LIM IT $ 1100.01mlo E PARTNERSIEXEcu-nVE OFFICERS ARE: EXCL 6610999 (NYA� 05/01/06 03101107 $ 1,000,DDO EL DISEASE -EACH EMPLOYEE WORKERS E COMPENSATION CONTINUED 6610997 (FL) 03101/06 03101/07 D 6610996 (CA) .03.101.106 .03/01/07 DESCRIPTION OF OPERATIONS/LOCATIONSfVERICLESfSPECIAL ITEMS CERTIFICATE H �.Pgll 0 �CANCELLATION*'.. j, SHOULD ANY OF THE POLICIES DESCRIBED HEREIN BE CANCELLED BEFORE THE F XPiRATION DATE THEREOF. THE INSURER AFFORDNG COVERAGE WILL ENDEAVOR TO MAIL 'In DAYS Vqk0lEr4 NOTICE TO THE FOR INSURANCE PURPOSES ONLY CERTIFICATE HOLDER NAMED HEREIN, BUT FAILURE TO MAIL SUCH NOTICE SHALL MPO,,L NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER AFFORDING COVERAGE, ITSAGENTS OR �EPRI SENTATIVES. OR THE ISSUER OF THIS CERTIFICATE. MARSH USA INC. BY: V\jalterGiNitrap A;4* - MM1(3102)1. VALID AS OF: 02/27/06 Mar 07 06 10:37a Michael Bedard Pu, 1-401-24G-28GO P.1 PAGF4 LPRRY 7613561493 11OME Imp3toVL%0T CONTIKACT Sold, Furrdshed and Installed by, Date: T1ID At-Ilome ServiceK, Inc', djfh1a The Home Depot At -Home SCM440 343A (,ftenwoqd Street. W-cester.,\4A 01607 Toll Free (90D) 61 Fax: 508-756-2859 .0-5182; Job Y: mK'J,i, 0 f,'024!9 JU Cni. lj�4 16427 CTUOS65522: 4o Atldt*C . 0: city It, Zip Houlc I ;(k*.'J..___!;� �e — City State Zip (it) receive e Home Depol)� , updates Ind promotion fromTh ilwe/Yots ("Purchaser -)l (he owners of the pro petty loclited at the above Installation addml� - oiler to stallition Of all matef i3h; as; k..(1114.0me epol T.7.S.A.' inc. C'Home Depot) to furnish, deliver and arraniZe for the in -,!I the ativhed Spec Sheet #: A Qf& �Q_<, m a rr b'd _ _, incorporated lierein by refelonc6and Bde, P3 reOf- r"ervts the sight to Called mis contralet it, upon re-inspcetion or the job, Holue Depot detcrinines that it 1"rill Its oblisaktions due to a structural probilern with the knuac, psicinF errors or because work required to ;;,�!.i4jlj was nat Included in the Spec %butt or Contr2eL DEplosTr PAVIKENT OPTIONS '::'11XTAN101JNT S 51-P 'Y T s '7f 1)Ep0,;I DUE .)I I'Lt-.'riON Amount due upollclegut6n this I'Allakent Method For NCE DV� 0,'J COMPLETION: Chg,j, CughicpChmk or URPoMAI Qxn%'eaVoneyQrdcr (1,14lia pyeW. to Tile Itome Depot) 2. CTWA Card. dowarother Payment opliculs -M'de 00 lklvw Vi. Mg.C.rd Diwover Affic"M FXPOU The Hulot Impell,,arnal L— rT_h.II..r1.'D1Cr--r1*W d-j�e%s A,,oauat LiElisficieAcculant (HIL&IMCCON"I A..,,ebl. CdL- S —<4. d— (uiLAHIWrnNl-Y) Actiff: Name as it appCots Oft card; J'Y'/ -By laytop(olgil3wrt below. FW4 49M 10 8110- litume DcrAn tolzbotse tha, ut "itto cc iminediately upon work, Purchuer will execute a Completion Certificate ,Itixfactory completion of tha puluilacraiscagre I es it) be jointly aad severany oblipated and liable hereunder. En' 1 -11011: This 11Peelilcul alld including ally Irtnaticing agreement. contain the complde agrMfficla can not be amendegi ot modified undess in writitT in a sepatate agreement signed by bolb parties. NO'TICE TO PURCHASER Dk, s:--� 1101.1.1,b,l I)e(4,o-e vou read It. You art, entitled to Is c4mnplettly Itiled-i fibecontriEfutthctk"YouliiPL XCEY 'In CO C pletion CertiRcate before. this P101.510e, t,&Iw farnhibhm home reptur t"ut- righl'. 0'. EQI 9 0 16 6011heTctosa completion Or the work to requesting Or mcciltICK, a C.'ZING11 U,1rCatr..,:ignmI by the iaw"r Frior to Ille CQJitrACL )f the third busittess day after the thbw ut this contruct. S" Notice lot You 113ilwactiolft at an), tinke prior In mkId ' W Of thig right. Thetv will"t. 0 semice charge equal to 25% of tilt ta)"Ifor.-i "1000"t It the Jot) 14 vl,vit tile Writ bushoesm d2Y. ...... 1A111!kC- TJr�LQW,JlWI:AGRFF_F0 BE B(A)NI) BY of; 1-111S CTWTRACT. IIWL ACKNOWLEWIF K!'_ T H I S CON LAACT AND TWO (XIM K IS ULD Co 1, 1 RS UYTI IL N(Yl'l('l ! 01 'CANCF1 - LATION IS SUMI-M TO REVIEW OF WOTIR :,!('NAI�:RE DELOW, IIWF� tTNT3ERSfAND TlIAI' TilL ALAW C 1'! t:;,V .\N;) lAVE AU1110MIX 1IOMI; I)IYOT TO VERIFY AND Xl;vll-',W MY/01)R CREDIT REr.c)RL) WI'1*11 AN *I' TRIM FROM ALL LLAIJILITY INUIRRIM FROM 'PACKS A(.iEN(_'*.Y AND Rrtl.riAN. OTS N THIS CONTRACI'lYTHERE ARE ANV BLANK$ Vale, SU:m" Or. Date: (�OrMTTMKS AKD WARMNEIV D .-; ;: AT-HOME installed i R 0.-' Siding and Windows SM Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR M893 Registr�40n 3/2006 Ppplement Card THE Home DepojAt�+H------- ffUNROEUN CHI40'6-Y--�Q—F. 3200 COBB GALLERi al-TANTA, GA 30339 Administrator Proudly sold, furnished and installed by RMA Home Services, Inc., a Home Depot authorized contractor. 345 Greenwood St. Unit 2 - Worcester, MA 01607 - 508-756-6686 - Fax 508-756-2859 - Toll Free 800-657-5182 NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEPRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: 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. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 10A. The debris will be disposed of in: Fire Department Sign off.- Dumpster Permit (Location of Facility) Siinatme of Permii Applicant -7 o, Date Aor -__ LOT NO. "Zi a I ZONE SUB DIV. LCIT NO. 0 OF OW LOCATION PURPOSE OF e C xJ/ OWNER-$ NAME NO. OF STORIES OwNews ADDRESS BASEMENT ON SLAB Altr-mITCCT*S NAME SIZE Or FLOOR TomagaS IST &No . SRD BUILDERV &PAN DISTANCE To NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET z i !r-- * POSTS . I "CAR DISTANCE FROM LOT LINES — SIDES :27 I GIRDERS AREA OF' LOT FRONTAGE "MIGHT Of FOUNDATION THICKNESS �4� - stZa OF FOOTING x 19 BUILDING. "6w 06 BUILDING ADDITION MATERIAL Of CHIMNEY Is SUILDIN42 ON SOLID Cot FILLED LAND 19 BUILDING ALTERATION WILL BUILDING CONFORM TO REQUIREMENTS Of CODE viv-1cs. 19 BUILDING CONNECTED To TOWN WATER to BUILDING CONNECTED To TOWN elrwzn BOARD OF APPEALS ACTION. If ANY 16 BUILDING CONNECTED TO NATURAL *A$ L.NT 0 PROPERTY INFORMATION INSTRUCTIONS LAND COBT jr/ SEC BOTH SIDES CST. SLOG. COST tnbt�w / PAGIL I FILL OUT SECTIONS 1 3 IXT. sum. Cos. Pewift. Ff. MT. SLOG. COST PER Room PAGE a FILL OUT SeCTION9 I - ta ELECTRIC MmPs MUST at ON OuTelot Or BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS #P_A"g MUST St FILED AND APF"VZD NY BUILDING INSPECTOR DATE FILED ir IL a samc PERMIT "0. 4 APPROYCO BY OWNER TEL'k- CONTR& W-1-9 CONTRALIC4 AUG Kim INSPECTOR 9 ui r cj U r Cc 4D C ce E CD 0 CL E.E L 0 CD t; cm G3 E CL CD rA ca Em if 2 =2 CIO OC E D cm CLC.3 CD 0 T. .0, cm S CO3 . =C3 0 cm Q 0 CD 'm c PQ 0 CD LL LOS ui E 5,6 ID L- C3 Im Q cm C.3 (D 0 !E r— CL 0 (a = M C3 0 = CL.I.. C/) 0 cf) P-4 ®r C/) z 0 u Cf) C/) Oil 91 4.j 41 'ON E cr. z ca CM r ca M CD E cim cO 0 CD CL cc 0 CL E: cm< E- * -a c cc q o CD ca Z ts CL CO) cc cc "a CO) is Lj co r. con rl) V) ui r cj U r Cc 4D C ce E CD 0 CL E.E L 0 CD t; cm G3 E CL CD rA ca Em if 2 =2 CIO OC E D cm CLC.3 CD 0 T. .0, cm S CO3 . =C3 0 cm Q 0 CD 'm c PQ 0 CD LL LOS ui E 5,6 ID L- C3 Im Q cm C.3 (D 0 !E r— CL 0 (a = M C3 0 = CL.I.. C/) 0 cf) P-4 ®r C/) z 0 u Cf) C/) Oil 91 4.j 41 'ON E cr. z ca CM r ca M CD E cim cO 0 CD CL cc 0 CL E: cm< E- * -a c cc q o CD ca Z ts CL CO) cc cc "a CO) is FIE &A At INSTRUCTIONS DEC BOTH SIDES PAGC I FILL OUT SECTIONS I . a PAGE 2 FILL OUT SECTIONS I . I a ELECTRIC MVTCPS MUST BE ON OUTSIDC OF BUILDING ATTACHCD GAltAGCS MUST CONFORM TO STATIC FIRE REGULATIONS PLANIII MUST BE FILItO AND ^Pp"vltD my BUILDING g"Sp4LCTOR ram Rx, - MO e - R RECORD OF OWNERSHIP JDATE BOOK IPAGE sun Div. Leff rO—C-ATION PURPOSE BUILDING t OWNCR*8 MANC NO. OF STORIES i1xit OWNER'S ADDRESe- BASEMENT ON 8LA8 AftCJ4IT9CT*S NAME SIZE OF FLOOR TINS11119 IST aND *RD 1SUILDER'll NAMC *PAN DISTANCE TO NEARCIT BUILDING 4/ DIMENSIONS OF SILLS " POST111 DISTANCE FROM STREET / � �— DISTANCE FROM LOT LINES — Slolter,, NEAR " Glotocks ARLA OF' LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING. NEW SIXL OF FOOTING x 10 BUILDING ADDITION MATZR:AL Of C14IMNEY 19 BUILDING ALTERATION 18 BUILDING ON SOLID OR FILLED LAND 7 WILL BUILDING CONFORM To REQUIREMENTS 01 CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SCWIER IS BUILDING CONNECTED TO NATURAL GAS L -N? INSTRUCTIONS DEC BOTH SIDES PAGC I FILL OUT SECTIONS I . a PAGE 2 FILL OUT SECTIONS I . I a ELECTRIC MVTCPS MUST BE ON OUTSIDC OF BUILDING ATTACHCD GAltAGCS MUST CONFORM TO STATIC FIRE REGULATIONS PLANIII MUST BE FILItO AND ^Pp"vltD my BUILDING g"Sp4LCTOR ram Rx, - MO e - a PROPERTY INFORMATION LAND COOT EST. SILD0. COST — — f- , , . , (, EST. DLW- COST PER/". Ff. EST. DLDG. COST ram ROOM agirnc PCAMIT No. 4 APPROyto my Z 71 INSPECTOR a OWNER TEL# CONTRAIAM-8 f COMA. LOC. 0; a PROPERTY INFORMATION LAND COOT EST. SILD0. COST — — f- , , . , (, EST. DLW- COST PER/". Ff. EST. DLDG. COST ram ROOM agirnc PCAMIT No. 4 APPROyto my Z 71 INSPECTOR a OWNER TEL# CONTRAIAM-8 COMA. LOC. JLA fa 7f pqy'l �T z ----------- �9 to oo V) Certify that this"-* lo� is not in co flood plain z LA �.Sl, 0 110 t, ra r, k n a,r, QU STO 14 E.C�L frGAGE, IUR PLAN A A N K - GLLINAS.RLGI tT-L E. 0 L 5 u r -t y 0;k 'No4-r,4 ANoovaq , M Ass, L.q c A -r 10 N: -Now :,i) ..CAL I ca -1-1 0MYNIS PIANXISILOC ?_7Z. ATILD ONTHE LAwsOFTHE CiVy/'row, L N,:�R F i:R r :SHOWN ANOTHAT'T CONFOlt"S 'TOTH a ZoNl- . &�.N C IL -VNQ LOT --- E5 a OF _0NA PLAN BY t> so c. W"LN COW—sr— ALCOR DATLD��_ LDIN lc6 N, N -T y E Ca I IST.9ty.oF C) ILL05.. 7,1114, D .,L 50c,K E N M! i NG DEPART Q. .Nf:�7 E L �,A P-4 r s i iroi ol.vs %INC in E As IAI �'z Y'ne-i -7. P i 7�— All A- Aff 2M r- t'. %'�IILDLANG C-EP/-\PTM L FORM U - 1A)T 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 local or state law, regulations or requirements. ****************Applicant fills out this section*�-**t************ APPLICANT: PhonTt�5LIC ):�Qo LOCATION: Assessor's Map Number Parcel Subdivision Lot(s) Street St. Number ************************Official Use only************************ RE�CCW, "NTIONS OF TOWN AGENTS: C6n�9_07vqtion Administrator L'1� Comments Town Planner Comments Food spect -Health L/�,,,§jeftic Ins-pector-'Health Comments Date Approved -q-7 Date Rejected I 6( Date Approved Date Rejected Date Approved Date Rejected Date Approved Date Rejected Public Works - sewer/water connections - driveway permit Fire Department Received by Building Inspector Ho ooao EUILDING DEPARTMESP-7.71 0 Date Location No. C;� 6 '59,S - S L0 A-) e C � d 6/ 'e- PV Date Zo -(?- 03 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # Od "i- (. A ri — 6430' Building Inspector SIGNATURE, -,AIW - . Building Commissio22E��tor of Buildings Date SECTION 1- SITE INFORMATION 1. 1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area (sf) F—tage (ft) 1.6 BUILDING SETBACKS (ft) Front Yard Side Yard Rear Yard Required Provi& Required Provided Requi Pr(yvi&d t54) 1.7 Water Supply ;G.LC.40. 1-5. Flood Zone Infonnation: Public 0 private 0 z0ft Outside Flood Zone 0 1.8 Sewerage Disposal System Municipal 0 On Disposal System 0 SECTION 2 - PROPERTY OWNERSEEIP/AUTHORIZED AGENT 2. 1 Vwner ot Record 76 �ylnlz- Name (Print) Address for Service Telephone Z-/ 2.2 Owner of Record: Name Print SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: 3y 1Yix1jX s -7— Address Sig'n,tur 3.2 Registered Home Improvement Contractor /V,O,C� Company Name d 6*1�- - -VN Address for Service: Not Applicable 0 License Number Expiration Date q —1 Not Applicable 0 Registration Number ? - ;2-- 0 4/ Expiration Date SECTION 4 - WORKERS COMPENSATION (AiG.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application'. Failure to provide this affidavit will 7esult' in the denial of the issuance of the buil�hg permit Signed affidavit.Attached -Yes ....... Y No ....... 0 SECTIONS Descriptionto Proposed W6rk(ch�emck applicable) New Construction 0 Existing Building 0 Repair(s) 0 Alt.erations(s) R-- Addition 0 Accessory Bldg. 0 Demolition 0 Other 0 Specify Brief Description of Proposed Work: ST,oeld�? 1710;?— —LIZ SECTION 6 - ESTIMATED CONSTRUCTION COSTS Itein Estimated Cost (Dollar) to be: Completed by permit applicant (a) Building Permit Fee Multiplier 1. Building 2 Electrical (b) Estimated.Total, Cost of Construction - 3 Plumbing Building Permit fee (a) x (b) 4 Mechanical (HVAC) 5 Fire Protection 6 T91AI (1+2+3t4+5) Check Nuittiber S� r SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WMN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUELDING PERN[IT 1, 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 OWNEgAUTHORIZED AGENT SCLARATION 11 —V/�- as Owner/. 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 VA L-A-AIZ-A- Prm�� Si eofO e e Date NO. OF STOREES SIZE BASENlENT OR SLAB OT �ND SIZE OF FLOOR TRIABERS 3KD SPAN DIDvENSIONS OF SILLS DRvIENSIONS OF POSTS DRvEENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF F001ING X MATERIAL OF CH11VFNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of IVIGL 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 IVIGL c 11, S 150 A. The -debris will be disposed of in: WA",T/,C- 0 V/z n r, , , , TV /Z , *", (Location of Facility) SignaKre of Rerr<Applicaritf- 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 Acciden . ts Mice of Investigations Boston, Mass. 02111 w0rk'ers'Compensatlon Insurance Affl-davit Print -am a homeowner perforrning all work -myself = I am a -sole proprietor and have no one working in any capacity Ad—d-ress 7 P, — 6 9, -:-> — am an employer providing workere compensation for my ern workin ployeL 9 On this job. 2, Phonehk- RA f9NIUMMSeculs coverage as reqdradunderSecUbn 26A OrW4L_ lacan. and/or one yeate ftVrftomnWt as wen as dvg MW tVffWWM46�da"k_ pwmMft. Ora fine W to $ t. 606 _00 penaftles ftVi6.1cMC(a97OPWOWOAM and afM Of(SiOD.Ma day aganst-nu- understan d that a copy Of this atgemwt may b&fMvardedtoff*Ofr*&orkrwW� &#,&wArfbrc&jera" verNkmoop. I do he,#by cwW under the pains awpenav&s Ofpaqivy Uy&d)&kAYn**npMvkbd abme, is bW& and - Carnxt Signature print YffiCial useonly do n6t wrRe in this area to be completed by city or town dfiCW OCheck if immediate mspwse, is reo*uked Buftng Dept x7tact person: phom RKMAY'S COMPENSATION 0 Building Dog - 0 LiMnsing Board D se"I", lectr�ans OffiC6 0 Health DepartrnLr, 't 0 Ofher L: W W IF CD CIS CL Cc cca =CD 0 CJ Eox ci C, =0 C 44- z cm fti P) r.= ca 2 CA ca cm co C4 E CD CLL) cm CD _CO3 RM CMIS C = cc cc 0 0 cm ID CC42 CD CO) 'COLs 0 �Lj CC -0 2, LA- CC 0 CL ..s =:s Z. U= E 4D c03 2 cm 0== = CO) CL 4D -5 0 :6 Go -0 0 . LO) cm b- C CLIS Co U) z 0 U) F� c/) z 0 p u c/) z 0 u cf) cf) u w 04 4S� 6 u 0 40. 'am C13 E CD CD CL 0 CO) cm CO) CD 'm :.e— A02 (D = E co cc 0 co CL Eft C L.) 0 CD Q CL CL coo cc CL. 0 CD CO) ts CL CO3 CL CO2 LLI 0 U) LU U) cc LLJ w Ir w w U) 0 V) 0 0 d c - 2) u co �r. —cd 0 E-4 u w cd —cd ZW Z 0 z U) o cf) IF CD CIS CL Cc cca =CD 0 CJ Eox ci C, =0 C 44- z cm fti P) r.= ca 2 CA ca cm co C4 E CD CLL) cm CD _CO3 RM CMIS C = cc cc 0 0 cm ID CC42 CD CO) 'COLs 0 �Lj CC -0 2, LA- CC 0 CL ..s =:s Z. U= E 4D c03 2 cm 0== = CO) CL 4D -5 0 :6 Go -0 0 . LO) cm b- C CLIS Co U) z 0 U) F� c/) z 0 p u c/) z 0 u cf) cf) u w 04 4S� 6 u 0 40. 'am C13 E CD CD CL 0 CO) cm CO) CD 'm :.e— A02 (D = E co cc 0 co CL Eft C L.) 0 CD Q CL CL coo cc CL. 0 CD CO) ts CL CO3 CL CO2 LLI 0 U) LU U) cc LLJ w Ir w w U) I I C) _�_ C The Commonwealth of Massachusetts Wfice V*q Only Department of Public Safety Permit %a . .- I 19 occul"ey 4 Fee 0"ckad BOARD OF FIRE PREVENTION REGULA11ONS S27 CMR 1ZOO, 3190 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK AH umork to bot performed in accordance vAth the Mas"chusens Elearkal Code. $27 R 12:00 ALL MORHATTON) (PLEASE PRIXTiN nm o;LTrP Date ('J City or Towh of N, M4bV_h,(-- To the Inspector' of Wires: The undersigned applies for a permit to perform the ele cal. work f <:� _L_ , 7��, A- Lo"tion (Stveet & Number) 0> U -_, JJ" J(J Owner or lenant [AIA)OA/ Owner's Address Is this permit in conjunction vith a buLl L Yes [Zy No C] (Check Appropriate Box) Purpose of Buildin _r,)Y_4 1604� Q Ytility Authorization NO. I , r_1 r_1 Existing Service Amps Volts Overhead L_J Undg,rd, L.J ho. of Meters Nev Service Amps Volts Overhead El Undgrd[3 No. of Meters Number of Feeders and Ampacity, Location and Nature of Proposed Electrical Work No. of Lighting Outlets No. of got Tubs Total No. of Transformers XVA No. of Lighting Fixtures Swimming Pool Abov" In- Md. 0 grnd. 0 Generators KVA No. of Receptacle Wilets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners I= ALAAMS No. of Zones No. of Detection and Initiating Devices No. of Sowding Devices ft. of Sol* Cocte-4--ad Detactio';7Sounding Devices Local [:] M=LcLpal [30tber Connection No. of Ranges Total No. of Air Cond. tons No. of Disposals Heat Total Total NO- Of haps Tons XW No. of Dishwashers Space/Arsa Heating KW No. of Dryers Heating Devices KW No. of Water Beaters XW No, of No. of Simns Ballasts LOW Voltage W rinx No. Bydro Massage Tubs Po. of Motors Total HP INSURANCE CDVERAGEi Pursuant to the requirements of Massachusetts Gmaral Laus I have a current Liabiliq Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES* NO [3 1 have submitted valid proof of same to this office. YES[:) NO If you have checked TES, please indicate the type of coverage by checking the appropriate box. ixsuwa J3 Bon 0 omm [:1 (please specify) M r, g r 14 A N T T T g A N r- p r. R 0 T � P n (Expiration' Vate� Estimated Value of Electrical Work 8 Work to Start Inspection Date Requesteds Rou —Final Signed 4..,4er the penalties of perjury: FIRM NAME Licenseit GREGORY TAYLOg Address 4 SAN MATEO DR.C14FT,M,1;P( _LIC. NO. LIC. NWI 9 2 6 8 F 508-255-5517 .. it. Tel. No. OWNERIS IXSURANCZ UAIVMts I an aware that the Licensett does not have the Lnsuraikca coverage —or -1 -t -s sub� tantial equivalent as required by Massachusetts General Laws, and Mat or signature on this it pplic&tL*n waives this requirement. Owner Agent Qlease check one) (Signature of Owner or Agent) Telephone No. PERMIT FEE 7j&n"d'� H28 -7 Date ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....... Cs. 0 W.x .............................. has permission to perform .......... ......... .............. ................... wiring in the building of .... ...... .................... at .6 ......... . ..... . North Andover, Mass. Fee.?.L410 .... . Lic. No. ............................................................. ELECTRICAL INSPECTOR 25. ()o PAID n�qgf�7 14. 6 '4 WHITE: Applicant CANARY: Buildi PINK: Treasurer