HomeMy WebLinkAboutMiscellaneous - 27 CHAPIN ROAD 4/30/2018�N
:10 Box 55098
3oston, MA 02205-5098
117-951-0600
Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS, Ch. 139, Sec. 3B
To: Building Commissioner or Board of Health or
Inspector of Buildings Board of Selectman
City Hall City Hall
NORTH ANDOVER, MA 0 1845 NORTH ANDOVER, MA 0 1845
RE: Insured: GREGORY A PLODZIK and KELLEY F PLODZIK
Property Address: 27 CHAPIN RD, NORTH ANDOVER, MA
Policy Number: HMA 0057703
Claim Number: BOS00048843
Date of Loss: 2/16/2015
Company: Safety Insurance Company
Claim has been made involving loss, damage or destruction of the above -captioned property,
which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chgpter 143, Section 6 to be
applicable. If any notice under Mass. Gen. Laws, Chqpter 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 number.
Blake Wilder Claim Examiner 2/18/2015
Safety Insurance Company
Homeowners Claims Unit
P. 0. Box 55098
Boston, MA 02205-5098
Phone:.(617) 951-0600 EXT 5317
Fax: (617) 531-6653
Email: BlakeWilder@Safetylnsurance.com
Date2�....,;� —,3
.....................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
Thiscertifies that ....................... ...........................................
. . .. ... ..........
has permission to perform ........ . ......... ........ .........................................
winng in the building of ...... ........................................
at ....... 7 ............. Z--., .............. . North Andover, Mass.
Fee.35 .............. Lic'. No . ............. ........ ............................ ..................
Check # ELEcrRICAL MpEcrOR
4 U %'a' 7
Official Use Only
Permit No.
Occupancy & Fee Chec&9f
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00
(Please Print in ink or type all information) Date * / ��
To the Inspector of Wires:
Town of North Andover
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number 1-1 C�Ce -\ V-\
Omer or Tenant GmCD 21 p,�� v<,
Owner's Address sc,<,N�
Is this permit in conjunction with a building permit Yes No 0 (Check Appropriate Box)
A,
Purpose of Building ��(Y\ Utility Authorization No.
Existing Service Amps
New Service Amps Vofts
Number of Feeders and Ampacity_
Location and Nature of Proposed Electrical
nkr)-) ; -�_, -k e_-) V-,
Voits Overhead 0
Undgmd 9 No. of Meters
Overhead 0 Undgmd 9 No. of Meters
OTHER:
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO -
have submitted valid proof of same to the Office YES = NO - If you have checked YES please indicate the type of coverage by checking the appropriate box.
INSURANCE - BOND - OTHER - (Please Specify)
Estimated Value of. Electrical Work$ 0 C7) C—:"-- (Expiration Date)
Work to Start - Inspection Date Resquested Rough —Final
Signed under the Penalties of perjury:
FIRM NAME
LIC. NO
LIC. NO. Z,�Va"2_
Bus. Tel No.
Address ov-,'o- �L!Z> - Alt Tel. No. Li -76, dr 0
OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its subskfntial equivalent as required by Massachusel
General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one)
ar—l--
.Telephone No. PERMIT FEE
(Signature of Owner or Agent)
Total
No. of Lighting Outlets
No. of Hot fuse
No. of Transformers KVA
Above 9
In 9
No. of Lighting Fbdures
Swimming Pool gmd 0
gmd 0
Generators KVA
No. of Emergency Lighting
No. of Receptacles Outlets
No. of Oil Burners
Battery Units
No. of Switch Outlets
No of Gas Burners
FIREALARMS; No.ofZone
No. of Detection and
Total
No. of Ranges
No of Air Cond
Tons
Initiating Devices
Heat Total Total
No. of Diposal
No. Pumps
Tons
KW
No. of Sounding Devices
NoJ of Setf Contained
No. of Dishwashers
SpacetArea Heating
KW
Detection/Sounding Devices
0 Municipal a Other
No. of Dryers
Heating Devices
KW
Local Connection
No. of
No. of
Low Voltage
No. of Water Heaters KW
Signs
Bailases
Wiring
No. Hydro Massage Tuds
No. of Motors
Total HP
OTHER:
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO -
have submitted valid proof of same to the Office YES = NO - If you have checked YES please indicate the type of coverage by checking the appropriate box.
INSURANCE - BOND - OTHER - (Please Specify)
Estimated Value of. Electrical Work$ 0 C7) C—:"-- (Expiration Date)
Work to Start - Inspection Date Resquested Rough —Final
Signed under the Penalties of perjury:
FIRM NAME
LIC. NO
LIC. NO. Z,�Va"2_
Bus. Tel No.
Address ov-,'o- �L!Z> - Alt Tel. No. Li -76, dr 0
OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its subskfntial equivalent as required by Massachusel
General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one)
ar—l--
.Telephone No. PERMIT FEE
(Signature of Owner or Agent)
Name
Name:
Location:
The Commonwealth of Massachusetts
Department of Industlial Accidents
Office of Investigations
Boston, Mass. 02111
Workers'Compensation Insurance Affidavit
Please Print
city Phone #
I am a homeowner performing all work myself.
I am a sole proprietor and. have no one w.vorldng in any capacity'
I am an employer providing viorkers� compensation for nvy employees worldrig on, this job
Comr)anv name.
Address
OW,
InsuranceCo. --Policv
ComR@!]y name:
A.ddress.,
., M6 -t; Phorw*
F . skiretosecure-coveragja as nxpimdunderSection 25A or MGL 152 can lad totheWpos&n ctakninatpenaKesor.artne UPPI
and/or one yews' impmorenentas
understand ttu-4 a copy of this statement may be forwarded to the Office ct Investigations of Um DA for cvjwjg& verification.
I do hereby catfy xxiar ffm pains aod peneffies ofpeqwy hW Me "bnwhw povided a&" a &w and emyea
Sigrrature Date
Print name
Official use only do not write in this area to be completed by city cr town ffKiW
C4y or Town
BUftng
ElCheck jFkmmx#af& tesponse is requked Lkensin
Selectrn
Contact person: Ptxm A E] Heaffh L
F1 Other
Location ---,? f) (' /1 A ? C-1
Date -30 -03'
No
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
CHUS
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
6�5
/P , 6e ---
Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAI!, RENOVAT5 OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER:
DATE ISSUED:
SIGNATURE:
Building ComdiissionEIns
ZStor of Buildings Date 16 6? -2
SECTION I- SITE INFORMATION
1. 1 Property Address:
1.2 Assessors Map and Parcel Number:
-00
Map Number Parcel Number
1.3 Zoning Information:
1.4 Property Dimensions:
- SS-.
\.C:;- u Z) 1% 1 �j 11 1
Zoning Di��c—t Proposed Use
Lot Area (sf) Frontage (ft)
1.6 WELDING SETBACKS (ft)
Front Yard
Side Yard
Rear Yard
Required Provide
Required Provided
Required Provided
% Z3,
\,5" Z I
3b
1.7 WataZly M.G.L.C.40. 54)
Zone
1.5. Flood Zone Information:
Ontside Flood
1.8 Sewerage Disposal Systemr
-pik,
Public Private. , D
— Zone
Mni..p.1 OnSiteDisposal System 0
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
Historic District: Yes No
2.1 Owner of Record
L-
am (P
Address for Service
Sijnaidie-
Telephone
2.2 Owner of Record:
Namo Print
ss for Service:
I
Signature
TeleEhle
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable D
t�n
P
Licensed Construction Supervisor:v
License Number
k3
Address
Q-3 5-
Expiration Date
Asnature
Telephone
3.2 Regrstered Home Improvement Contractor
L
Not Applicable D
—
1)k -7
-D
Compaby Name
Registration Numbei
L� -I_ej, 10
Expiration Date
Signatt�re
Telephone
00
M
X
z
0
rl!s
L
0
z
M
90
0
M
Faaa'
z
G)
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 ...... A No ....... n
(check all applica
SECTION 5 Description of Proposed Work bl,)
r New Construction 0 1 Existing Building 0 1 Repair(s) Alterations(s) 0 Addition 0
Accessory Bldg. 0 1 Demolition 0 Other 0 Specify
Brief Description of Proposed Work:
I CVVTIFnN f - V4ZT1[MAT1Vn VnNQTR1TrT1nIV rne.T.P. I
Item
Estimated Cost (Dollar) to be
Completed by pen -nit applicant
OMCLAL USE ONLY'
1. Building
4<--
0 4� L)
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
C)
Plumbing
Building Permit fee (a) x (b)
-3
Mechanical (HVAC)
-4
5 Fire Protection
6 Total (1+2+3+4+5)
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as 0-wiier/Authorized Agent of subject property
Flpf*,, authorize to act on
this building permit application.
Date
SECTION 7V OWNER/AUTHORIZED AGENT DECLARATION
as Owner/Authorized Agent of subject
propertv y
Herebv declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
Sip_ii`h�e of Owner/Aaenl Date
NO. OF STORIES SIZE '")
BASENIENT OR SLAB ND RD
SIZE OF FLOORTINIBERS 1 2 3
SIVkN -L I
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DiMINSIONS OF GIRDERS
I I I i(i I ITOF FOUNDATION TMCKNESS IVN
S1/1.: 01- I-OOTING X
MA FERIAL OF CIUVINEY
IS I It JILDING ON SOLD) OR FILLED LAND L
IS [WILDING CONNECTED TO NATURAL GAS LM k./A
C
MORTGAGE INSPE*CTION
SAY STATE SURVEYING ASSOCIATES INC. Joe# 11-11'Z4
100 CUMMINGS CENTER, SUITE# 316j, SEVERLY.MA.- 0191-r,
LOCATION :.A�-d.j:H.A
SCALE: I,,= So DATE: ........ La(�::0,oL . ...........
*"8*
REFERENCE:. Celq7-: 1,
. ........... b .1
4,65E)< **** ...........................
.... Alo
.................. ; .......
'0' - r. . . .........
TO:. VA110A) -r4O.S7-
The location of the building(s) as shown. either
compiled with the local Zoning setbacks at the time of
construction or is exempt from Violation enfomer
under Mass. G.L Title VII Chapter 40A Section 7 nent action
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NOTES:
11 This is a mortgage inspection survey and not an
instrument survey, therefore this plot plan is for
mortgage inspection purposes only.
2) This survey is based on survey marks of others.
3) Bushes. shrubs. fences and tree lines do not
necessarily indicate property lines.
4) Whenever an offset is 11' +- or less, an instrument
Survey is recommet ded to determine property
lines. and any possible encroachments.
6) Offsets shown are approximate. and are to be
used only for the determination of zoning, Not to
be Used to establish Property lines.
6) In my professional opinion the building(s) are not
located in the special flood hazard zone. as
defined by H.U.0. MAP# Z574.:�,?
'p, 6- 2-"73
AA
C HA P1 t,,J /; 0,
-r
4.
The Commonwealth of Massachusetts
Department of Industfial Accidents
Office of Investigations
Boston, Mass. 02111
WOrkers'Compensation Insurance Affidavit
Name Please Print
Location:
6-!�-33
I am a homeowner performin6-all work myself. -
I am a sole proprietor and have no one worldrig in any capacity'
I am an employer providing workers! compensation for my employees mwl(ing on this job.
w nmrndn- k A I r- L L
CME Ehane #- I b SQ T5—
Insurance. Co. P`0llCV # �-1 k �A
CornRM name:
A.ddrfts
Phone
Failure to secure coverage as required under Section 25A or UM 152 can Wad to,#* kpwow of "Wr*W, to. � 'it
penalties cit.a,11416 U0.
and/or we yeaW Wnprisonnmt-as-welLas jo-tbalmnjotA-STOPYjCFJCDRDERAxtafm
understand that a copy of this statemerit may belorwarded to the Office of Investijabons of the DIA for CU -do M I 19- a j d W A 9 a I n S t - M--
Verage Verification.
4
ofpedwy 6W Me k*m)edw provbed above is &W and coffect
Signaturet
Print
Offic1W use only do not write in this area to be cmvWW by city or town officiar
City or Town.
V,�--S-33
00m=k,Vkwxxftt& response is requked Lkensfng Boa
contact —Phone k SelectrnaWs C)
E] Heaffh Departr
Other
NORTH ANDOVER BUILDING DEPARTMENT
Tel: 978-688-954
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
Number is that the debris resulting from this work shall be disposed of in properly
licensed solid waste disposal facility as defined by MGL Chapter I 11, S 150 A.
The debris will be disposed of in:
(Location of Facility)
'Signature of PerAK2k�pblicant
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for this project
through the Office of the Building Inspector
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Location
No. 7 Date
kORT" TOWN OF NORTH ANDOVER
60 6. + 40
0
0- Certificate of Occupancy $
Building/Frame Permit Fee $
Foundat' P
CH _q
_�,, rl ermit Fee
r Pi
m!
C her P ibit Fee
Fee
�eT[rl Fee
TOTAL
YA
93 Building Inspector
It
k
9k U (,1 4 Div. Public Works
PiM11IT 140. 12,3 APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS.
��/AGE 1
MAP 4-40.
LOT NO.
2 RECORD OF OWNERSHIP IDATE
BOOK ;PAGE
�-1
ZONE
SUB DIV. LOT NO.
F
LOCATION
PURPOSE OF BUILDING,54,,, . j
#� f\r IC
OWNER'S NAME
ckue hzLlt
NO. OF STORIES SIZE 0
OWNER'S ADDRESS cl
—
V-
BASEMENT OR SLAB
ARCHITECT'S NAME
#o m a C),o
yi e -
SIZE OF FLOOR TIMBERS IST 2ND 3RD
BUILDER'S NAME 'rA-'vcj'eI)son'�
SPAN
DISTANCE TO NEAREST BUILDING
DIMENSIONS OF SILLS
POSTS
DISTANCE FROM STREET
DISTANCE FROM LOT LINES - SIDES
REAR
GIRDERS
AREA OF LOT
FRONTAGE
HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW
SIZE OF FOOTING x
IS BUILDING ADDITION
MATER:AL OF CHIMNEY
IS BUILDING ALTERATION
IS BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE
IS BUILDING CONNECTED TO TOWN WATER
BOARD OF APPEALS ACTION. IF ANY
IS BUILDING CONNECTED TO TOWN SEWER
IS 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
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
DATE FILED 2�,�'-- ?3
SIGNATURE OF OWNER OR AUTHORfZED AGENT
41-1
F E E e- 0(
PERMIT GRANTED OWNER TEL. It - ------
CONTR. TEL. It 4o 8
19 CONTR. LIC. D te- --o- 2-
3 PROPERTY INFORMATION
LAND COST
EST. BLDG. COST 4fj,i
EST. BLDG. COST PER SQ. FT.
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
BOARD OF HEALTH
PLANNING BOARD
BOARD OF SELECTMEN
NGPRCTOR
BUILDING RECORD
OCCUPANCY 12
SINGLE FAMILY
S-ORIES
MULTI. FAMILY
APARTMENTS
CONSTRUCTION
2 FOUNDATION
8 INTERIOR FINISH
CONCRETE
NE
a
1
2 13
CONCRETE BL'K.
BRICK OR STONE
HARDW D
PIERS
PL ASTER
DRY WALL
UNFIN.
3 BASEMENT
AREA FULL
FIN. B M'T' AREA
14 1/7
FIN. ATTIC AREA
t!O 8 M T
FIRE PLACES
HEAD ROOM
MODERN KITCHEN
4 WALLS 9 FLOORS
CLAPBOARDS
8
1
2
3
DROP SIDING
WOOD SHINGLES
ASPHALT SIDING
ASBESTOS SIDING
CONCRETE
-iARTH
�TARDW D
COMIACN
VERT. SIDING
)�SPH TILE
STUCCO ON MASONRY
STUCCO ON FRAME
BRICK ON MASONRY
BRICK ON FRAME
ATTIC STIRS
CONC. OR CINDER BLK.
WIRING
STONE ON MASONRY
STONE ON FRAME
SU ERIOR I I POOR
_W ,
ADEQUATE ONE
10 PLUMBING
1
5 ROOF
GABLE
BATH Q FIX.)
AMBRIEL
I
-tip
MANSARD
TOILET RM. (2 FIX.)
_
F LAT
SHED
WATER CLOSET
ASPHALT SHINGLES
LAVATORY
WOOD SHINGES
KITCHEN SINK
SLATE
NO PLUMBING
TAR & GRAVEL
STALL SHOWER
ROLL ROOFING
MODERN FIXTURES_
TILE FLOOR
TILE DADO
6 FRAMING
_11 HEATING
WOOD JOIST
PIPELESS FURNACE
FORCED HOT AIR FURN.
TIMBER BMS. & COILS.
STEAM
STEEL BMS. & COLS.
HOT W'T'R OR VAPOR
WOOD RAFTERS
AIR CONDITIONING
RADIANT H'TIG
UNIT HEATERS
7 NO. OF ROOMS
GAS
OIL
B'M'T 2nd
Ist I 3rd
ELECTRIC
NO HEATING
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.
--4.
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0FrFzjCzS
API.)SA
LS
n of
0 -,V
HEALTH AIVjD
PLANNI,rN,G OVER i
120
PLAN1VING& COM41LTN Norril ISIreel
Atldovcr
cI I
1 0
KAnj:j,V H.P. ELOPMEN r (6 17) ji
Djj?,EC- 1. 01,
ln accorciane,
NuMber 'he provisions of A4GL
disposed 0 � n
fi C 40,
150A. pro, is that th
)Crj C S 5,1 a
.Y
Ascd solid waslec debris condition of Build-
T�e 1 0
deb disposal re""ling fro Inr Permit
rls Will be cf - facilityas dc M tills Work
Isposcd Of in: filled bY MG Shall be
L C ill, S
60S�
lon Of F13 —Ci7l
Appj�PCrIlliL Ap i n,
Da I C
TOTE:
Demolit.:
thi s P r - 0 n Permit from the of
oject through the Office of torch Andover
he Building Must be obt,.ine
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- - - - ----------------------
Ffee Estimates
Fully Insured
Anderson Roofing & Car
Sh'ngles Tar and Gravel - sl tentry
PROPOSAL SUBMITTED TO Rubber Roof Single Ply ate
Copper VVOk
PHONE
1_n
�2 DATE
CITY,
.§IATE and ZIP CODE
ARCHITECT
J08 LOCATION
DATE OF PLANS
.We here Y Submit eStIM
ates for.
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we Pftpose hereby to furnish material and labor complete in accordance wi
'PaYMent,to be,made�as follows:, th above specifications, for the sum of:
dollars ($
material is gi`ia,�nt� t -t
m
All material Is guaranteed to be as
workmanlike man- sPecif-I
oer according t U0. All work to be completed in a
deviation from ab 0 standard practices A
only ve Specifications - i ny alteration o
upon written orders involving extra cos r
estimate. All ag"em , and will become an extra charg S Will be executed
Our control 0 ents contingent upo e over and above the
wrier to carry fire, t n strikes, accidents or delays beyond
Our workers* are fully covered by Wo omadO and other necessa insurance.
rkmen's Compensation Insurry
ance.
'!�ce of
Specif i,.a%.tiO--
I. s and Condlt!�q The above prices
accepted. Ons "resatistactory and are hereb
will YOU are authorized to do
be made as Outlined above. the work as specified.
Payment
Date Of Acceptance:
Page Of
105 Haverhill Street
Methuen, MA 07844
(508) 689-2191
Signature
<:
TE:
No
Thi Proposal May be
withdrawns y us if not accepted within
b
days.
Signature—
Signature
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