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0* TAORTsi .1 TOWN OF NORTH ANDOVER
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PERMIT FOR GAS INSTALLATION
This certifies that ... ...... ..............
has permission for gas installation
in the buildings of .............
le 1 .1 - Ile ;
at ................. .............. North Andover, Mass.
Fee-,�I� "T ... Lic. No... Q:-%- . ........
GASIIN�POCTCIR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
M
cl n -t E 1— MA Dste-��r Permft#
Building Location F ct- Mead6up jabmeesName Lar- C-1 V<:�CL(br-CA.
I -
Map: Lot: Zone: ---TypeofOccupartcy I -Fs tz--n ceL
New)9( Renovation Ll Replacement E3 Plans Submitted: /Ys Q No (3
InstallingCom panyName s6-rn ?r,, pa nr- Q*5 - -1-y-iC-
Address 1.4
EstimateValueof Work:
Business Telephone I- YOQ - -*.'9
Nameof Licensed Plumber orGas Fitter
Checkone: Certificate
Of Corporation
(3 Partnersbip
(3 Firm/Co.
INSURANCECOVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes Mr I No 13
If you have checked M please indicate the type coverage by checking the appropriate box.
A liability insurance policy Mr Other type of Indemnity U
Bond 13
OWNER'S INSURANCE WAIVER: I am aware that the licensee,does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Checkone:
Owner U Agent U
Signature at Owner or Ownees Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of
my knowledge and that all plum bing work and installations performed under the perm it issued for thi s application will be in compliance With
all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the;@eVerall LL aws.
By Type of License:
Plumber S6ndbure of Licensed Plumber or Gas Fit� �r
Tifle Gasfitter
R Master License Number 9
City/Town I U Journeyman
APPROVED (OFFICE USE ONLY)
3
InstallingCom panyName s6-rn ?r,, pa nr- Q*5 - -1-y-iC-
Address 1.4
EstimateValueof Work:
Business Telephone I- YOQ - -*.'9
Nameof Licensed Plumber orGas Fitter
Checkone: Certificate
Of Corporation
(3 Partnersbip
(3 Firm/Co.
INSURANCECOVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes Mr I No 13
If you have checked M please indicate the type coverage by checking the appropriate box.
A liability insurance policy Mr Other type of Indemnity U
Bond 13
OWNER'S INSURANCE WAIVER: I am aware that the licensee,does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Checkone:
Owner U Agent U
Signature at Owner or Ownees Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of
my knowledge and that all plum bing work and installations performed under the perm it issued for thi s application will be in compliance With
all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the;@eVerall LL aws.
By Type of License:
Plumber S6ndbure of Licensed Plumber or Gas Fit� �r
Tifle Gasfitter
R Master License Number 9
City/Town I U Journeyman
APPROVED (OFFICE USE ONLY)
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Location e-_e,�� -
No. Date
,40RTh
TOWN OF NORTH ANDOVER
0
Certificate of Occupancy
$
Building/Frame Permit Fee
$
Foundation Permit Fee
$
Other Permit Fee
$
TOTAL
$
C h e c k #
6 6 6,,'
Building
Insp r
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONEOR TWO FAMILY DWELLING
un 010V
BUILDING PERNUT NUMBER
DATE ISSUED:
SIGNATURE:
Building Commissioner/Inspector of Buildings Date
SECTION I- SITE INFORMATION
1. 1 Property Address:
C:919
1.2 Assessors Map and Parcel Number:
Map Number Parcel Number
1.3 Zoning Information:
Zoning DiAr idt Proposed Use
1.4 Property Dimensions:
Lot Area (sf) Frontage (ft)
1.6 BUILDING SETBACKS (ft)
Front Yard Side Yard
Rear Yard
RNuired Provide Required Provided
Required
Provided
1.7 Water Supply M.G.L.C.40.'§ 54) 1.5. Flood Zone Infonnation:
Public 0 Private 0 Zone Outside Flood Zone 0
1.8 Sewerage Disposal System:
Municipal 0 On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
AR/_-UC-Qot
Name (Print) Address for Service
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3. ].Licensed Construction Supervisor:
7D�,(\
Licensed Construction Supervisor:
's .> C.�- 4�(VL-5_ Pj qy�a-k7
Address
SOture Uf Telephone
Not Applicable 0
OL�/,z 1�
License Number
_�7
Expiration Date
3.2 Registered Home Improvement Contractor
,8 -(-
Not Applicable 0
Company Name
Registration Number
Address
Expiration Date
Signoir 0 U Telephone
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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 %vill resul
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes ....... 0 No ....... 0
SECTION 5 Description o Proposed Work (check a1pplicable)
New Construction 0 Existing Building 0 Repair(s) 0 Alterations(s) 0 Addition 0
Accessory Bldg. 0 Demolition 0 Other 0 Specify
Brief Description of Proposed Work: 0
SP�'e +- Ll�l 6J
I SECTION 6 - ESTIMATED CONSTRUCTION COqTq I
Itern
Estimated Cost (Dollar) to be
Completed by permit applicant
OFFICIAL USE ONLY
1.
Building
(a) Building Permit Fee
Multiplier
2
Electrical
(b) Estimated Total Cost of
Construction
&C,3c" D
-3
Plumbing
Building Permit fee (a) x (b)
-4 Mechanical (HVAC)
-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 BU"ING PERMIT
I, , as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
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
Print Name
Signature of Owne ent Date
�' 1 11 "M "I'll, 111MM Ws=
-NO. OF STORIES 17
BASEMENT OR SLAB
S17 -E OF FLOOR TINIBERS I ST 2 No 3 PJ)
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING
MATERIAL OF CHF\4NEY
[IS BUILDING ON SOLID OR FILLED LAND
I IS BUILDING CONNECTED TO NATURAL GAS LINE
0
BOARD OF BUILDINek96j'ATkj0�'N-aS
License: CONSTRUCTION SUPERVISOR
Number: CS 069120
Birthdate: 04/03/19�9
Expires: 04/o3/2005 . Tr. no: 10040
Restricted: 00
JOHN W LANZAFAME
30 TEMPLE DR
METHUEN, MA 01844
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narric
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phone # S V
E] I am a homeowner performing all work myself.
0- 1 am a sole proprietor and have no one working in any capacity
am an employer providing workers' compensa—ti
on for my employees working on this job.
40
A
W
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#
D One
a
C] I am a sole proprietor, g- eneral contractor, or homeowner (circle on7)
the following workers' compensation polices:
hired the contractors listed below who have
-- —1— — —.— —11—.. — — 11— — kne, lcnu tu inc imposition oi criminal penalties ots fine up to S19500-00 and/or
one years' imprisciamept as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 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.
I do hereby certt&lrdir, the p /it, and enallies ofperjury that the Information provided above is true and correct.
�p
SiRnature-71
Print name
Official use only do not write in this area to be completed by city or town official *
City or town:
check If im 1' te response is required
contact persom-
#
permitAicense # ----OBuilding Department
OlLicensing Board
OSCIcctmcn,s office
phone#; 01HIcalth Department
----00ther
Th e Contmon wealth of Massachusetts
Departnient of Industrial Accidents
OffIC-6 011MOS119.711011S
600 Washington Street
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
narric
I Y,
c
phone # S V
E] I am a homeowner performing all work myself.
0- 1 am a sole proprietor and have no one working in any capacity
am an employer providing workers' compensa—ti
on for my employees working on this job.
40
A
W
�5
a h
#
D One
a
C] I am a sole proprietor, g- eneral contractor, or homeowner (circle on7)
the following workers' compensation polices:
hired the contractors listed below who have
-- —1— — —.— —11—.. — — 11— — kne, lcnu tu inc imposition oi criminal penalties ots fine up to S19500-00 and/or
one years' imprisciamept as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 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.
I do hereby certt&lrdir, the p /it, and enallies ofperjury that the Information provided above is true and correct.
�p
SiRnature-71
Print name
Official use only do not write in this area to be completed by city or town official *
City or town:
check If im 1' te response is required
contact persom-
#
permitAicense # ----OBuilding Department
OlLicensing Board
OSCIcctmcn,s office
phone#; 01HIcalth Department
----00ther
North Andover Building Department
Tel: 978-688-9545
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 a properly licensed solid waste disposal facility as defined by MGL
c 11, S.1 5o A..
The debris will be disposed of in:
(Location of Facility)
Signature of 01ermit Applicant
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through.the Office of the Building Inspector
13
MCI
Chimneys
Siding
Mass Toll Free
1 -800 -WAIT -4 -US
(924-8487)
01
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UFJO IER
,^LL
40PJIE R404OF
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Residential & commercial Roofing
All Types Of
CHIMNEYS POINTED -REBUILT -CAPPED
Expert Masonry Work
Licensed & Insured
1,0cally Owned At Operated S h-4re j
,*� a
IKO 43aff waelw� ae ff LQ6j
L.R.W.. se #034200
We Wofl, Yea, ft*U.d
or� tj j'U A
City, State & Zip Code t\) a., .0 6" L-,Yz- 01sys—
Thone Date
`?'7,�?-
Job Name
Job Location I Job Phone
We Propose hereby to furnish and labor in accordance with specifications below, for the sum of:
4- TA 6 0
Dollars($ ��01 'L
C -#R / /
j<T-d-i0A S14.o(A P_ yr -7
All material is guaranteed to be as specified. All work to be completed in a workmanlike Authorized
manner according to standard practices. Any alteration or deviation from specifications be- Signature:
only upon written orders, and will become an
low involving extra costs will be executed 44W
extra charge over and above the estimate. All agreements contingent upon strikes, . accidents NOTE: This proposal may be e:�.
or delays beyond our control, Owner to carry fire, tornado and other necessary insurance. withdrawn by us if not accepted within days.
Our workers are fully covered by Workmen's Compensation Insurance.
We hereby submit specifications and estimates for: � /A � 0 ucr-n ()Vl -r- J_A-jL:n, R, (�,cr
Wnstall 3 feet of special Tave Seal" ice and water barrier protection along all bottom edges of roof
and top to bottom in each valley. If roof is stripped, we will apply conventional ice and water shield
ft. high in the same locations previously described and tar paper will cover the
remaining bare wood. Any rotted or damaged boards will be replaced at ( 2s— ) per linear ft.
or ( 6- a-) per sheet of plywood.
WrInstall heavy gauge aluminum drip edges along every edge surface of each roofline.
EdCover entire roof (s) with IKO 25 year all asphalt, non -fiberglass, premium grade shingles
(Color of choice).
lidReplace all pipe boots where possible.
9Seal all flashings with clear Geo -Cel sealant. No black tar unless previously applied.
VRemove all work-related debris.
"contractor warrants roof against all leaks due to defects in his workmanship for 12 years under
normal circumstances.
(SdLocal current references and proof of workman's compensation insurance gladly given.
0 6 -CCV�_ 771
Remarks:
6PZD CA-'rC_f+ tj /Z
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Acceptance of Proposal - The above prices, specifications
and conditions are satisfactory and are hereby accepted.
You are authorized to do the work as specified. Payment
will be made as outlined above.
Date of Acceptance: A/ 7
Signature: