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Home My WebLink AboutMiscellaneous - 271 CANDLESTICK ROAD 4/30/2018 (2)TO This certifies that. has permission for gas installation ............ in the buildings of. /7.4. e //0 ................... at . c.,C Fee :-�eP.Lo . Lic. No. ......... North Andover, Mass. ....M4 . .............. ... GASINSPECTOR Check # GOWNER TYPE OR PRINT CLEARILY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r'�Nbc_ CITY: T MA. DATE: (3 PERMIT# 'r -NaL -4 '4pc'ji�� - — 4- JOBSITE ADDRESS: a?/ a�JDL�(�- S -If I/-- k -E-) OWNER'S NAME4(46 SCAd2i�06t_(,GO ADDRESS: TEL: 0-\0 0 0 /1 FAX: OCCU TYPE: COMMERCIAL EDUCATIONAL El RESIDENTIAL NEW: 7RENOVATION: 0 REPLACEMENT: PLANS SUBMITTED: YES F-1 NO [I APPLIANCES1 FLOOR- Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR 0 aTS c> c, - GRILLE INFRARED HEATER LABORATORY COCK MAKEUP AIR UNIT OVEN. POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER LINVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE I have a current !!��insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES W"/NO F] If you have checked )LES age b h ki the appropriate box below. , please indicate the type of cover q c ec ing LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY F1 BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT F] SIGNATURE OF OWNER OR AGENT 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 m Knowledge and that all plumbing work and installations performed under the permit issued for this application wil provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 3 5� PLUMBER/GASFITTER NAME: -LICENSE# 04 6��SIGNATURE COMPANYNAMEN r- Sei(V&L A,� 4- 5�X ADDRESS: Y - V _j CITY: Lk_�Jl Ot STATE: zip: c) FAX: TEL: q7 9 LO 7 40 CELL: EMAIL: MASTER Q(JOURNEYMAN F1 LP INSTALLER [I CORPORATION [I # PARTNERSHIP El # LLC El # 3,6 -4 j - COMMONWEALTH OF MASSACHUSETTS PLUMBERS AND GASFITTERS L CENSED AS A MASTER PLUMBER ISSUES THE ABOVE LICENSE TO: MARK 8 ��PLNCE 'E� PO BOX '893 NUTTINb' LAKE MA 01865-0893 1138.2 05/01/1'r, .156.738, Fold. Then Detach Along All Perforations j IN 1, At bol, 1 41114 1 DATE: � I I( I (� LOCATION: OWNERS NAME: GENERATOR kw rimiavilmol 'URI NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR: PHONE NUMBER: ELECTRICAL RESIDENTIAL (: "GAS ) COMMERCIAL TEMPORARY LOCATION OF GENERATOR: *ZONING DISTRICT: *CONSERVATION APPROVAL ao 0 0 0 m ri; W Cd "ll ui Ckm C2 01 Ga LLJ Al. C, go CD C -P. ug L=Aj caj, CL cn -ei \10 co E cc.,L A2 SC31 %�-,s �- -6 C/) K E- 0 U co 0 cm CL Qj a, C/) Go CD cnc� -C, <= ?56J Cot I - 15" ro- CM cc , 8� CD uj L4% Co a, r*4 o L45 CO2 Mo COS CL z LU C=3 Iowa C-5 0 COE L) CD CL C2 CLI LLJ g 2 co M m emcm ::. I u 0 0 ral M \110 u cn �-Ij ro -z lu U) u 0 —co C/) P4 u a. 0 0� "ll ui Ckm C2 01 Ga LLJ Al. C, go CD C -P. ug L=Aj caj, CL cn -ei \10 co E cc.,L A2 SC31 %�-,s �- -6 C/) K E- 0 U co 0 cm CL Qj a, C/) Go CD cnc� -C, <= ?56J Cot I - 15" ro- CM cc , 8� CD uj L4% Co a, r*4 o L45 CO2 Mo COS CL z LU C=3 Iowa C-5 0 COE L) CD CL C2 CLI LLJ g 2 co M m emcm ::. I u 0 0 ral M co 0 E CO G3 CL 0 CO2 a) CM co LA w E clo co CD 0 CD A— 1—..= CL — Z., C13 cz C2 CD L - C.3 m Q E: cm ca cm cc = Cc C.3 CD CO) a) Q CL CO) CL (A is cr- LU U) 2-1 C) L) CD 2-7 2-1 CL :3 0 Cj 6 z -oz co 0 E CO G3 CL 0 CO2 a) CM co LA w E clo co CD 0 CD A— 1—..= CL — Z., C13 cz C2 CD L - C.3 m Q E: cm ca cm cc = Cc C.3 CD CO) a) Q CL CO) CL (A is cr- LU U) 2-1 C) L) CD 2-7 2-1 CL kc -o Location No. — 0(o Date TOWN OF NORTH ANDOVER 0 Certificate of Occupancy $ Building/Frame Permit Fee $ 'I C'. Foundation Permit Fee $ U fi/ 10permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL &1Z1 L 05123194 11:03 7267 f $ ev 6-4:9 Building Inspector 25.00" PAID Div., Public Works Locationc2l/ No. Date TOWN OF NORTH ANDOVER jaimimIlik Certificate of Occupancy 'Building/Frame $ Permit Fee $ 74A. CH Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ , 2—baLL-1--,5 TOTAL $ Ck, 36��4Building Inspector 7187 04/29/94 16:17 J. ?��DOM� Div. Public Works a 1-76cation No. 19 Date TOWN,OF NORTH ANDOVER Ce ific"t �of Occupancy $ ji 4 _13uilding/Frame Pelmit Fee $ Foundation Perm!! Fee $ 42 Other Permit Fee $ ----------- Sewer Connection Fee $ Water Connection Fee $ TOTAL $ A? de:VJN�013.05 150-00 PAID ...-Inspector 7,084 Div. Public Works Location. . 271 27 No. Q"l Date 7 Alp -33-Z - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL ��03/6/94 (Y9,05 Bupding InspeQtor 6938 /b-iv/;0UbIIc Worki' P E Rll I T N 0. 06 APPLICATION FOR PERMIT TO BUILD NORTH ANDOVER, MAtS. e t,,,kjPAGE 1 4. it - e4Z �t A) ,5 ,tj �UT NO. mA?- "j-4aR -7-/Wclu- 2 _ RECORD OF OWNERSHIP IDATE BOOK ;PAGE ZON E v )s!ft-6-WQr H7 -,U #Wr 057— /0 Ll i LOCATION PO PUR, SE OF 13UILDING I/ A I&t Ai� 6 9 A h L OWNER'S NAME AbAger �9wvldz &/v oiwwD NO. OF STORIES IR SIZE OWNER'S ADDRESSYeLl) pj P, & porf BASEMENT OR SLAB ARCHITECT'S NAME messi" SIZE OF FLOOR TIMBERS I ST )VO 2 N D 3R6 BUILDER'S NAME fMfX7- 1411VIS SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES - SIDES REAR GIRDERS o AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS /0 IS BUILDING NEW SIZE OF FOOTING x d,91 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 A/A IS BUILDING CONNECTED TO TOWN SEWER 40 IS BUILDING CONNECTED TO NATURAL GAS LINE YK INSTRUCTIONS SEE BOTH SIDES T/�oacn, Pz^wAgfv, /c/1 -j- -ro PAGE I FILL OUT SECTIONS I - 3 46-r -;,lq 0*4% SOWOf7V4 PAGE 2 FILL OUT SECTIONS I - 12 Mm 1 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING o O� r -IM ATTACHED GARAGES MUST CONFORM TO STATE FIRE�REGU—LAt+IW0S—"mn7o../,� �o PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED SIGNATUR WN R ko AUTHORIZED AGENT F E E p) V !7— J 1 11 U CM 2 5 PERMIT GRAM;IED/-�'-3L-11-W-�-, I I �,4-c 19 I-V I'D IING D I -H OWNER TEL. # JOS' '17r-rP�' CONTR, TEL. 13 /,9' CONTR. LIC. 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BOARD OF HEALTH MANNING BOARD 'BOARD OF SELECTMEN 0 BUILDING RECOAD OCCUPANCY 12 SINGLE FAMIL TOkIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMIL' )FFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES, GA - APARTMENTS I I RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTER It FINISH CONCRETE 1 2 ^j CONCRETE BL*K. PINE BRICK OR STONE HARDW D PIERS PLASTER DRY WALL UNFIN 3 BASEMENT AREA FULL FIN, B M T AREA V, 1/2 1 1/1 IN. ATTIC AREA �LO 8 M T FIRE PLACES HEAD ROOM MODERN KITCHEN 4 WALLS 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCrETE WOOD SHINGLi—S — TA—PTH ASPHALT SIDIN�__ — -4-ARDW D ASBESTOS SIDI�G_ — COMMON VERT. SIDING ASPH. TILE STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. & FLOOR BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME SUPERIOR POOR Poo I I EQUATE N0_N E 5 ROOF 10 PLUMBING GABLE Hip BATH 13 FIX.) GAMBREL MANSARD TOILET RM. 12 FIX.) FLAT A SHED WATER CLOSET ASPHALT SHINGLES LAVATORY -4 wOOD SHINGES KITCHEN SINK SLATE NO PLUMBING TAR & GRAVEL STALL SHOWER ROLL ROOFING MODERN FIXTURES TILE FLOOR TILE DADO HEATING 6 FRAMING 11 11 wOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. & COLS. STEAM STEEL EMS. & COLS. HOT W T'R OR VAPOR wOOD RAFTERS AIR CONDITIONING RADIANT H'T G UNIT HEATERS I .- — ____ OIL B'M T 2nd ELECTRIC 3rd NO HEATING v FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary 1 .0 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 sec . on***************** APPLICANT: hone LOCATION: Assessor's Map Number Parcel Subdivision �ru+D pme-C 7 LT Lot (s) Street -71 el'fAIZ),40SI-14' 6A -V St. Number ZI/ ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: ):�tu�� conservation Administrator Comments �A �s CLLf � Q — Town Planner Comments Food Inspector -Health Sd'p-tic Inspector -Health Comments Public Works - sewer/water connections - driveway permit Fire Department Qu �- 4-J, U) Received by Building Inspector Date Approved 1114 14� Date Rejected 7 / Date Approved Date Rejected Date Approved Date Rejected Date Approved 1,44 Date Rejected WWI . J Date -zz- _F4e )I :F K :I: S U.: AIIIFALS 111,111.1)INU (�:()NSI:l IVATION l.'.I.I\NNINC i "u Yown of, NORTH ANDOVE It 1"LANNING. KAH.VNI I I.P. NI: I.SI)N. D11 W(A ()I t CHIAINEY A1111LICAH014 ANO ITRAll I' L -�- 97 2 PERNIT # -1 10 UNER'S NAME: J V -T 7� 5 2'-- ]ILVER'S NAME:* 14 ON'S NAME: -bl-H 7W c - r�)' Lt �SONIS ADDRESS: TL Lo c Xtk(4 ;4 A-14- 0—�c)6 �SOWS TELEPHONE: /,0-3 ggcl— JERIAL OF CHIMNEY: nj 4-!3 cs/�-( IFERIOR CHIMNEY:— IM BER AND SIZE OF FLUES: EXILRIOR CHIMNEY: � X/a -�- x IICKNESS OF HEARTH: ,�U chbiney oa ()�AepCacc coji(jaiun to 41te Aequ.j./jcjji(m.(-.s uo the code and litivC "tuce.6 (III(( I -gwtatiou,s been aeceZved: 1E: .GNATURE OF MASON:,,� :RMIT GRANTED: 'BERT NICETTA 'ILDING INSPECTOR SPECTEV: -"MARKS: SOLID BLOCK HQUIREA) THIS PERMIT musr Gc- VISPLAVLO 014 711E VU1,11SLS %j L eo oll E. -X 1,10 1101, 1 114- 16 10 i' 154 Ak �`77, �L=- Sal -i IN -- -------- - --j CIO 0 z k ON r-4 ol k" "4 0 m u 0 �2 V) C/) u z z 0 �J. (U :1.� u - ca z x u w z —co r. r, u w r-4 u u to 0 1:4 u E — co bo :3 0 04 cu C: x 0 V) 0 C/) *44 A !R COD uj u CIO Cd co Go CD C3" u 9 ED LU ge ca 0 cm cc X Co -6 A CO2 Cc C. - CLIC CO) Cc* CCO3 z C-) c.* co co , ca G3 coi M Cc C43 r -L= - "R CB, Go) L- ca cm CD 0 CD CL ="a.— coi cc = I. CL Cc E MA :5 ca cm cm cm cm F. r �D C/) 0 u C/) Clb P-4 m 4C E45 L61 C6 LLJ LA-: U6 0 �21 TIT (ZL) 1:4 u 0 co 0 E CO ts C13 CO) co cm 0 CO2 co .Co.) CL -0 E ca CD oco L- I.— = CL c D CM co L- CL 00. ME CMCC CO2 Cc CJ CID CO) co CL CO3 cc cc 'a CO2 U- 2� 2) F -- LU C) L:) CD 0�1" cc LU F- uj LU F- LLJ To: The Building Department, Town of No. Andover Dear Sir; I am the prospective homeowner of the dwelling on Lot 27 (271) Candlestick Rd., No. Andover and I agree to accept the dwelling as is on this day August 1, 1994. 1 understand that the interior painting, the carp ng, and h (50 I IX-dw �fillflooring is not completed. I also understand that there are tem pora ood oprit s whic�4 will replace with t e gr9nite at a later date. -7N W-7RZ1,K--J T�VEIYES 1 q 13op Buyer /<'9 H1 /—'q )rp—L= IYE 5 /</ bate COMMONWEALTH OF MASSACHUSETTS Essex, ss. July 30 1994 Then personally appeared the above named Andrzej Treme-ski and Kamila Tremeski and acknowledged the foregoing instrument tp-49�e free act and deed, before me, Notary Public Se ler O'G-- T -Z'VAII's 'r/.te MY commission expires 7/12/96 Seller Ddte C NWEALTH OF MASSACHUSETTS Essex, ss. August 1, 1994 Then personally appeared the above named Robert L. Innis Robert Janusz and acknowledged the foregoing instrame'nt their free act and deed, before me, me blil� siofi expires 7/1�/-@i 162 Date . /�) . . ...... TOWN OF NORTH ANDOVER PERMIT FOR MECHANICAL INSTALLATION This certifies that ...................... has permission for mechanical installation K� . 9?1� in the buildings of -3.10.hn. . Oe.'. ....................... North Andover, Mass. at Fee. o.. .... Lic. N ... 4� .......................... GASINSPECTOR WHITE: Applicant CANARY: Building Dept. . PINK: Treasurer Commonwealth of Massachusetts Sheet Metal Permit Date: �1$1 1), Estimated Job Cost: Plans Submitted: YES NO Business License # Business Information: Name: Street:—I]I City/Town: �) 4-v%Aj)j;q A_ Permit # Permit Fee: S Plans Reviewed: YES NO Applicant License# Property Owner / Job Location Infon-nation: Name:TA!!�, �e_,r jog t4 Mulk (Ov,��VUfj lip j I Lie. Street: Q 14 VE City/Town: Telephone: q_=�Og Teleph Photo I.D. required / Copy of Photo I.D. attached: YES 7 NO _byNg - N Sta flnitial J-1 KM-I-unrestri�cted lic'ense J-2 / M -2 -restricted to d s 3 -stories or less and commercial up to 10,000 sq. ft. / 2 -stories or less Residential: 1-2 family :7 Multi -family Condo / Townhouses Other Commercial: Office Retail Industrial Educational Institutio Other Snuare Footaue: under 10 000 sn ft 10 000 z -ft Ilmhar nf Q+nw;nea 5 . . Sheet metal be completed: New Work: Renovation: HVAC 7 Metal Watershed Roofing _ Kitchen Exhaust System Metal Chimney / Vents Air Balancing Provide detailed description of work to be done: all INSURANCE COVERAGE: I have a current liabili insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes El Non If you have checked Yes, indicate the type of coverage by checking the appropriate box below: A liability insurance policy El Other type of indemnityE] Bond F] OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner E] Agent F� Signature of Owner or Owner's Agent By checking this boxE1, 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 sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation: YES NO Prouess Inspections Date Comments Final Jusnection Date Comments Type of License: By El Master Title El Master- Restricted City[Town E]Journeyperson Signature of Licensee Permit # Fee $ ElJourneyperson-Restricted License Number: Check at www.rnaSs.igov/dDI Inspector Signature of Permit Approval -- � j -2 cn Ln LULI cn x uj I -- 'IT Do LUW w —j -4 CO C) An z —j < WU) w Lu IM o LU 2 LD -1 - !LL �:z W > < 0 0 u co Ir .A < < �-q CD .uj t.Lj u w —j LU X .< 1 �! 1-- 0 0 > m (n LU 0 ul < LLJ —j ]02 LU co Im Z :z < CD LLI LJ) Z 0 < r- E)l En cn 0 u I LD t-- 0 LD N z N2 2378 Date... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ... ........... . ............. ................ has permission to perform ......................................... wiring in the building .................................................... at ............... ...... ........ . North Andover, Mass. ....... Lic. N07�-Y4--.... ....................... INSPECTOR Check # WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 77WC0AM0A7VE4L77I0FAUMCFJUSE77N BOARD OFFIREPREVEMONREGUL4720AN527CWlRI2:W 0 A-r1—LJL.A11U1VPUff1—jUJUVfl.j 1U1—P,-1VPU1UVJPLXL-11UL—A1,L VVUT(A ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 cMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date 15-13-10-00 Office Use only Permit No. Occupancy & Fees Checked Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. F7F— PARCEL Location (Street & Number) C9, -7 61.1iled 41C.11C I— lu Owner or Tenant L>71"i 14-s c - Owner's Address S Am C- (Check Appropriate Box) Is this permit in conjunction with a building permit: Yes Co No F Purpose of Building -s, 4 L F� ,, -, �,, — Utility Authorization No. Existing Service Amps / Volts Overhead Underground No. of Meters New Servic Amps / Volts Overhead Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work AS-� -53� No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total Z KVA No. ofLighting Fixtures Swimming Pool Above Belo F-1 Generators KVA ground d No. of Receptacle Outlets No. of Oil Bumers No. ofEmergency Lighting Battery Units 13 No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total ( Tons No. of Detection and No. ofDisposais No. of Heat Total Total Ill Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating EWT No. of Self Contained I Detection/Sounding Devices Local M-1 Municip�l Other No. �f Dryers Heating Devices KW Connections No. of Water Heater; KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTBER- .11 c- 0, lz 1111k"W"I'l gill Pill- 's -.31 - ao WctktoSkat hEpec1imDa1oReqtx*d signodunckrTrFumhnofpaiury -, FRNINANIE -rf e- I Esbm&dVa1w&3aobcalWctk$ -?-000— FzuWi 20 — Fmal Or Liewsel-b. Lkmm Liummillb / -�-3 -? ;> Adl=— c J�rj AILTeLNTQ lr�25-1 -3 7S- OW�,WSR4SURAI,UEWANER,Iainaw&e#A&LmamdmnottuwdrrBw&=wxmWcr±3aistntiole4m]atasmgmedbyNIasmd"&C=aallav�s anddidniysgnakncndwpwntapphcatKnw&*M�;dwreqzi mut (Please check one) Owner M Agent M Telephone No. PERMIT FEE $ Signature of -Owner or Agent Location No. Date 44 /J�- I �)t)'A--) Of AORT#q TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ CHU Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # q 5 'A to 134 7 6 8 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING lu oio BUELDING PERMIT NUMBER: DATE ISSUED: A lilt SIGNATURE: 1 6fg ll- Building CommissionerfinspOft(ir of buildings Date SEU110IN I -SITE ILN]"OHMATION 1. 1 Property Address: 1.2 Assessors Map and Parcel Number: ,2-7 Ccvn d- c, 10('4 0 2- 3 ty k, r� n Ac) x-) cr Map Number . Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning Distr �ct Proposed Use Lot Area Fronoge (ft) 1.6 BUILDING SETBACKS (ft) Front Yard Side Yard Rear Yard Required Provide Required _� �Provided Req*red Provided 1.7 Water Supply M,G.I.C.4 . 0 154) 1.5. Flood Zone Informatio, I n: 1.8 Sewerage System: Public X Ptivate 0 Zone — Outside Flood Zone 0 Municipal 0 On Site Disposal Systern)( SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record d(ex4eev– 4'()14� —tLf,�s 2-71 Name (Pri t Address for Service 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 ,� co o -c'-:00 T� (:?n Licensed Construction Supervisor: t License Number \AQ-"JA_�A�e- OAnL)�.jer Mn Address 3- �FA -) ( -,P5 �92z, _,q/ 20i Expiration Date SZ164' "f, Irr" Telephone A 3.2 Registered Home Improvement Contractor Not Applicable 0 Cn, Company Name -3 93 'Z � A0 Registration Number Address M;� 2 ( z e,-) Z) Expiration Date Telephone LA01 L70 M 1%j 0 z M 90 0 M r r z 0 SECTION 4 - WOREERS COMPENSATION (NLG.L C 152 § 25c(6) _ I Workers Compensation Insurance affidavit must be completed and submitted with this application. in the denial of the issuance of the building permit. Signed affidavit Attached Yes ....... U No ....... 0 SECTION 5 Description of Proposed Work (check all applicable)_ New Construction 0 1 Existing Building 'N' I Repair(s) 0 Alterations(s) Accessory Bldg. 11 1 Demolition Brief Description of Proposed Work: [I I Other 0 Specify r)+- arec'. Failure to provide this Addition 0 will result SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be OFFICIAL USE ONLY Completed by permit applicant I Building (r) Cp (a) Building Permit Fee 9,5-0 Multiplier 2 Electrical (b) Estimated Total Cost of /0/ ig 0 0 Construction 3 Plumbing Building Permit fee (a) x (b) 4 Mechanical (HV6�� 5 Fire Protection Check Number 6 Total (1+2+3+4+5) SECTION 7a OWNER AUTHORIZkTION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, /f�' I as owner/Authorized Agent of subject property Hereby authorize_Keorine: K -en aqA kee-.-� Cnns4 -to act on Mv bel work authorized by this building permit application. 2 -Signature of Owner Date SECTION I 7b OWNER/AUTHORIZED AGENT DECLARATION as Owner/Authorized Agent of subject 1, 1k --60 Ke,o ae - 8 / -'en I property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief of Date NO. OF STORIE S SIZE -- BASEMENT OR SLAB iST ND 3�- -SlZ-E OF FLOOR TITVMERS 2 —SPAN DIMENSIONS OF SULS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHTOFFOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHEVINEY IS BUILDING ON SOLID OR FULED LAND IS 13UH,DING CONNECTEDTO NATURAL GAS LINE P FORM U - LOT RELEASE FORM INS"TRUC71ONS: —7nis form is used to verify that all nec--ssary 2pprovals/permits fro Mi. Boards and Departments having jurisdiction have been obt2ined. This does not relieve the applicant andlor landowner from compliance with any applic--!:ble or requirements. "AFFLICANT FILLS CUT THIS qc�- C A 6 FHCNE Uj- lfs�p_ LOCATION: As-zesscesiMap Numicer /0(" Iq PARC=-; n 2-3 5 SUECIVISICN L07 (S) STREFT Lv-� S -1. N U 110 E E F, 2- -7 OFFICIAL US' ONLY rRECOMMENE)ATIONS OF TOWNAGENTS: 1319,sf WE&2 -�— I CCNZERVATIGN AL)MINISTRATOR DATE APPROVED �, CATE REJECTED COMMENTS TOWN PLANNER CATE APPROVED CATE REJECTED COMMENTS .1. FOOD INSP 'ECTPk:HEALTH DATIEAPPROVED I DATE REJECTED R -HEALTH CC MMENT S CATE APPROVED DATE REJECTED PUELIC WORY-3 - SV/EF/WATF-,:R CONNECTIONS DRIVEWAY PERMIT FIRE 0EFAF7VEN7 RECEIVE:) EY EU11-DiNG iNSPEC-7CR Reyi:se,d S�e7 im OA7E_ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print Name: C, - Location: /* — 4/7 1 , 't— F7aftf a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity = I am an employer providing workers' compensation for my employees working on this job. Company name: Address Ci!y: Phone Insurance Co. Poligy # Company name: Address City: Phone #: Insurance Co. Polipy # mm"M Failure to secure coverage as required under Section 25A or IVIGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. of pedury that the inthrmation provided above is true and correct. 11 -S-zl[) \ official use only do not write in this area to be completed by city or town official' E] Building Dept MCheck if immediate response is required Building Dept E] Licensing Board [:] Selectman's Office Contact person 7 Phone A E] Health Department Other FORM WORKMAN'S COMPENSATION Fr\ r1b �Jffi 14 0 '-v 'e,, 0 9LJ 0 -Z F '16 tz .q I C -7 U a -T) C) Op L! L L VY I L! IL A r 1. _J y \a-1 urt Eil 0 It 0 FM4 0O2 C.3 U j CL CL= '0 r Cc CD CO2 C/) COE CD C.3 LU 4& E.S :16. 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