The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 264 JOHNSON STREET 4/30/2018 (2)N? 0 1p 0 Location No. Date TOWN OF NORTH ANDOVEFF 0 Certificate of Occupancy $ 4L Building/Frame Permit Fee $ Foundation Permit Fee - Other Permit Fee Sewer Connection Fee Water Connection Fee TOTAL 10353 Building Inspector Div. Public Works ;R3flT NO.- / 7�� — MAP i -40.o--9 7 TO -KE I APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE I INSTRUCTIONS SEE BOTH SIDES PAGE I FILL OUT SECTIONS 1 3 PAGE 2 FILL OUT SECTIONS 1 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTAC�ED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FLkED �1)d 3 ) -/ RE OF OWNER OR AUTHORIZED AGENT f F E E PERMIT GRANTED,� 19 1� 6-Tte- I i' �t oo 6,- 00 /� (�� 5--3 ',�- 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST EST. BLDG. COST PER SQ. IFT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BUILDING INGPKCTOlt �7 OWNERTEL# 4y CONTR.TEL.# CO NTR. Lic. # H.I.C.# 6�72'07 7 LOT NO. o o 0 ? 2 RECORD OF OWNERSHIP JDATE BOOK 1PAGE 1-1 SUB DIV. LOT NO. -- I F LOCATION PURPOSE OF BUILDING OWNER'S NAME r,).7 /a).+# L_ -j, i5� L/g, NO. OF STORIES SIZE OWNER'S ADDRESS U-0 s7— BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET -wo-STW-- DISTANCE FROM LOT LINES - SIDES REAR GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING x 18 BUILDING ADDITION 12 Ke T -K) pi MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE 16 BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER 16 BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS SEE BOTH SIDES PAGE I FILL OUT SECTIONS 1 3 PAGE 2 FILL OUT SECTIONS 1 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTAC�ED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FLkED �1)d 3 ) -/ RE OF OWNER OR AUTHORIZED AGENT f F E E PERMIT GRANTED,� 19 1� 6-Tte- I i' �t oo 6,- 00 /� (�� 5--3 ',�- 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST EST. BLDG. COST PER SQ. IFT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BUILDING INGPKCTOlt �7 OWNERTEL# 4y CONTR.TEL.# CO NTR. Lic. # H.I.C.# 6�72'07 7 I OCCUPANCY SINGLE FAMILY 11 HEATING SiCIRIES MULTI. FAMILT-� OFFICES APARTMENTS TIMBER BMS. & COLS. STEAM CONSTRUCTION 2 FOUNDATION HOT W'T*R OR -VAPOR 8 INTERIOR FINISH CONCRE7E AIR CONDITIONING 7 NO. OF ROOMS CONCRETE BL7Z -RADIANT UNIT MEATERS PINE GAS BRICK OR ST&NE B'M'T lit 1 -3rd HARDW D NO HEATING PIERS PLASTER DRY WALL 3 BASEMENT 11 1 FkTTIC ARE PLACES 4 WALLS FLOORS CLAPBOARDS 2 3 DROP SIDING NCEE WOOD SHINGiES EARTH ASPHALT SIDI�� _f�A_RDVfD ASBESTOS SIDING COMMON STUCCO ON FRAME 5 ROOF WINING JPERIOR j POOR E�[_QUATE I NONE 10 PLUMBING BUILDING RECORD 12 THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. t 1 11 ATILE 6 RAMING WOOD JOIST TILE FLOOR DADO 11 HEATING PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. & COLS. STEAM STEEL BMS. & COLS. HOT W'T*R OR -VAPOR WOOD RAFTERS AIR CONDITIONING 7 NO. OF ROOMS H'T'G -RADIANT UNIT MEATERS GAS Oil B'M'T lit 1 -3rd ELECTRIC NO HEATING oz ON r-4 4N rl; rA 4 ui CLM 'Cow u �2 8 LL4 w V) 0 or. 0 0 �2 r. u .4 —co r. 0 C: lz go V) o E V) ui CLM M 0 P-4 CO 1-4 F� CO z 0 CO z 0 u 0 4-01 E CL. CA CM C CA ccl ca co 0 CD L- i�. = CL. CZ CD CL CL CL cmcc ca cc CL 0 CD CIO MPP CD CL ca cc cc "a C40 CL Cc *Coo W= CF 06 'cc to cm mi %D cc "go a CM CLC.3 LZ A .L ie:s ccrl, 0 Cc ma r C=M 0 CL c C3::, LA- cc, m 0 I cc Lu to CL= CC23 z C2 0 CL 32 M 0 P-4 CO 1-4 F� CO z 0 CO z 0 u 0 4-01 E CL. CA CM C CA ccl ca co 0 CD L- i�. = CL. CZ CD CL CL CL cmcc ca cc CL 0 CD CIO MPP CD CL ca cc cc "a C40 Town of North Andover OFECE OF COMMUNITY DEVELOPMENT AND SERVICES 146 Main Street WILLIAM J. SCOTT North Andover, MaSsachusetts 0 1845 Director In accordance w ,ijlLthe provisions of MGL c 40 S 54, a condition of Building Permit Number '7_� is that the debris resulting from this work shall be disposed of in a property licensed solid waste disposal facility as defined by MGL c I 11, S 150A. The debris will be disposed of III: 'F,�z /V, 14. (Location of Facility) I Signature of Permit Applicant 31 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. BOARD OF APPEALS 6M9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Registration jo2097 INDIvINAL F lyge on 06/30/98 ExpiTati BRADIV, JR �O,Ujton DTive/ Box 448 "ampstead N" 03826 ADMINIS-MA'TO2 0 9 Lpcation 2 6 No. Date ORT" TOWN OF NORTH ANDOVER Certificate of Occupancy $ - ------ Building/Frame Permit Fee $ 0 0 Foundation Permit�,ee $ 11�' 00 _ . $ Other Permii Fee �,-'Sewe.(Con nect ion Fee $ W i?Connection Fee $ ate 01, TOTAL J. 0 49 I A Building Inspector 6229 Div. Public Works PERVIT NOf 2. C A2 APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. 4-� /PAGE I MAP +40. LOT NO. 12 RECORD OF OWNERSHIP IDATE BOOK ;PAGE ZON E SUB DIV. LOT NO. LoCATION RPOSE OF BUILDING 'C 401) A.) f)J00 0 Z '4 1 OWNER'S NAME mldw� NO. 011"ATORIES SIZE OWNER'S ADDRESS q :j� 1�ovy e,,fl 7— BASEMENT SLAB ARCHITECT'S NAME SIZE OF FLOOR �TERS IST 2ND 3RD BUILDER'S NAME SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES - SIDES REAR GIRDERS 1XI AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS te-B0+h9+P*G NEW __faj11nM1h16_ �JoLj/ SIZE OF FOOTING kl� IS BUILDING ADDITION MATER:AL OF CHIM IS BUILDING ALTERATION IS BUILDING O��OLID OR FILLED LAND WILL 9=4G CONFORM TO REQUIREMENTS OF CODE IS BUILD!>Q�`CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS B��ING CONNECTED TO TOWN SEWER 41BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS SEE BOTH SIDES PAGE I FILL OUT SECTIONS 1 3 PAGE 2 FILL OUT SECTIONS 1 12 4 ELECTRIC METEPS MUST 13E ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED PERMIT GRANTED OWNER TEL. #A� �'o 40, CONTR. TEL. 19 C0117 Pn gn't / PROPERTY INFORMATION COST I �' EST. BLDG. COST EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BOARD OF HEALTH PLANNING BOARD BOARD OF smAcTmcm SIUILDINW -INGPECTOR 1- 0 BUILDING RECORD OCCUPANCY 12 �INGLE FAMILY S-ORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT. AND DISTANCE FROM MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA - APARTMENTS RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE - a 2 13 CONCRETE BL K. INE BRICK OR STONE HARDW D PIERS PLASTER 6R -Y —WA L L —N — — (7N—F I 3 BASEMENT I I AREA FULL FIN. B M T AREA 1/1 1/2 l/. FIN. ATTIC AREA NO 8MT FIRE PLACES HEAD ROOM MODERN KITCHEN 4 WALLS 9 FLOOR$ CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE -iARTH WOOD SHINGLES ASPHALT SIDING HARDW'D —COMtACN ASBESTOS SIDING VERT. SIDING �SPH I—ILI STUCCO ON MAiO--NRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. & FLOOR_ BRICK ON FRAME CONC. OR CINDER BILK. STONE ON MASONRY WIRING STONE ON FRAME SUPERIOR !OOR r 5 ROOF -�—DEQUATE NONE 10 PLUMBING GABLE -- I -dip BATH (3 FIX.) G—AMBRE Ll iTA—Tj�SHED MANSARD TOILET RM. (2 FIX.) WATER CLOSET ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING TAR & GRAVEL STAL SHOWER ROLL ROOFING MODERN FIXTURES Tii-E FLOOR TILE DADO 6 F M =IN G 11 HEA71NG WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER EMS. & COLS. STEAM STEEL BMS. & C61—S. HOT W*T*R OR VAPOR WOOD RAFTERS AIR CONDITIONING RADIANT H'T'G IT HEATERS GAS__ 7 NO. OF ROOMS OIL Sl 7� B'M'T 2nd ELECTRIC NO HEATING 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 local or state law, regulations or requirements. ****************Applicant fills out this section***************** /APPLICANT: Phone -bB Z-cD07 ._,.40_�CATION: Assessor's Map Number Subdivision Parcel Lot (s) cz,� � -c),( - — ;1 --Street — - �) z a ff /J 9 -) Sle E 1,- 7 St. Number ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Conservation Administrator Comments Town Planner Comments Food Inspector -Health Septic Inspector -Health Date Approved Date Rejected Date Approved Date Rejected Date Approved Date Rejected Date Approved clo Date Rejected Comments Z&- Sez0z1,6 - V ",&,e0A1 ssbs Public Works - sewer/water connections - driveway permit Fire Department Received by Building Inspector Date 1� COMMONWEALTH OF DEPARTMENT OF PUBUC SAFETY 1010 COMMONWEALTH AVE. MASSACHUSETTS BOSTON, MASS. 02215 I ENCLOSE CHE CK OR MONEY ORDER LICENSE EXPIRATION DATE z lt,'S 3 CONSTR. SUPERVISOR FOR REQUIRED FEE, ,0613011993 MADE P,AYABLE TO RESTRICTIONS EFFECTIVE DATE LIC -NO. NOW > G06/30/1991 002836 "COMMISSIONER OF PUBLIC SAFETY" r A -PAUL R CHARLAND (DO NOT SEND CASH). iSS4'030-24-7958 45,JULIETTE ST; ' ANDOVER MA 01810 PlEASE N04MIDCREASE PHOTO (BLASTING OPR ONLY) FEE: 100.00 EfFECTIVE-le'011c' 9 HEIGHT; NOT VALID UNTIL SIGNED BY LICENSEE AND OFFICIALLY MOT STAMPED OR SIGNATURE OF THE COMMISSIONER DOB: 07110/1933 ",�70 NOT' DETA CDON&E STUr THIS DOCUMENT MUST BE CARRIED ON THE PERSON OF THE HOLDER WHEN ENGAG- TU IF UIENSEE SIGN NAME IN FULL -ABOVE SIGNATURE LINE OTHERS - RIGHT THUMB PRINT E 0 IN THIS OCCUPATION M.SSIONER 20OM-2-87-81429 2 �-LD �- CP m z Z I VL/4 51-01 V -r lip I- r r c r!== z Ac c c r!== == = == 0 m a z 70 4 Z> m m z m r m >1 m N < J 0 3: 2 �-LD �- CP m z Z I VL/4 51-01 V -r lip I- r r c r!== z Ac c c r!== == = == 0 0 m a z 70 4 z m z m r N m 0 0 3: 0 0 m a z 70 4 z m m -0 CP can n M -4 am -4 r = =:;,a = =:i, 2 d W =-i, - = =::ij 3 = ==�, a S W I M M I N GF F='<D <D L C: E N T E F;� 410 SOUTH UNION STREET LAWRENCE. MASSACHUSETTS 018,43 N 0 3: ri Z Z I S W I M M I N GF F='<D <D L C: E N T E F;� 410 SOUTH UNION STREET LAWRENCE. MASSACHUSETTS 018,43 Loy rl.&-P 7 4 Jv H -fu, 0 T Ice;, Oki !�o AS BUILT PLAN.' 0 F e 6,FL4cpH a m -r J SUOLN"URFACE DISPOSAL SYSTEM ,LOCATEDIN 0 e:T 1.1 -A�400VIFV- AS PREPARED FOR DATE: SCALE: 10'r -fol MERRIMACK ENGINEERING SERVICES,, INC. PROFESSIONAL ENGINEERS 0 LAND SURVEYORS 0 PL4NNERS "PARKSTREET 0 ANDOVER. MASSACHUSETTS 01810 Or TEL (617)475-3M3.3M5?21 x 5 c, 7, 1 Pllrg, SCY. 5g -Oct wr 67, -1:� eq, -9:� -T, g 44t, ze?, r Z..*5 ±1_1 vo? -T� e. -Z 7.7 -r- en Oki !�o AS BUILT PLAN.' 0 F e 6,FL4cpH a m -r J SUOLN"URFACE DISPOSAL SYSTEM ,LOCATEDIN 0 e:T 1.1 -A�400VIFV- AS PREPARED FOR DATE: SCALE: 10'r -fol MERRIMACK ENGINEERING SERVICES,, INC. PROFESSIONAL ENGINEERS 0 LAND SURVEYORS 0 PL4NNERS "PARKSTREET 0 ANDOVER. MASSACHUSETTS 01810 Or TEL (617)475-3M3.3M5?21 5g -Oct 67, -1:� eq, -9:� -T, g 7 , 11 ? r Z..*5 ±1_1 vo? -rg-- 11 7.7 Oki !�o AS BUILT PLAN.' 0 F e 6,FL4cpH a m -r J SUOLN"URFACE DISPOSAL SYSTEM ,LOCATEDIN 0 e:T 1.1 -A�400VIFV- AS PREPARED FOR DATE: SCALE: 10'r -fol MERRIMACK ENGINEERING SERVICES,, INC. PROFESSIONAL ENGINEERS 0 LAND SURVEYORS 0 PL4NNERS "PARKSTREET 0 ANDOVER. MASSACHUSETTS 01810 Or TEL (617)475-3M3.3M5?21 0 PIC$ ON r-4 L�l W W� 0 u 0 u 0 �o PW z 0-4 cz 0 u u co x P4 to Z cz 0 to 0 C4 C/5 —cz �c 0 E-4 u PW to —cz a. E-4 Ow 0-4 u z Q) 0 ui 0 z ca C2 ci CD CE CD CJ ts cn CD E ca co !! C� CD 3: Cos ca CLC.3 LO, ,CD - cm CD A2 r - me C=, cm CJ -41�,c CL 0 L- CD CD 3: 0 0 �- CD *� me=R :5 -LD 'COD — I — a ca -EL M j LU E C.D co CS 1-. 0 CDjE I= — C.3 CD CD = CL W CDM M .0 co = CL*. - 0 4;� P-4 01 C/) 71 0 u rn 0 C) 4-j �u Q4 u 0 CLI) E CD z CD I ca 0 M E CD CD Q m CL CO3 0 M (A C.3 cc co CL CO) .s (D CM Co cc M 0 co CL 0 CL CD .4--f 00 co CL COD LL v cc LU CL cc C:) Uj cc C) m L) 0 Zi z LL CD a to -Z Location 064/ 10 No. 0/�S— — Date VICO23 A 1401tTh TOWN OF NORTH ANDOVER AL "dwilik 0 40 Certificate of Occupancy $ -4zi- Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 38sca- 18 5 �,7 -1,/v /y, 6�,- Building Inspector J.- .31 J. Z Jul r 11JAMA I 111jil 1. 1 Property Address: 1.2 Awessors Map and Parcel Number: 6)GV c117 C/1 Ale - q A1,6 0 vzza Map Number Parcel Amber 1.3 Zoning Information: 1.4 Property Dimensions: Zoning 5�i; �d Proposed Use Lot Am (sf) Frontage (tt) 1.6 BUHDING SETBACKS (ft) Front Yard Side Yard Rear Yard Required Provide Required Provi&d ReqWred Provided 1.7 Water Supply M.GJ-C.40. 54) 1.5. Flood Zone kfonnation: 1.9 SawerW Disposal System Public 0 Prhaite 0 Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System 0 SECTION 2 .- PROPERTY OWNERSE11P/AUTHORIZED AGENT Historic District: Yes No 2.1 Owner of Record A?U* Name (Print) Address for Service: 5� ZY — Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable 0 7rx-Fa e� R T Ts H46 -a - Licensed Construction Supervisor: License Number Ro /7411"A/2b �(JWIT171914- A919' Address q --o17-6-7- 781-6 q 7 - e9d471� Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable 0 S-7�- FEY,- H E-/Z- Cobpany Name 1,R3 6 69 's �, 4 j Registration Number Xd ss Signature *7ffl - 6 4�� Expiration Date Teliphone 00 M X z 0 0 z M 90 0 on M r" ro 1110101111 z G) TONM OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT a= RENOVATFO OR DEMOLISH A ONE OR TWO FAMILY DWELLING U'. BUILDING PERMrr NUMBEEL DATE ISSUED: 6?, /,57- (C � SIGNATURE: /0* 0 I Building Commissioner/192L=Wr of Buildings Date J.- .31 J. Z Jul r 11JAMA I 111jil 1. 1 Property Address: 1.2 Awessors Map and Parcel Number: 6)GV c117 C/1 Ale - q A1,6 0 vzza Map Number Parcel Amber 1.3 Zoning Information: 1.4 Property Dimensions: Zoning 5�i; �d Proposed Use Lot Am (sf) Frontage (tt) 1.6 BUHDING SETBACKS (ft) Front Yard Side Yard Rear Yard Required Provide Required Provi&d ReqWred Provided 1.7 Water Supply M.GJ-C.40. 54) 1.5. Flood Zone kfonnation: 1.9 SawerW Disposal System Public 0 Prhaite 0 Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System 0 SECTION 2 .- PROPERTY OWNERSE11P/AUTHORIZED AGENT Historic District: Yes No 2.1 Owner of Record A?U* Name (Print) Address for Service: 5� ZY — Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable 0 7rx-Fa e� R T Ts H46 -a - Licensed Construction Supervisor: License Number Ro /7411"A/2b �(JWIT171914- A919' Address q --o17-6-7- 781-6 q 7 - e9d471� Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable 0 S-7�- FEY,- H E-/Z- Cobpany Name 1,R3 6 69 's �, 4 j Registration Number Xd ss Signature *7ffl - 6 4�� Expiration Date Teliphone 00 M X z 0 0 z M 90 0 on M r" ro 1110101111 z G) I SECTION 4 - WORKERS COMPENSATION (MLG.L C 152 6 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 o Proposed Work (check applicable) New Construction 0 Existing Building 0 Repair(s) 0 Alterations(s) 0 1 Addition 0 Accessory Bldg. 0 Demolition 11 Other Specify _WAVDOW 5 Brief Description of Proposed Work: /AI:5�MU- 7 7L Ld U I X? 0 Led 11 AJ 47— 5 SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applican t .014LY USE- I Building (a) Buildin�V�t Fee' Multiplier 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) IY4 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERNUT T 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 OWNER/AUTHORIZED AGENT DECLARATION 1, asOwne uthorizedAgent fsubject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Nam Signatureof 0 er/Agent Date . . . . . . . . . . . . . . . . . . . . NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR lUvMERS I ST 2ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHRANEY IS BUELDING ON SOLID OR FELLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE C- 7-, ReLy. 123088 ProWindows Inc. www.prowindows.com 86 HOWARD STREET. WALTHAM. MA 02451 (781) 647-9225 FAX (781) 647-9392 LICENSED INSURED ................................................................................................................................. NAME: Michael & Ursula Butler DATE: 7/12/05 ADDRESS 264 Johnson St, North Andover, KA, 0 1845 HOME 978 682 6087 WORK CELL EMA][L Butlenn963,1daol.com Fumish and install the following, all to include LowE/Argon filled glass. 7 PELLA ARCHITECT SERIES CASEMENT WINDOW UNITS, PINE WOOD INTERIOR, BLACK EXTERIOR, CHAMPAGNE HARDWARE AND SNAP IN GRIDS TO CLOSELY MATCH E)aSTING SETUP. INSTALLATION INCLUDES REMOVING EXISTING STEEL WINDOWS, HARDWARE, AND EXTERIOR TRIM. INSTALL NEW WINDOWS LEVEL AND PLUMB. CAULK AND INSULATE. INSTALL INTERIOR WINDOW SCOTIA. WRAP EXTERIOR WITH CUSTOM BEND BLACK ALUMINUM. CONTRACTOR RESPONSIBLE FOR REMOVING ALL DEBRIS. 3 TWO WIDE CASEMENTS, WIDER WIDTHS # $1850.00/window $5,550.00 4 TWO WIDE CASEMENT @ $1,750.00/window $7,000.00 0 1 OVERSIZED PICTURE WINDOW WITH 36 LITE SNAP IN GRID $2,275.00 Estimated time to complete is 2-3 days rOTAL INVESTMENT = $14,825.0 L� '5 b 0 0 MAKE CHECK PAYABLE TO PROWINDOWS INC. Estimate includes cost of all trash disposal. Painting is responsibility of the homeowner. All workmanship is warranted for life. Payment terms are 1/3 up front, and balance due upon completion of contract unless otherwise specified. Any and all extras will require separate contracts and are payable prior to start of work. Contractor, to be reimbursed by homeowner, will pull permits if necessary. Work to begin 4-6 weeks following receipt of deposit. Contract is good for 30 days after�ontractor si$nature below. I accept the terms of this contract. date: _�WC'�57 Signature of contractor. JU L -n J\.- date: bT��T C6 -1 ACOIRP. CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 08/11/2005 PRqDUCER (781)344-3200 FAX (781)344-142S Malcolm & Parsons Ins. Agcy. Inc. 6 Freeman St. P.O. Box S27 Stoughton, MA 02072 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED ProWindows Inc. 86 Howard Street Waltham, MA 024S1 INSURERA: H T Bailey South INSURERB: American International Group INSURER C: INSURER D: INSURER E: d'nV=PA(' =Q THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDIN ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NSR LTR INSRC ADD'd TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY DATE EXPIRATION LIMITS AUTHORIZED REPRESENTATIVE 00 ig GENERAL LIABILITY NPP972098 07/23/2005 07/23/2006 EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 50,000 CLAIMS MADE M OCCUR MED EXP (Any one person) $ 5,000 A PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 1,000,000 7 POLICYF__j JERCO� F-1 LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) BODILY INJURY $ ALL OWNED AUTOS SCHEDULED AUTOS (Per person) BODILY INJURY $ HIRED AUTOS NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR F1 CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION AND 7229089 06/09/2005 06/09/2006 1 TWC STATU ORY "M jS I JOTH rR EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $ 500,000 B ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. DISEASE - EA EMPLOYEE $ 500,000 OFFICERIMEMBER EXCLUDED? If yes, describe under E.L. DISEASE - POLICY LIMIT $ 500,000 SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS CIFIRTIFICATF Hni nFR fAK1fCI I ATIMI ACORD25(2001/08) FAX: (866)786-8470 j/@ACORD CORPORATION 1988 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Service Magic Inc. EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL Attn: Oscar Ugarte DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, 14023 Denver West Parkway BUT FAILURE TO MAIL SUCH NOTICE SHALL I OSENOOBLIGATIO ORLIABILITY Building 64 Suite 200 OF OR R1 S. NY KIND UPON THE INSUREI ;,;rs 14 Golden, CO 80401 AUTHORIZED REPRESENTATIVE 00 ig ACORD25(2001/08) FAX: (866)786-8470 j/@ACORD CORPORATION 1988 �Pll M"T.CGINTROCTOR BOARD OF BUILDiNG REGULATIONS License: QQNSTRUCTION SUPERVISOR t. Nu!n or -CS, 066853 i _th rt PROW] NPOW-S. N Tr. no: 11404 JEFFREY ;F JEFFREY P F SHE: 86 HOWARD T T WALTHAM, 02154 �Pll M"T.CGINTROCTOR g 12M PROW] NPOW-S. N JEFFREY ;F 46NOWM0, ST WALTIwww 14154 The Commonwealth of Massachusetts Department of Industrial Accidents fill Office of Investigations 600 Washington Street I I III Uk[ I Boston, MA 02111 www.mass.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/organization/Individual): t4 p6U) tic— Address: SIG ALd W A- Q_t- Cjty/State/Zip:_W!41,��, /VA. LIP Phone#: 7el — 4 L/ 7 — ?6;�4 619� Are you an employer? Check the appropriate box: I -XI am a employer with 6- 4. 0 1 am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2.E1 I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.0 1 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. 5. F1 We are a corporation and its officers 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. 0 New construction 7. E] Remodeling 8. E] Demolition 9. E] Building addition 10.0 Electrical repairs or additions 11.0 Plumbing repairs or additions 12.n Roof repairs 13F] Other "Any applicant that checks box # I must also fill out the 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 new affidavit indicating such. I +Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurancefor my employees. Below is the policy andjob site information. Insurance Company Name: 4AfeMlC#9A1 At 4,!5-1W A -ri -0 AJ -1i t �fP,_o LP Policy # or Self -ins. Lic. Z�J ? 69 F Expiration Date: 46 — Job Site Address:A��.o IJAJSO d6.A1VtQI1)E:R_ City/State/Zip: 13 L) 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 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 certify under the pains andpenalties ofperjuiy that the information provided above is true and correct. Qfficial use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License #. _,:�3 - 40 Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 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 of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance 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 (LLC) or Limited Liability Partnerships (LLP) with no employees other than the mernbers. or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the pen -nit 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 pen-nit/ricense 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 permit 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 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 . www.mass.gov/dia �o 2 le w; W 0 0000 cl 110" 0 F- O.L ui 0 E u x a4 u X co 0 C/) cl 110" 0 F- O.L ui C/) z 0 C/) U Cf) z 0 u Cf) z 0 u Cf) Cf) 0 C, rs u C CD zoo C E ts CD z CL. CO) cm ca .co) FE ID CD CD L- I.. = CL C2 CD CL CL CA S C4 CL cl CD 90 2! tS CD 0 CL. C.3 CO2 cc cc CL CO) w LLI U) cz w LLI 12 w w U) C3 C.3 CLIO CL. = cc CIO EoX C3 c cm cL. ca E 0 42 C., 3: cm C42 0 M -Co OIL C32 Cc S LO2 'm ID cc -CD's cm 2 Mo:; 11.2 CD cm W CL rA COD UA C=L:5 W cm z C.3 CD CL .0 lgs -11. 10 OM= -L Zo- C C=m C/) z 0 C/) U Cf) z 0 u Cf) z 0 u Cf) Cf) 0 C, rs u C CD zoo C E ts CD z CL. CO) cm ca .co) FE ID CD CD L- I.. = CL C2 CD CL CL CA S C4 CL cl CD 90 2! tS CD 0 CL. C.3 CO2 cc cc CL CO) w LLI U) cz w LLI 12 w w U)