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North Andover Board of Assessors Public Access
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IMProperty Record Card
A - A ------
Location: 27 DEWEY STREET
Owner Name: ANDREW,JOYCE
Owner Address: 27 DEWEY STREET
City: NORTH ANDOVER State: MA Zip: 01845
Neighborhood: 5 - 5 Land Area: 0.15 acres
Use Code: 101-SNGL-FAM-RES Total Finished Area: 1741 sqft
ASSESSMENTS CURRENTYEAR PREVIOUS YEAR
Total Value: 287,100 287,100
Building Value: 137,000 137,000
Land Value: 150,100 150,100
Market Land Value: 150,100
Chapter Land Value:
http://csc-ma.us/PROPAPP/display.do?linkld=2431769&town=NandoverPubAcc 12/11/2014
10674
Date
............
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
NZSZ4ZCP-�U-S"�'
T his certifies
has permission to perform...' -:3 .. be ..............
...... .................................................
I'% plumbing in the buildin s of. .... 4k.x ..... /- /- e-
9 ....................................................
it ....... ......
- % ..... .............. North Andover, Mass.
Feel Lic. No. ..... 3 ... e67 ...........................................
PLUMBING INSPECTOR
Check #
7)1
E7 --
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY MA DATE Z]PERMIT# —1 b(
JOBSITE ADDRESS OWNER'S NAME
M
POWNER
ADDRESS TEL
TYPE OR
OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAC$j
PRINT
CLEARLY
NEW: Ell RENOVATION:29 REPLACEMENT:E11 PLANSSUBMITTED: YESE11 NODI
FIXTURES I FLOOR- BSIVI
1 2 3
4
5
6 7
8
9
10
11 12 13 '14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOIUSAND SYSTEM L—A --J1 --il .--II IL=
DEDICATED GREASE SYSTEM =
DEDICATED GRAY WATER SYSTEM I
DEDICATED WATER RECYCLE SYSTEM I —J
DISHWASHER
11 --J
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREADRAIN
INTERCEPTOR (INTERIORj
KITCHEN SINK -A—]
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE / MOP SINK 1 L --j
TOILET
URINAL
ING MACHINE CONNECTION
-J
WATER HEATER ALL TYPES
TER PIPING
0 HER
f F—
,
I�NS RANCE COV ERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO [11
It U CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY-;;� OTHER TYPE OF INDEMNITY Pj BOND E-11
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
PAassachusefts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER F-1 AGENT IR—I
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 ith 11 P rti ient provision of
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAMEL I C&)=Q LICENSE # ""tIGNATURE \j
Mpg JP ni CORPORATION RI # PARTNERSHIPD# LLC
COMPANY NAME mino qo h4qsM %��,AtJZRESS b Q
CITY J STATE ZIP TEL
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_CN The Commonwealth ofMassachusetts
M Department oflndustriqlAcc!6�ts
Office of Investigations
600 Washington Street
Boston., MA 02111
9 www'-mass.govIdia
Workers' Compensation Insurance Affidavit: BundersfContractorsfFle,etricians/Plumbers
Applicant Information Please Print Ledbly
Name (Business/OrganizationAndividual):
Ad&ess:
City/State/Zip: Phone4: CCt_710 (��_2_7qO
Are you an employer? Check the appropriate box: -
Typo of project (required):
1 -0 1 am a employer with
4. El I am a general contractor and 1
6. El Now construction
employees (fiffl and/or part-time).*
2. V( I am a sole proprietor or partner-
have hirea the sub-coirtractors
listed on the attached sheet. :
7. Remodeling
ship and'have no employees
These sub -contractors have
8. Demolition
working for me in any capacity.
workers' comp. insurance.
5. D We are a corporation and its
I
9. El Building addition
[No workers' comp. insurance
required.]
officers have exercised their
ME] Electrical repairs or additions
3.0 1 am a homeowner doing all work
right of exemption per MGL
11.[] Plumbing repairs or additions
myself. [No workers' comp.
c. 152, § 1(4), and we have no
12.Q Roofrepairs
insurance required.] t
employees. [No workers'
13.n Other
comp. insurance required.]
'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
T Homeowners who submit this affidavit indicating they are doing all workand then hire outside contractors must submit anew affidavit indicating such.
tContractors that check this box mustattached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
lam an employer that isproviding woAcers'compensation insurancefor myemployees. Below isthepolley andjob site
information.
Insurance Company
Policy # or Self -ins. Lic. M Expiration Date:
Job Site Address: -Pity/StatefZip:
Attach a copy of the workers' compensation -policy declarationpage (showingthe policy number and expiration date).
Failure to secure coverage as requiredundor 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 maybe forwarded to the Office of
'Investigations of the DIA for insurance coverage verification.
I do hereby certlo under thepains and it- yperjurytliattlieIn
s rormationproviaea aDore is true ana correct.
I -C IAA*\ - nate. `6 1, -7 1 / (-/
A) tt-q -7 - ?�� q 6
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit0cense
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
ContactPerson: -
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 ofhiro,-
express or implied, oral or written."
An employeils 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
pinploying employees. However the
owner of a dwelling house having not more than three apartments and ��6 r�sidos therein, gr the occupant of the
dwelling house of another who employs persons to do maintenan66, constraction or�r6pair W'oik on such divelling house
or on the grounds or building appurtenant thereto shall not because of s6h employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or lo'cal lie-ensmig agency sh I all with . hold 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 an*y of its political subdivisions shall
enter into any contract for the performance ofpublic 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
necossary� supply sub-contractor(s) name(s), address(es) and phone number(s) along with their cortificate(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 cany workers' compensation insurance. If anLLC orLLP does have
employees, a policy is required. Be advised that this affidavit maybe 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 thic application for the penuit orlirleinse 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 Eno. I
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.
Pleas ' e 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 pormit/liceriso applications "many given year, need only. submit one, affidavit indicating current
policy information (ifnecessaty) 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 maybe provided to the
applicant as proof that a valid affidavit ii Oil file for fature permits or licenses. Anew 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 t*o bum leaves etc.) said person is NOT required to complete this affidavit.'
The Office of Investigations'would like to thank you in advancefor your cooperation and shQuld you h any questions,
pleas a do not hesitate to give us a call. ave
The Department's address, telephone and faxnumber:
The CQMMORwoalt� of Massochuse
tts
Depax(ment ofhidustrial Accidents
OfAce of favestigatio-R&
600 Washiugtoa Strod
BostmMA02111
TQI,#617-727�4900oxt4Q6-orl-8.77, ASSAFE
Revised 5-26-05 Fay, # 617-727-7749
Date ...
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
C . ILAe
This certifies that
.. ....... ............................................ ) .... ... .......... 1�� .......................
has perniission to perfofrn ��� '�� &-\C, �(R , '/�'
.................................................................. f ......................................
wiring in the building of ....... �A Y, LL -L
.. ...................................................................................
... ............... ............... . North Andover, Mass.
at ................... I .........
'0 -
Fee Lic. No.
..............................
'�R
Check # ELEOO CZ NS � /��>
I YIV. 0
C� -
Official Use Only
Commonwealth of Massachusetts
Permit No.
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS .[Rev. 1/071 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
No. of Ceil.-Susp. (Paddle) Fans
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
No. of Luminaire Outlets
(PLFASE PRflVT flV flVK OR TYPE ALL MFORAM TION) Date:
Generators KVA
City or Town of. NORTH ANDOVER To the Inspector of Wires:
Above Ei In- o
Swimming Pool grnd. grnd.
By this application the undersigned gives notice of his or her i . ntention to perform e lectrical work described below.
No. of Receptacle Outlets 3
Location (Street & Number)-2-7.-D-eweo �j AA4A
FIRE ALARMS
Owner or Tenant A w), 0-c- Telephone No.
No. of Switches
Owner's Address kA,
No .of Detection and
Initiating Devices
Is this permit in conjunctio b 'Iding permit? Yes No (Check Appropriate Box)
No. of Air Cond. Total
Tons
Purpose of Building -'RA es"JeT. 6,kJ - Utility Authorization No.
No. of Waste Disposers
Existing Service Amps Volts Overhead Undgrd No. of Meters
I N!!9.4tr
New Service Amps Volts Overhead UndgrdD No. of Meters
I KW
.. . . .............. .
Number of Feeders and Ampacity
No. of Dishwashers
Location and Nature of Proposed Electrical Work:
Municipal
Local El Connection n Other
Completion of the following table may be waived bv the Insvector of Wires.
No. of Recessed Luminaires 1-Y
No. of Ceil.-Susp. (Paddle) Fans
No. of Total
Transformers K -VA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Above Ei In- o
Swimming Pool grnd. grnd.
No. o Emergency Lighting
Batte!j Units
No. of Receptacle Outlets 3
No. of Oil Burners
FIRE ALARMS
INo. of Zones
No. of Switches
No. of Gas Burners
No .of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
I N!!9.4tr
rons
T-1
I KW
.. . . .............. .
No. of Self-CWn—ta`ln-ed
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Municipal
Local El Connection n Other
No. of Dryers
Heating Appliances KW
Security Svstems:*
No. of bevices or Equivalent
No. of Water KW
Heaters
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Esuivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wirm-g:
No. of Devices or Equivalent
A-
IOTHER: A1123'oc-5 Rt!� /"a./), -/- 1),?,e -/ e-1- J! 7 "./4 W V1
Attach additional detail if desire4 or as required by the Inspector of Wire
Estimated Value of Electrical Worki,41P! (When required by municipal policy.)
Work to Start: in7spec—tion-s to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing ofrice.
CHECK ONE: INSURANCE )9 BOND [--] OTHER [I (Specify -
I certify, under the pqins andpenalfes ofperjury, that th informado n ficadon is true and complete
j �
FIRM NAIVE: f eoL C C-, I C_A, LIC. NO.: LJ r/T
Licensee: Signature_6,/V LIC. NO.:
h h b If V el. No.:
(If applicable,,!Enter t lmlh� icens.1num er inj�,. Bus. T
Address: :11 T:dCC-k2L1 CC-- , Alt Tel. No.:
*Per M.G.L c. 147, s. 57-61, security work requires Department bty "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (ch one) E] owner E] owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE. $
Y) —
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Mr.
I he Commonwealth ofMaswhusetts
Department ofindustrialAcelknis
Office ofInvesfigaflons
6#0 Washington Street
Boston, AM 02111
vww.ma&s.gov1d1a
Workey$, Comp engation Insurance Affidavit: Buffders/Contractors/FIectricians[PI*P eKs
PleaseTrint M
ApCheant lhho n L o A In
-Name (Business/Organi-zaRonftdvidual): eclt�_
City/State/Zp: V >,Fr.
Phone 4:
Are yo -a an employer? check the appropriate box:
1. 1 am a employer VMh 9,
4. E] I am a general contractor and I
employees (fallandloxpart-time).*
have nod the sub-confractors
listed on the attached shoot.
2,. El I am a s olD proprietor or P attncr-
ship an&lavano.employaa�
These sub -contractors have
WoAdng forma in. any capacity.
workers' comp. insurance.
5. El We are a corp oralion and its
tNo workers, comp. jusuranco
offteers have axarclsed.thafr
required.]
3. El I am a hoineowner dQ1119 all Work
light of exemption per MGL
myself EEO workexs2 r OMP.
o, 152, §1(4), andwahaveno
t
employe6s. PTo workers'
comp. inuratica levirad.]
Type of project (req*ed):
6, New cOnstructioll
7. Remodeling
8. El Demolition
9. 0 Building addition
10.[] Electrical repairs or additions
JJ.[] plumbingrepairs or ad4itions
12, Q Ro oflapairs
1311 other
KAny applicant that CheCkS bDXBI MUStalSOfffldutlhosertionbel()wsho-wingtheirWorkem'compensaUonpDilcYmIOnna-Quu.
%forneownerawfio submitthig affidavit indloathgthey ke doing all worKand then hire outside contractors mustsubmit a nw affidaVit indicatifig siibfi.
�Contraoforsthat cheoktbis box must attached a,a �'ddlflonal sheet s1owing thc� naine of the sub-coutraotors and their wo&rs' comp.policyinformation.
yman em peiisationinsuranceformyemployeeg. Below is thepolley fffidjoh site
ployer that isprovidigg workers' com
infamation.
Insurance Company Name%
P oJiGy # Or S alf—ia& VG. Expiration D ate:
6c
-lob Site Address-, pity/state/zip: N
Attach a copy of 00 -Workel:$'cO-*mPen�ation-poliey declaration page (showing -the Policy number and exPiratl0a date)-
duuderSecf1on2,5AofMGLo.l52 can lead to the, imposition of criminalPanalffes of a
Failure, to secure, coverago.as require
nc in
fine -up to $1,500.00 andlor bne-year mprisonment, as wellas chilpenalties in the form of a STOP -WORK ORDER a laf a
EqNablst�ha+lator. Be, advised that a copy of this statement may be forwarded to IhG Office -of-
ofupto$250.00ad
investigations oftho for 1PJAe, coverage verification.
I do It ere- by
that Me informadonprovided akove fs true and correct.
Offleial use oply. Do not vrite in Mis area, to be cotqlefed by cli�p or town official
C11yorTown:
Permit/License#
Issuing Authority (circle 6110):
1. Board of Health 2. BuildingDepartment I Cltyffown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
M - - 44.4
Information and Instructi
ons
MassaGh-asoffs exouexalyaws chaPt0rl52-r0%*eS allemployers to providoworkers, compensationfortheir employees.
Pursua�t to this statute, an employee is defined as 11 .. overypBrson id the service of another under any c6tract oflr1rq,-
express orimplied, oral orwxjtten.,,
An etqloy��js defm-ed as "m individuaj, partnership, association, cotToration ar othorlogal entity, Or anytWo 0.rmore
of the t6r6jo)�uj engaged in ajofiit enter
prise, and including the, legalreproseirtativas of a:deceased employer,.or the
'of!anindividuaLpartnership, askolation or other legal errtfty� amployingenipl
'6olverortaisteo oyces. Mwever the,
mmor of a dwelling house haOignotmore than three apartments and who resides thorolu, or the occupant oft�a
dweft houso of another who employs poisons to do maintenance, construction orrepair work 'on su6h dwelling house
or on the grounds or building appurtenant thereto shall not becatiso, of such employment be doomed to be an employor.,,
MOL chapter 152, §25C(6) als o states that "every state Or ideal 11 in
c-enshig agency shall withhold the issuance or
renewal of a 11cense or p ermit to op orate a business or to consiruct buildings in the commonwealth for any
aPPlicant who has not produced -acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL cfiap�tor 152, §25C(7) states'Noiffier the commonwealth nor any of its political sub6hons Shaff
enter into any contract for the p Prformmce ofp-abEc work until ,
acceptable evidence of compli�uco with the insurance
requirements of this chapterhave beenpresented ta thb cwtracting authority.',
Applicants
Pleas,o:f[U out thoworkers, componsailonaffidavit completely, by ollooldngtho boxes that apply to your situation and, if
A6cogsary, supply sub-contractor(s) name(s), addiess(es) andphonenurober(s) alongwiththeir Go
,rtificate(s) of
hisurance. Limited Liability Companies (LLQ or Limited Liability Partnerships (UP) with no employees other that the
members orp�rtuars, arGnotreqa1redto carryworkers, compensation insurance. If aaLT—C orLLP dooshave
ORIP10YOPs, a PORGY is required. Be advised fhattfii� af ff davit maybe submitted to the Department of Industrial
Accidents for confirmation of insurance cover
age. Also be suxeto sip and date the affidavit. !he affidavit should
be Totuladdto the city or town that -ffi6 applicatign for thoperruit or license is being requedeqxot the De�artnaarrt of
Industrial Accidents. Shouldyo-a have any questions regarding the law or ifyo aroxe iedto
u qa r obtain a *orkersl
C0r!aPo11saffQ1LPORCY, please call the Department attho, number listed below. Solf-iu=ed companies should enter their
self-insurance license number on tha appropriate ifilo. * . . I
City or Town Offfelals
Measobosurothatthoaffidavittis complete andpri-atod"logibly. The, Department has provided a space at the bottom
ofthe affidavitforyou to fiff o -at in the event the. Office of Investigations has to contact you regarding the applicant.
)?lease bo -sure, to El inthe pormit/Rconso number Whichwill be used as a reference number, la addition, anappycant
thati�aust submitmultiple pormit/Rceme applicationsin any given year, need only submit onG affidavit judicaft curr&nt
PORGY infOnnation (ifnecessmy) and under "Yoh Me Address" the applicant should write "all locations ia___�(cj�r or
tov&)." A: �Opy dthe affidavitt that -has been officially stainped or marked by the city or town maybe provld�d to the
applicant as ptbof that a. valid aff Wavit-idon file �or future permits orj1conses. Anow affidavitimstbe, MeLdbut each
year. Where a home owner Or citizenis obtaining a license or-�orrnit notrolated to any business or commercial venture
(i.e. a dog license orpJarmit to bum leaves etc) said person is NOTxequired to complete this affidavit.
The, Offlee Of invesggationiwould Eke to ffiank you in advance for your cooperation and shQuld yqu have any cpst!OF,
please do not hosiffte to give us a call.
The Depattmeaes address, telephone, and fax munbor:
ThQ CQM-. Mon -W. ("afth of Musachmott'q
A-Taxtwent d1ad-Wal AccidanOt
Office ofluodigAvolm
6b Wa�Wj.jgtm
_ SfteGt
:B Mon, MA 02111
TOL # 617-721Z-4900 (� A 406 Qx- 1-877�
,W
Revised 5-26-05
P'l
ease visit our web site at http://www.mass.gov/dpl/boards/EL
CUBE ELECTRICAL CONSTRUCTION INC
AMIR TABRIZI (EL)
52 FARDON ST
BILLERICA MA o1821-3630
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Location
No. c:2 OX f7 Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
TOTAL
o2a U
Check #
15219
3
/wt C(
,6n=
Building Inspector
TO" OF NOR j H - NDOVER
.T .A
UILDING: DE E
PARTM,, NT
3UILDING PERNUT NUMBER.*
3IGNATURE:
3ECTION. 1- SITE INFORMATION
i. i Property Address:
,kningl3istrict.
1.6 BURDING
Use
Of Buildings Date
1. 7 Water Supp�.Y M.al-C.40. § 54). 1.5. Flood Zone
Zone
0,
3ublic 0 Private
SECTION 2 - PROPERT I Y.OWNERS]HP/AUTHOR M'
:2.1 Owner of R
t4ame (Print)
Signature Telephone
2.2 Owner of Record:
Name Print
// --0? 9 —lop 9P 90 /
1.2 Assessors Map and Parcel Number:
010 0
Map Number Parcel Number
1.4 Property Dimolsibbs:
LotArcatsf) Tr ti
Y, Rear Yard
Providecl Required Provided
1.8 Sew Disp6sal S
Outside Hood Zone 0 muni'*1 On Site.
Signature
Telephone,
SECTION.3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor- Not Applicable 0
To D 660 1
Licensed Con ton Supervisor:
47 License Number
Address
Expiration Date
ZLe- /-1
Signature Telephone
3.2 Registered Home Improvement Contractor
n CA, -,o .5'OU, �d d
Not Applicable D
12-9 4 /?
Company Name 1 .0- . Registration Number 11-1
Address
Expiration Date
31gnature Telephone
Address for Service:
Signature
Telephone,
SECTION.3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor- Not Applicable 0
To D 660 1
Licensed Con ton Supervisor:
47 License Number
Address
Expiration Date
ZLe- /-1
Signature Telephone
3.2 Registered Home Improvement Contractor
n CA, -,o .5'OU, �d d
Not Applicable D
12-9 4 /?
Company Name 1 .0- . Registration Number 11-1
Address
Expiration Date
31gnature Telephone
SECTION 4 - WORMS COMPENSAT157K �RQL C' 152 § 2R(4j
'�pflcAti�o-. 'F
Workers Compensation Insurance affidavit must be Completed mitte ibis,
E-Eand Mu6mitteMA
With this qn
P n ail
in. the denial_ of the issuance of the building permit.
$igned affidavit Attached Yes ...... p ;po ........ 0
e
SECTION 5 :1)!eknPti6h of Pfbp6iid rk (the kA. I!-' b.1
wo 2k
4 �i
New Construction 0 T
Existing Building C kepair(s)
0 Alterations(s) 0
Accessory Bldgt.D:l Demolition' 0 Other D. §�ecif
y
Brief Description of Proposed Work:
NSTRUCTION COSTS
Estimated Cost (Dollar) to
(a) Bulldmg Permit F&
fb) Estimated Total Cost of
Construction
Building Permit fee. (b)
provide this affidal4t will —result
ition 0
SECTION 7a GWNER AUTHOR17ATION TO BE COMPLETED WBEEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERAHT
as 0,%mer/Authorized Agent of subject property
Hereby authonze
to act on
My behalf, in all matters relative to work authorized by this building permit application.
Si
Te of Owner Date
SECTION 7b OWNER/AUTIFIORIZED AGENT DECLARATION
as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are brue.and accurate, to the best of m knowledge
and belief y
Plint Name
Signature of Owner/Agent
BASENIENT OR SLAB
SIZE OF FLOOR TRVfBERS Sr
SPAN
D84ENSIONS. OF SH -LS
DMENSIONS OF POSTS
DMNSIONS OF GIRDERS
HEIGHT OF FOUNDATION
�IZ—EOF FOOTING
MATERIAL OF CHI]VfNEY
TS —BUILDING ON SOLD) OR FILLED LAND
1�) BUILDING CONNECTED TO NATURAL GAS LINE
Date
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SIZE
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NSTRUCTION COSTS
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(a) Bulldmg Permit F&
fb) Estimated Total Cost of
Construction
Building Permit fee. (b)
provide this affidal4t will —result
ition 0
SECTION 7a GWNER AUTHOR17ATION TO BE COMPLETED WBEEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERAHT
as 0,%mer/Authorized Agent of subject property
Hereby authonze
to act on
My behalf, in all matters relative to work authorized by this building permit application.
Si
Te of Owner Date
SECTION 7b OWNER/AUTIFIORIZED AGENT DECLARATION
as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are brue.and accurate, to the best of m knowledge
and belief y
Plint Name
Signature of Owner/Agent
BASENIENT OR SLAB
SIZE OF FLOOR TRVfBERS Sr
SPAN
D84ENSIONS. OF SH -LS
DMENSIONS OF POSTS
DMNSIONS OF GIRDERS
HEIGHT OF FOUNDATION
�IZ—EOF FOOTING
MATERIAL OF CHI]VfNEY
TS —BUILDING ON SOLD) OR FILLED LAND
1�) BUILDING CONNECTED TO NATURAL GAS LINE
Date
5�
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SIZE
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Page of
Proposal
elt!
-a es 1105 Haverhill Stre,-,
F.I;iv insured Methuen, MA 01844
THOMPSON'S ROOFING (978) 691-13155
Shingles — Slate — Rubber Roof
Single Ply — Copper Work
PROPOSAL SUBVI-7 LD TO PHONE DATE
Mrs. Mackenzie 111-19-01
JOBNAME
27 Dewey Street
I' �JTY, S-,�TE A,,f) ZIP CODE
JOB LOCATION
-Nor-."i Andover MA 01845
A"" JI -ECT
DATE OF PLANS
SPHONE
'Ve her,,cy submit specifications and estimates for:
Strip OIL all rooi shingles on house
Rer,a--;'-' ail loose boards
,ns-�all aluminum drip edge around roof line
pp;y ice and water shield 3 ft. up all along edges and in valleys
Apply 151b. felt paper on rest of roof area
Res'-'k-'Lngle with a 25 year 3 tab shingle
--tall new flanges around soil pipe
Waterproof chimney flashing
On roof fasten down �2 inch insulation 4x8 sheets
�pp-`y .060 rubber fully adhered
install metal around edges
Remove all work related debris
25 year wai:ranty on material
10 year guarantee on.labor
lconstruction lic.#060112
imp:--ovement #128612
'We PrOP05C hereby to furnish labor
material and — complete in accordance with above specifications, for the sum of:
�ur thousand eight hundred ------dollars($ 4,800.00
Payment to be made as follows:
All is 9LLaranteed to be as specified. All work to be completed in a workmanlike manner
3ccor( n(- t,� standard practices. Any alteration or deviation from above specifications involving Authorized
-xtra cc s�s will be executed only upon written orders, and will become an extra charge over and Signatu
i-jcve t:ie estimate. All agreements contingent upon strikes, accidents or delays beyond our
/Mis
coritrol. Owner to carry fire, tornado and other necessary insurance. Our workers are fully Note: proposal may be
covered by Wor,:,Per�,'s Compensation Insurance. withdrawn bv us if not accentpA within
Zfccqtanct of Vropozat— The above prices, specifications and
conditions are sa*isfa,,tory and are hereby accepted. You are authorized to do the
work as specified. Payment7ill b.- ma
i I � ( le as outlined above.
:aie of -1.cceotance: 0 1
Signature
Signature
T
PELHAM INStiRIKE SERVICES INC
L i A B I L I T Y
NH 03076 -
DBA
Thompso,)s Construction & Roofi
West St. NH 03079
I e.m
R A N C E DATE 04-23-01 (MM/DD/YY)
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.
I N S U R E R S A F F 0 R D I N G C 0 V E R A G E
INSURER A� Liberty Mutual
INSURER B. The Maryland
INSURER C�
INSURER 0.
INSURER E:
----------------
_ -11— trAT[n
HIS
SUED TO THE 1INSURED NA:OED ABOVE �(jl� HIL 'UL P I I '-" � —
N E LISTED BELOW RAVE BEEN IS DOCUMENT WIT�j RESPECT TO WHICH T
THE iNSU CONDITION OF ANY CONTRACT OR OTHER
ENT TERM OR HEREIN IS SUBJECT TO ALL
!�.Tr,-�N'D:NG ANY REQUIREME BY THE POLICIES DESCRIBED REDUCED By PAID CLAIMS.
PERTAIN. THE INSURANCE AF17ORDED
MAY �E ISSUED OR MAY AGGREGATE LIMITS SHOWN MAY HAVE BEEN
10 S
EXCLUS N AND CONDITIONS OF SUCH POLICIES. POLICY EFFECTIVE POLICY EXPIRATION LIMITS
POLICY NUMBER DATE (MM/DD/YY) DATE (MM/DD/YY)
3� INSURANCE $1,000.000
I CArw nrrHRRENCE
�jE�A, LIABILITY
B �[xj COMMERCIAL GENERAL LIABILITY SCP 34865353
C, _��*,S �,ADE [x] OCCUR
%�GGREGATE LIMIT APPLIES PER
Cy PROJECT C ILOC
_�L ]P- j
.AUTT'I",C"S.'! IABILITY
j ANY �,uTO
, -LL OWNED AUTOS
L ��EDULED AUTOS
H T RED AUTOS
�0-00E] AUTOS
j
GARAGE LIASILITY
X-Ec'S LIABILITY
CLAIMS MADE
N I ION S
S COMPENSAT ION AND WC2.31S-314995-019
A EMPI_�jyc�,R'�z '.331LITY
A
04-17-01 04-15-02 FIRE DAMAGE (Any one fire) S 300.000
MED EXP (Any one person) $ 10,000
PERSONAL & ADV INJURY $1.000,000
GENERAL AGGREGATE $2.000.000
PRODUCTS - COMP/OP AGG $2.000.000
COMBINED SINGLE LIMIT
(Each accident)
BODILY INJURY
(Per person)
BODILY INJURY
(Per accident) $
PROPERTY DAMAGE
(Per accident)
AUTO ONLY - EA ACCIDENT
OTHER THAN EA ACC
AUTO ONLY: AGG
EACH OCCURRENCE
AGGREGATE
WC STATUTORY [ ] OTHER $ 100,000
F'E CH ACCIDENT $ 100-000
04-21-01 704-21--02 E SC S
E.L DI A S E -EA EMPLOYEE $ 500,000
E L DI SEA E -POLICY LIMIT
OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
NO. CHELMSFORD. MA
J8b: Roofing Jo�) at 6 MIDDLESEX ST
TER
CERTIFICATE HOLDER [ ]ADDITIONAL INSURED: INSURED LET
DEA.MICIS
5 MIDDLESEX ST.
40. CH,�,_ImSFORD.
mA 01863
I
CANCELLATION
SHOULD ANY OF THE ABOVE UL:�UK ED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF. THE ISSUING INSURER WILL ENDEAVOR
TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED
TO THE LEFT. BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION
AGENTS OR
OR LIABILITY OF ANY KIND UPON THE INSURER . ITS
RE�PRESENTATIVES-
t t ""v r
A T
UTHORIZED�REPRESENTATIVE
4 Z�b
IL Page 1 of 2
Location 2:2
No. Date
AORT" TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Bui Iding/Frame Permit Fee $
Foundation Permitfee $
CHUS
Other PerOeit%F�e�r-" $
Sewer Connection Fee $
Water Connection Fee $
TOTAL
4� �li�?3051011% 15:45
7204
$
Building Inspector
35.00 PAID
Div. Public Works
PERI�T NO,.A APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. /PAGE I
L ----
P.,
MAP i-40.
LOT NO.
2 RECORD OF OWNERSHIP IDATE
BOOK ;PAGE
39NE
SUB DIV. LOT NO.
ATION
'm? 7 &,ctLw I
L---
PURPOS
R'S NAMEjo
?>`*E q, c e � � / &)
NO. OF STORIES SIZE
OWNER'S ADDRESS -7
BASEMENT OR SLAB
ARCHITECT'S NAME
SIZE OF FLOOR TIMBERS IST 2ND
3RD
=DER'S NAME
SPAN
DISTANCE TO NEAREST BUILDING
DIMENSIONS OF SILLS
POSTS
DISTANCE FROM STREET
DISTANCE FROM LOT LINES - SIDES &1 /',,4 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
Pec 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
V-DATF rjLIM
SIGNATrE OF OWNER OR AUTHORIZED AGENT
F E E 0
PERMIT GRANTED _�NER TEL. #
�-MNTR. TEL, #9U&
Y 19 CONTR. L11C.
3 PROPERTY INFORMATION
LAND COST
;rs:� BLDG. COST
44
EST. BLDG. COST PER SQ. FT.
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
BOARD OF HEALTH
PLANNING SOATD
BOARD OF SELECTMEN
BUILDING RECORD
OCCUPANCY 12
SINGLE FAMILY
S-OPIES I
MULTI. FAMIL�:�
FFICES
APARTMENTS
CONSTRUCTION
2 FOUNDATION
CONCRETE
8 INTERIOR
3
PINE
PLASTER
DRY WALL
I UNFIN.
FINISH
1
2 13
CONCRETE BL K.
BRICK OR STONE
PIERS
3 BASEMENT
AREA FULL
FIN. B M T AREA
V, 1/7 1/1
FIN. ATTIC AREA
t!O 8 M -T
FIRE PLACES
HEAD ROOM
MODERN KITCHEN
4 WALLS 9 FLOOR$
CLAPBOARDS
B
1
21
3
DROP SIDING
CONCRETE
EARTH
WOOD SHINGLES
ASPHALT SIDING
ASBESTOS SIDING
VERT. SIDING
STUCCO ON MASONRY
HARDW D
COMMON
ASPH. TILE
STUCCO ON FRAME
BRICK ON MASONRY
ATTIC STRS..& FLOOR
BRICK ON FRAME
CONC. OR CINDER BLK.
WIRING
STONE ON MASONRY
STONE ON FRAME
SUPERIOR j__j tOOR
ADEQUATE NONE
5 ROOF
10 PLUMBING
GABLE
1J.HIP
BATH (3 FIX.)
GAMEIRELl
MANSARD
TOILET RM. (2 FIX.)
WATER CLOSET
FLAT
SHED
ASPHALT SHINGLES
LAVATORY
WOOD SHINGES
KITCHEN SINK
SLATE
NO PLUMBING
TAR & GRAVEL
STALL SHOWER
ROLL ROOFING
MODERN FIXTURES
P
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'T G
UNIT HEATERS
7 NO. OF ROOMS
GAS
OIL
ELECTRIC
B'M'T 2nd
T,_tl 3,d
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.
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Loccluon
Date
No.
TOWN OF NORTH ANDOVER
Certificate of Occupancy
Building/Frame Permit Fee
Foundation Permit Fee $—
,-
Other Pef-mvit-Fee y3j. 1 $3—
TOTAL $
Check #
23349
Building Inspector