HomeMy WebLinkAboutMiscellaneous - 263 JOHNSON STREET 4/30/2018 (2)I
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Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS, Ch. 139, Sec. 3B
To: Building Commissioner or
Inspector of Buildings
1600 Osgood Street
North Andover, MA 01845
RE: Insured: Andrew F. Shea, III and Andrew F. Shea, IV
Property Address: 263-265 Johnson Street
Policy Number: FP2319864
Date/Cause of Loss: 2/20/2015, Water/ice Dams
File or Claim Number: 31798-W
Claim has been made involving loss, damage or destruction of the above captioned property,
which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER
143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS,
CHAPTER 139, SECTION 3B is appropriate, please direct it to the attention of the writer and
include a reference to the captioned insured, location, policy number, date of loss and claim or
file number.
Wade Anderson
On this date, I caused copies of this Notice to be sent to the persons named above at the
addresses indicated above by First Class Mail.
llwI4 5,-- / S- - /'5 -
Signature and Date
ANDERSON ADJUSTMENT CO., INC.
50 Nashua Road, Suite 303
PO Box 1098
Londonderry, NH 03053
This certifies that ......
has permission for gas installation .................
1-7
in the buildings of. . -
jo Z.W,
at ... �Veo-i ...............
Fee-&�-.S�. Lic. Nob'/,�./ ...
Check# 1,?2 �7
......... . North Andover , Mss.
GASINSPECTO
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY MA DATE /3 PE
_11 RMIT #
JOBSITE ADDRESS JV� <�4— JOWNER'S NAME [
GOWNERADDREss
L TE= __________IFAX=
TYPE OR
PRINT
OCCUPANCYTYPE COMMERCIAL EDUCATIONAL RESIDENTIALVd
CLEARLY
NEW: F-1 RENOVATION: 0 REPLACEMENT:E] PLANS SUBMITTED: YESE] N 0 R -J
APPLIANCES -1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER I
COOK STOVE
DIRECT VENT HEATER 77.
DRYER ITJ L.J _3
–7-1
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR C
GRILLE
INFRARED HEATER
LABORATORY COCKS
IMAKEUP AIR UNIT - -
- - - - -
0 "-N
VIt
POOL HEATER
ROOM / SPACE HEATER
ROOFTOP UNIT
TEST
- ----- .......
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
--6THER F— . . ....
......... . .. __j --ill ---- ---
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES NO
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICYO OTHER TYPE INDEMNITY D BOND 01
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
I 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 my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision ofthe
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
011C4 _J
PLUMBER-GASFITTER NAME -L,�.C-&e77 LICENSE# SIGNATURE
IMP Q MGF 01 JP [3 JGF LPGI CORPORATION jj# = PARTNERSHIP 0# LLC [3#
COMPANY NAMEI e ZZ— ADDRESS L
CITY TEL
STATE 2MZIP[0�-�
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The Commonwealth of Massachusetts
D2 Department of IndustrialAcci&nts
Office of Investigations
600 Washington Street
Boston., MA 02111
UV www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/ContractorsAElectricians/Plumbers
Applicant Information Hease Print Leeibly
Name (Business/Organizatiordlndividual): E e.
Address: /W/�V CO'Clk X119
City/State/Zi Phone #: ql)g� 1�f 7
Are you an employer? Check the appropriate box:
Type of project (required):
1. D I am a employer with
4. El I am a general contractor and 1
6. E] New construction
employees (full and/or part-time).*
2Q?J I am a sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet. T
7. E] Remodel'ing
ship and'have no employees
These sub -contractors have
8. E] Demolition
working for me in any capacity.
workers' comp. insurance.
9. F1 Building addition
[No workers' comp. insurance
5. F-1 We are a corporation and its
10. 0 Electrical repairs or additions
required.]
3 -El I am a homeowner doing all work
officers have exercised their
right of exemption per MGL
ILEI Plumbing repairs or additions
myself. [No workers' comp.
c. 152, § 1(4), and we have no
12.0 Roof repairs
insurance required.] t
employees. [No workers'
13FJOther
comp. insurance required.]
!Any applicaritthat checks box#1 mustalso fill outthe section below showing their workers' compensation policy information.
T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a now affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
Iam an employer that isproviding workers' compensation insuranceformy employees. Below is thepolicy andjob site
information.
Insurance Company Name;
Policy # or Self -ins. Lic. 9: _ Expiration 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 requiredunder Section 25A of MGL c. 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 hereby certio under thepains andpenalties ofperjury that the information provided above is true and correct.
Sianature:(!:2��� Date: 311-2
Phone#: q'2 4 le �
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
PermitUcense 9
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing rnspector
6. Other
Contact Person:
Phone#:
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 oftire,
express or implied, oral or written."
An emplqyer� is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in ajoint 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 subdivij - sions shall
enter into any contract for the performance of public 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-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLQ 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 confinn�ation 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 pennit/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 p* ermit to bum 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:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston., MA 02111
Tel, # 617-727-4900 ext 406 or 1-871MASSAFE
Revised 5-26-05 Fax # 617-727-7749
_-www.Mass,g0V1dia,
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TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
Ck
This certifies that ................................. .........
has permission to perform ......... ..........................
plumbing in the buildings of ..................................
at .......................................... North Andover, Mass.
;.r7 -< .............
Fee.'�-./ Lic. No .......
;X PLUM�ING' INSPECTOR
Check #
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
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A
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASF117ING
(Print or Type)
ZVI W, Massachusetts Date Aid -Permit #
PeWit Fee
Building Location Owner's Name Plew/�Cenj
Type of Occupancy
New L]
Renovation Replacement Plans S �"d: YesEj No E]
Installing Comp Name P/0,4
Check one: Certificate
Address—//IO ceg& Corporation
[4-5-irt ner ship
Business Telephone-2olV/1- 7 2i� I Flim/Co.
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE:
I have a current >Wfy insurance policy or Its substantial equivalent which meets the requirements of MGIL Ch. 142.
Yes Fk No []
11 you have checked yes. please Indicate the type coverage by checking the appropriate box.
A liability Insurance policy [&� Other type of Indemnity [I Bond U
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 p-e--rmit application waives this requirement.
Check one:
SignaturWof —Ownet —oi Owner s Agent Ownerr, 1 Agent
I hereby certify that all of the details and infoirnation I haye submitted (or nler:,�l iin,,i.,10 a plica *on at Lie accurate to the best of my
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knowledge and that all plumbing work and installations performed under Ih ep m -for this 1p i at' in compliance wi all
V/ F L a
pertinent proyisions of the Massachusetts State Gas Code and Chapter 142 of the WV s
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Title G litter �,�gnatufe o ice lum e -r— i�-
License Number q
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Journeym3n Inspection Date Requested
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2ND FLOOR
3RD FLOOR
4TH FLOOR
5 T H FLOOR
6TH F L'O 0 R
7TH FLOOR
8TH FLOOR
Installing Comp Name P/0,4
Check one: Certificate
Address—//IO ceg& Corporation
[4-5-irt ner ship
Business Telephone-2olV/1- 7 2i� I Flim/Co.
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE:
I have a current >Wfy insurance policy or Its substantial equivalent which meets the requirements of MGIL Ch. 142.
Yes Fk No []
11 you have checked yes. please Indicate the type coverage by checking the appropriate box.
A liability Insurance policy [&� Other type of Indemnity [I Bond U
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 p-e--rmit application waives this requirement.
Check one:
SignaturWof —Ownet —oi Owner s Agent Ownerr, 1 Agent
I hereby certify that all of the details and infoirnation I haye submitted (or nler:,�l iin,,i.,10 a plica *on at Lie accurate to the best of my
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knowledge and that all plumbing work and installations performed under Ih ep m -for this 1p i at' in compliance wi all
V/ F L a
pertinent proyisions of the Massachusetts State Gas Code and Chapter 142 of the WV s
L',r:,n,e
lumb Of as
Title G litter �,�gnatufe o ice lum e -r— i�-
License Number q
C�`( =Town
Journeym3n Inspection Date Requested
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Date. . ............
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ................. A
has permission for gas installation ....... ........ / ..........
in the buildings of .......................................
.. ...... North Andover, Mass.
at t- 1�".-3 ... � Z. ,' ...........
Fee ...... Lic. Noz� .. ....
GAS INSPECT6R
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Print or Type)
do a4AWV - Massachusetts Date &-/S—
Building Locatic,
Owner's Name�
New E]
sr
Renovation Replacqf4ent [:]
FIXTURE
re rm —it � -07
Permit Fee �r
of Occupancy
Plans Submitted Yes El No E]
Installing Compan N e N q- A Check One Certificate
Address Z� 7,2)"ee�Lj 5/— El Corporation
4WIle Ale 1W M 14 0 k1t 4;—Partnership
Business Telephone 21:y' -d V�- - 17>d 0 Firm/Co
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE:
I have a current insurance policy or its substantial equivalent which meets the requirements of MGL Ch 142
Yes Vy No F�
If you have checked yes, please indicate the type of covering by checking the appropriate box
A liability insurance policy Pr", Other type of indemnity E] Bond F
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 [—] Agent
I hereby certify that all of the details and information I have submitted (or entered) in above,*Iication are tr n ur to the best of
my knowledge and that all plumbing work and installations performed under the permit i for this atic, ill b ' c liance w' all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Ge Laws
B Tffe of License
lumber Sign ture of License Plumber or Gas Fitt
Title Gasfitter
City/Town 5;,Wster License Number /Mva 5(
0 Journeyman I I
APPROVED (OFFICE USE ONLY) Inspection Date Requested
I
EM
Installing Compan N e N q- A Check One Certificate
Address Z� 7,2)"ee�Lj 5/— El Corporation
4WIle Ale 1W M 14 0 k1t 4;—Partnership
Business Telephone 21:y' -d V�- - 17>d 0 Firm/Co
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE:
I have a current insurance policy or its substantial equivalent which meets the requirements of MGL Ch 142
Yes Vy No F�
If you have checked yes, please indicate the type of covering by checking the appropriate box
A liability insurance policy Pr", Other type of indemnity E] Bond F
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 [—] Agent
I hereby certify that all of the details and information I have submitted (or entered) in above,*Iication are tr n ur to the best of
my knowledge and that all plumbing work and installations performed under the permit i for this atic, ill b ' c liance w' all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Ge Laws
B Tffe of License
lumber Sign ture of License Plumber or Gas Fitt
Title Gasfitter
City/Town 5;,Wster License Number /Mva 5(
0 Journeyman I I
APPROVED (OFFICE USE ONLY) Inspection Date Requested
I
Location �/
No. Date 2,4
&ORTN I TOWN OF NORTH ANDOVER
0.
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
TOTAL
1; 1-74
Check #
4,
4"" �]3 Building In VICtor
11
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
TO CONSTRUCT REPATE, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
'APPLICATION
BUILDING PEPMT NUMBER: DATE ISSUED:
SIGNATURE: '000 L���
Building Commiisionedlnf of Buildings Date
.T
,Etor
SECTION I- SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
ZI;7 67
Map Number Parcel Number
,A
1.3 Zoning Information:
Zoning Di;—& �d Proposed Use
1.4 Property Dimensions:
Lot Area (sf) Frontage (ft)
1.6 BUILDING SETBACKS (ft)
Front Yard Side Yard
Rear Yard
ReqWred Provide Required Provi&d
Req*rcd Provided
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information:
Public 0 Private 0 zone Outside Flood Zone 0
1.8 Sewerage Disposal System:
Municipal 0 On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHIEP/AUTHORIZED AGENT
2.1 Owner of Record
Name (Print Address for Service:
k —e, r-2
Sign re Telephone
2.2 Owner of Record:
. Name Print Address for Service:
Signature Telephone
9ECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor:
e;V-- � A �,
Address
Signature -7 Telephone
Not Applicable 0
License Number
Expiration Date
3.2 legistered Home vem Contractor
1-70 71�
Not Applicable 0
0 2C
Company NaffV-1.)
Registration Number
Address
Expiration Date
Signature Telephone
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SECTION 4 - WORKERS COMPENSATION (NLG.L C 152 § 25c(6) I
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 ....... 0
SECTION 5 Description of Proposed Work (check
New Construction 0 1 Existing Building 49r I Repair(s) Alterations(s) 0 Addition 0
Accessory Bldg. 0 Demolition 0 Other 0 Specify
Brief Description of Proposed Work:
Irl -04 ?_ elp ��' - I J(/,- I I L -i' _5�0
I SRCTION A - F.STIMATF.n CONRTRUCTInN M4ZT4Z I
Item Estimated Cost (Dollar) to be
Completedb permit applicant
SE�qNLY
1. Building
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) x (b)
4 Mechanical (HVAQ
5 Fire Protection
-6 Total (1+2+3+4+5)
Check Number
Or,%- I 1U11 I a V W 11 LIK A
,X UX1/,A11VfN M ISE UUMFLEIED WHEIN
OWNERS AGENT OR/tW4=OR,#d*LIES FOR BUILDING PERMIT
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
1, as Owner/Authorized Agent of subject
property
Hereby declare fliat 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
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations 0
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
2,.X � —2 1� -4
Location: J 0 4,3�,9 ae :E=
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a home6vner performing all work
= I am a sole proprietor and have no one working in any capacity
�employerprovlidl wcrkers'ccmpen r my employees working on this job.
r.nmn-qnv nqmp- ;77rSVIV 7eo-1110L-11� 4"�-
c2
itity:
Phone
4 - - 7 tO :) 7L / /3 /V, e � 9-, V t9 X1 o,,,o-
Company name:
Address
City: Phone#:
Insurance Co. Policy #
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00
andlor one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DtA for coverage verification.
i do herby certify under the
Print
the inthrmation provided above is true and correct.
?'a, / ro,-t-
Official use only do not write in this area to be completed by city or town official'
nCheck if immediate response is requi-ed Building Dept
Contact person 7 Phone
FORM WORKMAN'S COMPENSA77ON
�2 01e 6
Phone # tZ /q!: I Z 5?
Building Dept
Licensing Board
Selectman's Office
Health Department
Other
Town of North Andover tkORTH
Building Department 0
27 Charles Street
North Andover, Massachusetts 0 1845
(978) 688-9545 Fax (978) 688-9542 riD
DEBRIS DISPOSAL FORM
In accordance with the provisions of MGL c 40 s 54, and a condition of
Building permit the debris resulting fi7om the work shall be disposed
1_:
of in a properly licensed solid waste disposal facility as defined by MGL cl, 1, sl 50a.
The debris will be disposed of in /at-
dC7
V
Facility loc tion
)c/
SignSt-ure of Abp 'cant
ate
NO ' TE- A demolition permit from the Town of North Andover must be obtained for this
project through the Office of the Building Inspector.
FORM - U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to venify that all -necessary ap,roval / permits from
p
Boards and Departments having junisdiction have been obtained. This does not relieve the
applicant and or landowner from compliance with any applicable requirements.
APPLICANT 00 /V Erg rso PHONE r—i�g P
ASSESSORS MAP NUMBER 97 LOT NUMBER
-!:,-A - Lo
ZIA�Xbih.,�
STREET ";�4 3 �=_STREET NUMBER
i—d a a a a a a a a a 8 a M a a a 0 0 00down"Nagam " .... `0
OFFICIAL USE ONLY /* 14-
0 N -940.
kk. .... . 1
REC NgvENDATIONS OF TOWN AGENTS ;�_
a 0 E a a d N 4 a M 8 a was M a N R a a M W 0 N x go
DATE APPROVED.(0
CMSERVATION ADMINISTRATOR
%_ i DATE REJECTED
CA (A AJ AJ
��.=4 r e "y
TOWN PLANYEY�nV,_)
COMMENTS,
DATE- APPROVED /, I L2- �2� o )
DATE REJECTED
DA'I1 APPROVED
FOOD INSPECTOR - HE.AL'111 DATE REJECTED
DATE APPROVED
SEPTIC'NSPECTOR - HEALTH
DATE REJECTED
COMMENTS
PUBLIC WORKS — SEWER / WATER CONNECTIONS
DRIVEWAY PERMIT
DATE APPROVED
FIRE DEPARTMENT
DATE REJECTED
COMMENTS
RECEIVED BY BUILDING INSPECTOR DATE
.'46, (0y:? -�L/'
IL"API^
MORTGAGOR 2AP &mr—i
ADDRESS OF PRINCIPLE BUILDING
7,c*3-Z(or 0WA&KJA--.
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E K SURVEY INC
# HAVERHILL, MA #
Phone 978469-1985 4 Fax 976-469-7046
DEED REF.
— V96 PG. Z2z
PLAN REF. 7?f(p
DATE OF INSPECTION rd-!qVoq zaab
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RUDEL
No. 36mg
CERTIFICATION TO: — NuM40144X MIM 4'. The location of the principle 5tructure/s
This Mortgage Plot Plan was prepared specifically for ej CfS1 CoWkV4K
mortgage purposes only and it is not intended or represented 1V 10 vhth the local zoning bylaws in effect when constructed
to t>e a property line or land survey. This plan is not to be used and/ or is exempt from violation enforcemnent
to establish any of the prop" lines for any purpose. No action under Mass B -L Title VII, Chap. 40A, Sec. 7.
responsibility is extended to the land owner or occupant. 0 Subject building is not in a Flood Hazard Area.
This certification is based on the location of survey marker 0 Subject building is in a Flood Hazard Area.
o(others. Flood Hazard determined from the FIRM map#
Dated
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Location
No. Date �z
of AORTII TOWN OF NORTH ANDOVER
"A W
Certificate of Occupancy $
Building/Frame Permit Fee $ 91-
I CHUS
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # 1/w/
13 7 lk 7 L11, I ( Lc � ---
Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAI�, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
..............
BUELDING PERNUT NUMBER: C/-// DATE ISSUED:
SIGNATURE: / 7 X4�
Building CpMadssioner/lEs wor of BuildiiTg—s Date
SECTION I- SITE INFORMATION
1.1 Property Address:
1.2 Assessors; Map and Parcel Number:
A—)
Map Number
Parcel Number
1.3 Zoning Information:
1.4 Property Dimensions:
Zoning Dis—U �ct Proposed Use
Lot Area (sf)
Fronta (11)
1.6 BUILDING SETBACKS (ft)
Front Yard Side Yard
Rear Yard
Required Provide Required Provided
Required Provided
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information:
1.8 Sewerage Disposal System:
Public 0 Private 0 Zone Outside Flood Zone 11
municipal 0 On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSEE[P/AUTHORIZED AGENT
2.1 Owner of Record
10� ?nza��� 1,030
Name (PriA Address for Service
Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
I i9ens onst
11.1 L L' ed C ruction Supervisor:
/ I
Not Applicable 0
.km 7�)u Ya",�
Lic, - ed qonstruction Supervisor:
A -7
�-�O'--Bc-k
License Number
&,3
Address
ic
0
Expiration Date
Signature Telephone
3.2 Registered Home Improv ent Contractor
77
Not Applicable 0
Y -C -"Q-
ConKny Name
-7p-u .71� �- &-3
Registration Number
Address
o"
Expiration Dat
Signature Telephone
AW I-,"
SECTION 4 - WOREERS COMPENSATION (AG.L. C 152 § 25c(6) I
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this aft
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes ....... 0 No ....... 0
SECTION 5 Description o Proposed Work Ccheck applicable)
�ck
New Construction 0 Existing Building 0 Repair(s) 0 erations(s) 0 Addition 0
Accessory Bldg. 0 Demolition 0 Other 0 Specify
B . fDe f Proposed Work:
I SRCTION 6 - F.STYMATF.D C0NqTR1TCT1nN r0rTIZ I
result
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
0 FFICIALVStONLY
1. Building
(a) Building Permit Fee
Multip ier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) x (b)
4 Mechanical (HVAC)
5 Fire Protection
6 Total (1+2+3+4+5)
Check Number
btL;IIUIN'/aUWfNERAUI'IiUKIZA'I'IUIN TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUI]IDING PERMIT
1, as Owner/Authorized Agent of subject property
Hereby authorize Rl� to act on
My behalf, in all matters relatj*e to work thonpzed qbthis bui g permit application.
Signature of Owner Date
SECTION 7b OWNERJAUT-110,RIZED 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
M
Town of North Andover tkORTF,
1 61
+ 0
Building Department 0 YL
27 Charles Street
North Andover, Massachusetts 01845
(978) 688-9545 Fax (978) 688-9542
DEBRIS DISPOSAL FORM
In accordance with the pr of MGL c 40 s 54, and a condition of
Building permit # 11 the debris resulting from the work shall be disposed
of in a properly licensed soli waste disposal facility as defined by MGL c1l, s150a.
TheZris will be disposed of in -
f -tL
/a
e��"6Wa,w T�
Facility
Signature of Applicant
Date
NOTE: A demolition permit fi7om the Town of North Andover must be obtained for this
project through the Office of the Building Inspector.
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