HomeMy WebLinkAboutMiscellaneous - 27 FURBER AVENUE 4/30/2018N
O_
J
Q
O
�O
oO
O
O
TOWN OF NORTH ANDOVER
PERMIT f ORPt/UMBING
This certifies that . �_: .... )?6� . 014 ..............
has permission to perform ..... Re A Q.1- *4%/ ve .,-: ................
plumbing in the buildings of .....................
at.;.? ... Fc� . �7,� i ) .................. North Andover, Mass.
z
Fee. � 2 7. . Lic. No. .. ....... . ........
PLUMBING INSdCTOR
Che ck # � ( S 5 .
7929
MASSACHUSETTS UNIFORM APPLICATION FOR P . ERMIT TO DO PLUMBING
(Type, or print)
NORTH ANDOVER, MASSACHUSETTS
Building Location Owners Name tA 0— t,, Date
Type of Occupan ly. Amount
New Renovation Replacement' Plans Submitted Yes No
.0
VYV'rYT1C1�1U-L-
(Pnnt or type)
Instalag Company Name
Adr1rt-.cc
Check one: Certificate
ElCorp.
ElPartner.
rAFirm/Co.
Name of Licensed Plumber. 73�6 eek AOL'VA wA
Insurance Coveraae: Indicate�—the type of insuA ce coverage by clecking the appropriate box:
Liability insurance policy ID Other type of indemnity F1 Bond
ri
Insurance Waiv I, the undersigned, have been made aware that the li
three insurance censee of this . application does not have any one of the above
Signature Owner Agent
El F1
I hereby certify that all of the details and information I have submitted (or entered) in abo application are true and accurate to the
best of my knowledge and that all plumbing work d i tall 'ons rf
it, an 'ns a� Pe o" under Pe Issued f thi 1*
compliance with al pertinent provisions of the Massa U, 1; s aPpucation will be in
s tp
Lchusett ZglAcodp- tsr 9f t�e General Laws.
City/Town
APPROVED (oFFicE usE oNLy
)e of P
1 . �nbij License
Master rM journeyman ,
Datq4/nJ,/?
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ...... . ...........................
has permission to perform / ......
wiring in the building of ........................................
rul /
ataA ............ O -el . ..... A-V'e . . . . ........................ North Andover, Mass.
Fee.'::�O Lic. No.d.j.jld.f .......
'i�ECMICAL INSAPECTOR�
Check #
ESLI-S
) � 0 -� -,,;,
NAME
ADDRESS Al
SERVICE AMPS / VOLTS
NO METERS I NEW
_L_qHAN
j _
PERMANENT TEMPORARY
ADDITIONAL:
PERMIT NUMBER F -5 -vs -
SR# 521? //0 2�
ELECTRICIAN_ C�tgC,46
RECEIVED BY
DATE CALLED
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No.
Occupancy and Fee Checked
[Rev, 1/071 ne;ivt-. — I
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
M work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRflVT-flV-VVK OR YTPEALL INFORMATION) Date: 11-2q-o-�Z
L. -I
City or Town of- NORTH ANDOVER To the -Inspector of Wires:
By this application the undersigned gives notice of his or -her —intention to perform the electrical work described below.
Location (Street & Number) 7- -2 14-V
Owner or Tenant rr. /, C -
Owner's Address
e
IN
Is this permit in conjunction with a building permit?
Purpose of Building
E3ist ing Service /,9'0
New Service 2—oc)
Amps 120 /Z�OVolts
Amps /2b/ZY0Volts
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Telephone No.
Yes F-1 No E] (Check Appr2priiate BoX)
UtilitY Authorization No.-5'���.
OverheadF' Undgrd No. of Meters
Overhead D--"— Undgrd No. of Meters
e -
Estimated Value of Electrical Work: ---- --urlut aciau y aesirea, or as required by the Inspector of WireT.
—7--7— (When required by municipal policy.)
Work to Start- Inspections 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 cov7age is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND OTHER [] (Specify:)
I ce?Wft, uirnader thh&eadinsandpenaldes Of th f the informado
pf rpu?y, a ,n on this application is true and complete
FIRM NAME:
LIC. NO.:
Licensee:
1'. Sign�ae
(If applicah e, enter "exe n the license n LIC. NO.: 207,
�=mber I 'ne.) Bus. Tel. No.: 7?,?- 77
Address: A ke :� alell, Alt. Tel. No.:
*Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "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 (check one) F� owner D owner's ag
Owner/Agent -ent
Signature Telephone No.— [f LRM�IT �FEE.- $
064-A & C-11 -I
,� v � k
('-L7
f
u
r _; www.nms.gov1dia .
Workers' Compensation Imitrance Affidavit: Buflders/ContractorsMectricians/Plumbers
Nanie (Business/C)Tganizafion/individual):
Ad&es
City/State/Zip:
M
Phone #:
1 Am you an employer? Check the appropriate box:
The Commonweaft of Massachusetts
4. 1 am a general contractor and 1
Department of Industrial Accidents
have hired the sub -contractors
Office of Investigations
14 1 ji
600 Washington Street
Boston, MA 02111
r _; www.nms.gov1dia .
Workers' Compensation Imitrance Affidavit: Buflders/ContractorsMectricians/Plumbers
Nanie (Business/C)Tganizafion/individual):
Ad&es
City/State/Zip:
M
Phone #:
1 Am you an employer? Check the appropriate box:
17 1 - a employer with
XMpioyees
4. 1 am a general contractor and 1
(full and/or part-time).*
have hired the sub -contractors
2.-�11 a -sole proprietor or partner.
listed on the attached sheet
ship and have no employees
These sub-contractDrs have
working for me.in* any capacity,
workers' comp. insurance.
[No work=, comp. misurance
5. El We are a corporation and its
required.]
3.17 1 am a homeowner doing all work
officers have exercised their
right of exemption per MOL
myself. [No-workersi, comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees, [No workers'
comp. insurance requireZ)
Type Of Project (required):
6. [] Now construction
7. El Remodelmig
9. Demolition
9. Building addition
10. Electrical repairs or additions
I I Z Plumbing repairs or additions
12.E] Roof repairs
13.[] Other
IQ, 6iIC,;K5 OUX ff I Mug also T111 Out the sec;tjon below showing their workert' compensatian policy mformatiolL
liomeownets who submit this affidavit indiatting they am doing all work and then him -outside contractors must submit a new affidavit indicating ffuch.
4Contracton; �at chack this box mustattachad an additionn! sheershowittg. the name ofthe sub-corrftwuns and their work=, comp. policy inforomfion,
I am an employer thatis-prquiding workers' compensadon irtsurancefornw employeeL Belo
informadork w is Me policy andjob site
Insurance Company Name:
Policy 9 or Self -ins. Lic.
Expiration Date:
Job Site Address: CitY/Stat&Zip:
Attach 2 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 cer*
the pains andpenalties that the informadon pro vided above is true and correct
Signature: D
Phone ?
Official use only. Do not wrile in dds area, to be completed by city or own official
City or Town: PermilvLicense #
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'fbregoing engaged in a joint enterprise, and including the legal representatives of a de=ased employer, or the
receiver or bllStCe -0f 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 wdrk on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MOL 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.te construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence -of compliance with the insumncecoverage required."
Additionally, MGL chapter 152, §25C(7) states 'Neither the commonwealth nor any of its political subdivisions shall
enter into any contact for the performance of public work tmtil acceptable evidence of complia6ce 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 ceitificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other thaii 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 affidavitmay 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 pem'ft or license is being requested, notthe Department of
Industrial Accidents. Should you have any questions reprding the law or if you am required to obtain a workers;
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insuranc'e'license sumber 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 afficiRvit 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 permittlicense number which will be used as a reference number. In addition, an applicant
that.must submit multiple perinit/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 it,
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the V
L
applicant as proof that a vzli affidavit s on file for future permits or libenses. A new affidavit must be filled out each r
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 persbn is NOT required to complete this affidavit.
The Office of Investig,4ions 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. # 617-7274900 6Xt 406 or 1 -8 -77 -"SAFE
P,evised 5-26-05 Fax 4 617-727-7744
www.mass.gov/dia
f Location 22
I
No. Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
?�flding/Frame Permit Fee $
Nwart-p, prmit Fee
- // 1" e� e
A'I � 4
Otheri4w,�, e-4, $
Sewer Connecfio�'� Fee $
Xor ter Connection Fee $
TOTALP �9,q,
$
Building Inspector
Div. Public Works
PER31ff NO. 3,3
I - -%
LM -1
m
m
APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS.
L -,/PAGE I �
MAP 4qO.
LOT NO.
12 RECORD OF OWNERSHIP IDATE
BOOK *.PAGE
.ZON E
SUB DIV. LOT NO.
LOCATION VZ"
L--�
PURPOSE Oe:MUCMWG 117
NEWS NAME oto I r)
I
14—
NO. OF STORIES SIZE
NER'S ADDRESS
BASEMENT OR SLA13
ARCHITECT'S NAME
SIZE OF FLOOR TIMBERS IST 2ND 3RD
4(51�DER'S NAME
SPAN
DISTANCE TO NEAREST BUILDING
DIMENSIONS OF SILLS
DISTANCE FROM STREET
'61STANCE FROM LOT LINES SIDES
REAR
POSTS
GIRDERS
AREA OF LOT FRONTAGE
HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW
SIZE OF FOOTING x
-w-s-,ILDING ADDITION
MATER:AL OF CHIMNEY
IS BUILDING ALTERATION
IS BUILDING ON SOLID OR FILLED LAND
<-ILL BUILDING CONFORM TO REQUIREMENTS OF CODE
IS BUILDING CONNECTED TO TOWN WATER
46ARD 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 t 12
4
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PL�NS MUST SE�F,;LED AND APPROVED BY BUILDING INSPECTOR
VDATF
UA 44
L"' SIGN,4ftl4if OF OWNER ilk"AUTHORIZED AGENT
F E E ?r /,5
PERMIT GRANTED
19
OWNER TEL. ISM-
CONTR. TEL. #
CONTR. LIC. #
3 PROPERTY INFORMATION
LAND COST
;'EST. BLDG. COST
" &�
EST. BLDG. C09f ISER SQ. FT.
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
BOARD OF HFALi-m I
PLANNING BOARD I
BOARD OF SEL.ECTURN
Nul—ING INSPRU51
I OCCUPANCY
SINGLE FAMILY S'ORIES
MULTI. FAMILY
APARTMENTS i 1_ OiFFIC'E'S
5 ROOF 10 PLUMBING
GABLE I BATH (3 FIX.)
r.AMRQF I _� ±M!'Ap.lAll TOILET RM. 12 FIX.1
T SHI
WOOD SHINGES 111. KITCHEN SINK I
ROLL ROOFING 11 MODERN FIXTURES
::11 TILE FLOOR
CONSTRUCTION
2 FOUNDATION
6 FRAMING
8 INTERIOR FINISH
CONCRETE
-- 3
1
2 13
CONCRETE BL'K.
FORCED HOT AIR FURN.
E
STEAM
STEEL BMS. & COLS.
BRICK OR STONE
HOT W'T'R OR VAPOR
H RDW D
AIR CONDITIONING
PIERS
RADIANT H'T'G
PLASTER
UNIT HEATERS
7 NO. OF ROOMS
GAS
OIL
D'RY WALL
B'M'T 2nd
Ist I _�,d
ELECTRIC
NO HEATING
1_�_NFIN
3 BASEMENT
AREA FULL
FIN. B M'T* AREA
1/1 1/7 1/1
FIN. ATTIC AREA
t!O 8 M T
FIRE PLACES
HEAD ROOM
MODERN KITCHEN
4 WALLS
9 FLOORS
CLAPBOARDS
—
_-EONC
B
1
2
3
DROP SIDING
—
RETE
-EARTH
WOOD SHINGLE�__
ASPHALT SIDING
HARDW D
ASBESTOS SIDING
COMMCN
-ZpH -TLE
VERT. SIDING
STUCCO ON MASONRY
STUCCO ON FRAME
BRICK ON MASONRY
ATTIC STRS. & FLOOR
BRICK ON FRAME
CONC. OR CINDER BLK.
STONE ON MASONRY
WIRING
5 ROOF 10 PLUMBING
GABLE I BATH (3 FIX.)
r.AMRQF I _� ±M!'Ap.lAll TOILET RM. 12 FIX.1
T SHI
WOOD SHINGES 111. KITCHEN SINK I
ROLL ROOFING 11 MODERN FIXTURES
::11 TILE FLOOR
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.
f — .
TILE DADO
6 FRAMING
11 HEATING
WOOD JOIST
PIPELESS FURNACE
FORCED HOT AIR FURN.
TIMBER BMS. & COLS.
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
B'M'T 2nd
Ist I _�,d
ELECTRIC
NO HEATING
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.
f — .
i
/�
606w't
I
ri U 9 . L L - -_)z: L & ; ')�j UUUU �MNI HAeUU s e r 1 e s
MORTGAGE PLOT PLAN
EK SURVEY
17 ROYAL STREET, LAWKENCEt MA- 01341 Tel. WA -075-1413
MORTGAGOR 0mv1K —DEED REF. 31611 120. 31
ADDRESS OF PRINCIPLE BUILDING PLAN REF.
27 FURBER AVE. DATE OF INSPECTIO14 JULY 23, 1992
N. AnovER, mk.
LOT 176
A I _. 0 v ftb
WPA= j " %W w
OMACC LOYS 177 Al 178
9.000 qf.
tz
2
rmy
WOOD
lei
4 11 j Tko. W -O �
AVENUE
LOT 179
mom 7%1w wwton" Insimtkift Was DOWN
.Pmtftdy ftr nwtpw pwvom and le rfat t1lo
bg rold VW m a vim)% 9K MXWWY NOW118
no r%mpwwbw4 W dwr Twd" *vm saw
gftww by anyone ~= &* aw -
old " ejawa in coraHmAbn wo ft
Rwtmo fvmwmf to so martlaw.
r. i
i rUNIM SAME 714AT IN MY POW AL
ommm &A ptjob stnachreA and
outimAdmis. ,FORM
Wft Va WwdiiA_ rw#*wwft of ihe Issid
soliq wdhwwm ad. OW 00 Oft"WIM U
of m3w kwv4mnwu low my
paperty Ines amept a lows
MAI&
C071FICAT1W T* 01. prop" is nut In a Read lkmw Ar"
Ct isguipsly is in a Rsod Hood Arm
Ibis out"lostwe Is beew an t%e motion Of mmwy llmkw C33. miomwoon b WNMWmt to **a be Amw H=
of gum% und dwa nut apmm t a pRWorty simmy, Vmm%M Flood Howd ktemhW fto tk kftd Federd Flood
off"ta lhown dn not to bs used far tbe smU6WmWt Of hsmwm Rds " fed#
pmpwty n"L
C\
r-.4
r —0
IV) w
C*
0 am
z
0
0
or.
C-0
41
L,
Cd
R.
X.
0
z
co
g COD
ui
oz
C3
0
0
E
r —0
IV) w
C*
0 am
z
C/)
0
C/)
C101t m
01
P�
0
U
�21
ell
CD
E
LL
z
co
g COD
ui
C3
0
co
C.)
cm
CL
LU
ca
CD
CL
<
.52
E
co ca
CD
=C3
CD
0 CD
CD
CD
CM b
co
Q
M
CD
4=3
co
0.
0 CL
:4- ce
E E
ca
'0
Cc Cc
C.)
J -0
CA
CD
z
CD
CD
CL=
E
b..
0
CL
CO
Co m
0
0
CL
C�
L..
CO3
cc
ca
2 ca
CD
CD
03
ca
CA
CO2
E
ca
rb�: CD 0
73
cm
X:
CLC.3
ea CD I
W:5
CD
cc
c=m
=C)
CD
Cf.
Cc
A 0
Z
CL.
=CM
CD
fA CD
CD
CD=
CLO- 0
COD
�g
=0
CD
e -0 =0
�LL
e — =m
Co
I--
cc
rb=-
CLM
= 45 CD
C.)
LU
U
CD
cm
Q CD
CL.
co)
.0 0
m 0 =
0
CD
b-
0
4- CL:4E-- Cl
C/)
0
C/)
C101t m
01
P�
0
U
�21
ell
CD
E
LL
z
co
ui
0
co
cm
C:)
LU
ca
CD
<>
<
.52
E
co ca
LU
cn
CD
0 CD
CD
CM b
Q
M
CD
0.
ca
'0
Cc Cc
C.)
J -0
CA
CD
z
_j
<
0
CL
COD
cc
03
Cc
LL
CO2
E
CD
M
E
z
LL
L.L
Cf.
ate. .//,� �/.. :�?"f ......
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATA10
(U
This certifies that ....................
has permission for gas installation .................. A
in the buildings of ...
.............................
at ........ North Andover, Mass.
Fee.,.2 Lic. No..�' C/. V .( ... ..........................
GASINSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR P3EF/,[T TO DO GASFITTING
U-nnt of lypej
7 -n.
Mass. 19 Permit It' � ' - � - ---.:-2—'
Building Location J"-2 Owner's Nam
Type of cccupanc��_:_�, �11—
New C] Renovation C] Replacement pl-�. Plans Submitted: YesEl"' No Cj
Installing Company
Business Telephone �Plf
Name of Licensed Plumber or Gas Fitter
Check one:
0 Corporation
[I Partnership
.1
Certlflcate 7
INSURANCE COVERAGE:
I have a current Ila-billity Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
i Yes ED"'- No 0
If you. have checked yes. please Indicate the type coverage by checking the appropriate box
A llatiililty Insurance policy 0' Other type of indemnity 0 Bond 0
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not havft. the Insurance co�erage required by
Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature at Cwner or Owner's Agent CwnerO Agent [I
I hereby certify that all of the details and Info(ratIon I have submitted (or entered) In above application are true and accurate to the best of my
knoMedge and that all plumbing work and installations performed under the armit I ued for this gppllc!Uon^be In compliances with all
Pertinent provisions of the Massachusetts State Gas Code and Chapter 142 ofthe G eral Laws.
BY. T a of Ucense:
Plumber i natur a Ucensid Pluffiber-o-rUZ-TI—tter
Title Itter
City/Town i3,,TS,,rt,1er License Number.,�&,.g
AprrK7v,rD (0FF10EUSFZTrTr— Journeyman
V3
(1)
Uj
cc
LU
in
2
-1
Uj
1..
>-
=
"Z -
.0
ILI
0
tu
.4
ILI
0
Uj
I
>
W
W
W
Cr
W
0
=
US
W
U
W
J
di,
W
0
0
IJ
>
=
J
Uj
>
0
W
LL.
<
0
0
0
>
E
0
0
CL
SUB—aSMT,
BASEMENT
ISTFLOOR
2ND FLOOR
f
I
3RD FLOOR
4TH FLOOR
STH FLOOR
6TH FLOOR
7TH FLOOR
STH FLOOR
Installing Company
Business Telephone �Plf
Name of Licensed Plumber or Gas Fitter
Check one:
0 Corporation
[I Partnership
.1
Certlflcate 7
INSURANCE COVERAGE:
I have a current Ila-billity Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
i Yes ED"'- No 0
If you. have checked yes. please Indicate the type coverage by checking the appropriate box
A llatiililty Insurance policy 0' Other type of indemnity 0 Bond 0
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not havft. the Insurance co�erage required by
Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature at Cwner or Owner's Agent CwnerO Agent [I
I hereby certify that all of the details and Info(ratIon I have submitted (or entered) In above application are true and accurate to the best of my
knoMedge and that all plumbing work and installations performed under the armit I ued for this gppllc!Uon^be In compliances with all
Pertinent provisions of the Massachusetts State Gas Code and Chapter 142 ofthe G eral Laws.
BY. T a of Ucense:
Plumber i natur a Ucensid Pluffiber-o-rUZ-TI—tter
Title Itter
City/Town i3,,TS,,rt,1er License Number.,�&,.g
AprrK7v,rD (0FF10EUSFZTrTr— Journeyman
Location
No. ds Date 101-140y,
TOWN OF NORTH ANDOVER
41
Certificate Occupancy
of $
S CMUS
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # a,2921-3
'i 77 13
building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
f
jn& or
Seefin for !use
BUILDING PERMIT NUMBER: DATE ISSUED:
LqZ /,/),o
SIGNATURE:
Building Commissioneffln�L=tor of Eluildinp Date
SECTION I- SITE INFORMATION
1.1 Property Address:
C�7
1.2 Assessors Map and Parcel Number:
Map Number Parcel Number
1.3 Zoning Information:
Zoning Di�-U ict Proposed Use
1.4 Property Dimensions:
LA.Area (sf) Frontage (ft)
1.6 BUILDING SETBACKS (ft)
Front Yard Side Yard
Rear Yard
ReqWred Provide RcqWred Provi&d
Reqwred Provided
1.7 Water Supply M.G.L.C.40.. 54) 1.5. Flood Zone Information:
Public 0 Private 0 1 Zone Outside Flood Zone 0
1.8 Sewerage Disposal System:
municipal 0 On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
7 17, L21 r i C, t: Y,
2.1 Owner of Record
hera . lyncA
Name (Print) Address for Service
92r C�a
0 0
Signature Telephone
2.2 Owner of Record:
name Print Address for Service:
Si' ature Telephone
V-
S19CTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor:
35a -Ls d,- - d�nllllv /b, H
Ad ss I
2?(f 60 -2� 96Y
I s-ture Telephone
Not Applicable 0
License Number
1.211��16-11
Expifation/Date
T 721 red Home Improvement Contractor
s t
RO 44
Company Name
Not Applicable 0
Registration Number
2/-/ Y '/
;d d Lrs
�zA
-C-)
irat4h Date
ignature, Telephone
I
SECTION 4 - WORXERS COMPENSATION (M.G.L. C 152 § 25c(6) _�
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 aR appkable)
New Construction 0 Existing Building 0 1 Repair(s) 0 I-Alterations(s) 0 1 Addition 0
Accessory Bldg. 11 Demolition 0 Other 0 Specify
Brief Description of Proposed Work:
S�/'o Qod ,eroaP c4,,71J
I SECTION 6 - ESTIMATED rONSTRUCTInN Cn.4QT.Q I
item
Estimated Cost (Dollar) to be
Completed by permit applicant
OFFICLAL USE ONLY
I . Building
Soo. 0 n
(a) Building Permit 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)
Check Number
aK,%.JLJL%J1" IV Ut UUMFLEIED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner/Authorized Agent of subject property
Hereby authorize
My behalf, in all matters relative to work authorized by this buildiiig permit application.
to act on
Signawre ofOwner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
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
V
of Owner/.
NO. OF STORIES SIZE
-BASEMENT OR SLAB
-SIZE OF FLOOR TROBERS 3 RD
-SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
D.UvENSIONS OF G.U�DERS
-HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHEVMY
LIS BUILDING ON SOLID OR FILLED LAND
I IS BUILDING CONNECTED TO NAMZAL GAS LINE
L,
0
North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM 6 /
In accordance with the provision of IVIGL c 40 S 54, a condition of Building Permit
Number is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by lVIGL
c 11, S 150 A.
The debris will be disposed of in:
(Location of Facility)
4d -J, IN
Signature of Permit Applicant
Z -i 2 // �—/Zv— V
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
A
Id &.'etLOcta
<,,Ao C61
d71-1
.,� 0(-+
vj,�-
thaposal t -age njo.
J & J Roofing
Specializing in All Types of
L.=:pRoofing - Ventilation - Carpentry
978-683-2968 603-898-1058
or
('0 /�,
t-ages
PROPOSAL SUBMITTED TO
PHONE —T—DATE
.....
`�he
. ... ..................................
ri - - ... .........
�e(l Lyncl-� ..
.
I
....... . .............. .
STREET I
JOB NAME
J-) FuAq Ave
CITY, STATE and ZIP CODE
JOB LOCATION
0 IM
ARCHITECT
DATE OF PLANS
JOBIPHONE
We hereby submit specifications and estimates for:
.�+Y p ......... e.n4j.-re . ....... cl�� (a -y?( ct'� +.W.G I-CLY ................
Repl.ace..any 0( d-axno... ecL-bocL(.a-:�4 q� r.enQ4'..t. oar.8.5- uro..5.� ef
S
4"
qll.ey..5 . ........ ancL acroz en+.Ire to e( p.;..+cke� . ....... 5�ed ......... 6;xm.e-(5 ...........
Pr6 . ........
Or flrapMr hereby to furnish material and labor — complete in accordance with above specifications, for the sum of:
be made as follows:
All material is guaranteed to be as specified. All work to be completed in a workmanlike
manner according to standard practices. Any alteration or deviation from above specifications
involving extra costs will be executed only upon written orders, and will become an extra
charge over and above the estimate. All agreements contingent upon strikes, accidents
or delays beyond our control. Owner to carry fire, tornado and other necessary insurance.
Our workers are fully covered by Workman's Compensation Insurance,
F 5(--)G. ,,o
dollars ($ 4_
e: This proposal m e
I
us if not accepted witlh�n days.
Arreptaurr of Proposal—The above prices, specifications
and conditions are satisfactory and are hereby accepted. You are authorized Signature C.,
to do the work as specified. Payment will be made as outlined above.
Date of Acceptance: i Signature
.....
`�he
. ... ..................................
ri - - ... .........
....... . .............. .
Or flrapMr hereby to furnish material and labor — complete in accordance with above specifications, for the sum of:
be made as follows:
All material is guaranteed to be as specified. All work to be completed in a workmanlike
manner according to standard practices. Any alteration or deviation from above specifications
involving extra costs will be executed only upon written orders, and will become an extra
charge over and above the estimate. All agreements contingent upon strikes, accidents
or delays beyond our control. Owner to carry fire, tornado and other necessary insurance.
Our workers are fully covered by Workman's Compensation Insurance,
F 5(--)G. ,,o
dollars ($ 4_
e: This proposal m e
I
us if not accepted witlh�n days.
Arreptaurr of Proposal—The above prices, specifications
and conditions are satisfactory and are hereby accepted. You are authorized Signature C.,
to do the work as specified. Payment will be made as outlined above.
Date of Acceptance: i Signature
vyl
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUP
ERVISOR
NUMber: CS 065870
Birthdate: 12/17/1974
Expires: 12/17/2004 Tr -no: 5629
Restrict&d. 00
JAMES P FREDERICK
352 ISLAND POND RD
DERRY, NH 03038
Adr;;4istraator
0
71. &"�� ��
<2�N Board of Building Rtgul'tiOn a�nd �Stnndar
HOME IMPROVEMENT CONTRACTOR
Registration: 126777
Expiration' 1119/2006
Type: i6dWual
JAMES P. FREDERICK
JAMES FREDERICK
352 ISLAND POND
DERRY, NH 03038 Administrator
s
0
0
LU
0
Rs
CL
M M
ro-
4D
C�
0 CL
#A
C
Low 0
cm li
E
M
c c 90
Cc
.0 ;,m -cc Go
m 'o
"on
CLCJ CD
16, 10
-Law
.00 ccb
com 0 P1 M
cm
C2
C.)
M
co
0 CL
me ci
CL—
C*3 m
Lu .0
0 c
a . -2 ro m 0
p Sw CLA z
LAJ
ca
C.3 .0 s
ca CL 4D 10
Go m �M%
Zm 00. 1 L 74w- w 21.
M
0
CO
0-4
%p
IN,
u
0
42
E
z
cm
CA
CD
.ca
i
CD CD
CL
3:
0
C:L
cc 0 CL
ZE cm<
E
cc
.2
CL. 0
C40 Z
CL
C.3 GO
cc
cc
'a
co
is
w
U)
w
U)
19
w
w
19
w
LU
U)
w
0
C14
L
>
u
0
ng
r.
u
cd
X
0
C4
0
0
0
0
LU
0
Rs
CL
M M
ro-
4D
C�
0 CL
#A
C
Low 0
cm li
E
M
c c 90
Cc
.0 ;,m -cc Go
m 'o
"on
CLCJ CD
16, 10
-Law
.00 ccb
com 0 P1 M
cm
C2
C.)
M
co
0 CL
me ci
CL—
C*3 m
Lu .0
0 c
a . -2 ro m 0
p Sw CLA z
LAJ
ca
C.3 .0 s
ca CL 4D 10
Go m �M%
Zm 00. 1 L 74w- w 21.
M
0
CO
0-4
%p
IN,
u
0
42
E
z
cm
CA
CD
.ca
i
CD CD
CL
3:
0
C:L
cc 0 CL
ZE cm<
E
cc
.2
CL. 0
C40 Z
CL
C.3 GO
cc
cc
'a
co
is
w
U)
w
U)
19
w
w
19
w
LU
U)
The Commonwealth of Massachusetts
Department of Industrial Accidents
Ofrice of Investigadons
Boston, Mass. 02111 -
WOrkers'Compensation Insurance Affidavit
Fame Please Print
Name:
Location: C�
F-1 I am a homeowner performing all work myself.
F] I am a sole proprietor and have no one working in any capacity
E� I am an employer providing workers' compensation for my em oyees working on this job.
Corrivany name: 1;m F-Ce4r, V 71� 71 P, 1-11,4 �
f (7, 1140
el
CompaDy name:
Address
ch: Phone *
2? AF? -
315S
Insurance Co. Policv #
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of.a fine up to $1,50(),Oo
andfor one years' imprisonment-as.web.as -CIALperialfies in 1helbrm da.sT.0p.W.0RK
ORDER..arid..a.fineaf.(3100..00)-aAay against me. I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification,
/ do hereby certify gpder the
of pegury that the inthnnation provided above Js true and correct.
7
Print name 'IN
Phone #
Official use only do not write in this area to be completed by city or town official'
City or Town Permit/1-icensina
Building Dept
[]Check if immediate response is required C] Licensing Boald
r-1 Selectman's Office
Contact person: Phone #.- E] Health Depaftment
Ei Other