HomeMy WebLinkAboutMiscellaneous - 28 GROSVENOR AVENUE 4/30/20180.
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Location
Mo. Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
CHU Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
161186 � Me7�>
B&ilding Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRU RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
**"io for u" 010�
BUELDING PERMIT NUMBER: DATE ISSUED:
SIGNATURE: E:�
Building Commissioner/IaEL3mtor of Buildings Date�
SECTION I- SITE INFORMATION
1. 1 Property Address:
--2-, e � ft3 �
Cl//5
N". A/0 vot
1.2 Assessors Map and Parcel Number:
05�Z ---003-3
Map Number Parcel Number
1.3 Zoning Information: JZXL'-5TT A,'
Zoning DiAr �ct Pioposed Use
1.4 Property Dimensions:
Lot Area (s Frontage (fl)
1.6 BIJUDING SETBACKS (ft)
Front Yard Side Yard
Rear Yard
Required Provide Required Provided
red 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 SeweMe Disposal System:
Municipal D On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSEIIP/AUTHORIZED AGENT
2.1 Owner of Record
J
1,rame (Pri Address f(;r Service
/C/�
SiFat4 re Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor:
Address
Signature Telephone
Not Applicable 4 --
License Number
Expiration Date
3.2 Registered Home Improvement Contractor
Not Applicable 0
Company Name
Registration Number
Address
Expiration Date
I Signature Telephone
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SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) I
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes ...... )!E�.No ....... F1
SECTION 5 Description of Pr�posed Work (check A atpplicable)
New Construction 0 1 Existing Building U I Repair(s) 9"- 1 Alterations(s) 0 Addition 0
Accessory Bldg. 0 Demolition 11 Other 0 Specify
Brief Description of Proposed Work:
I SECTION 6 - ESTIMATRI) CONRTRUCTTON CnrT.- I
Itein
Estimated Cost (Dollar) to he
OFFICIAL USE ONLY
C leted by permit applicant
I Building
VV
(a) Building Pennit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 PlumbinE
Building Permit fee (a) x (b)
4 Mechanical
(HVAC)
10
5 Fire Protection
6 Total (1+2+3+4+5)
r-- --- ---
r"'*
Check Number
1U%JWi'MJKAU1nVJKJLf�A11qJA 1qJUhUUM-rL.L1EJ)WHkJN
AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
d
1, %�- 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 Owmer Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
L— A
property
Hereby declare that the statements and information on the foregoing application are true
and belief
9 V16W '-/ &'�
Print
:7 uthorized Agent of subject
accurate, to the best of my knowledge
Si�atuire orOVVn-er1§genW — Date
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Date. .......
0 TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
SACH S
This certifies that.. ........ 17�4 .................
has permission for gas installation ...........
2-�
in the buildiWf .* .........................................
North.Andover, Mass.
F & 4�. ... Lic. NO-5�� -3// ... .........
GAS INS OR
Check
4930
44
.4
MASSACHUSEMLNUORM
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Locations
New Renovation
TO DO GAS FrYMG
Date
444k 411e Permitit ;lf,3d
Amount $ C-110� 1$��
Owner s Name Y// �7 a,"q
IJPlans Submitted
/ El El
C"b*c one: Certificate Installing Company
(Print or type) de16 ( qf . Corp.
Name U
Partner.
Address IV -e /9-/,/ -e- o
Business Telephone -2 g- i�- O-Fim/co.
Name of Licensed Plumber or Gas Fitter LIILjl� 4wq
INSURANCE COVERAGE Check one: No
I have a current liability Insurance policy or it's substantial equivalent. Yes[3--
If you have checked yes, please indicate the type coverage by checking the appropriate box. Bond 13
Liability insurance policy Other type of indemnity 0
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 perrr�t application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner Agent 0
I hereby certify that all of tfie (letaiis ana iniormation 1 nave NIJUHULMU kul rJIMICU) III atjvv� aFpj�aLIUJA Ul� — UIJU --- — Ll—
best of my knowledge and that all plumbing work and installations perfpm�ed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts S�a�aXode'and ChaptV42 of the General Laws.
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
[�Plurnber "96 S�/ -
Gas Fitter License NurnbeT
Master
Joumeyman
�7-TH. FLOOR
,8TH. FLO -jR
C"b*c one: Certificate Installing Company
(Print or type) de16 ( qf . Corp.
Name U
Partner.
Address IV -e /9-/,/ -e- o
Business Telephone -2 g- i�- O-Fim/co.
Name of Licensed Plumber or Gas Fitter LIILjl� 4wq
INSURANCE COVERAGE Check one: No
I have a current liability Insurance policy or it's substantial equivalent. Yes[3--
If you have checked yes, please indicate the type coverage by checking the appropriate box. Bond 13
Liability insurance policy Other type of indemnity 0
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 perrr�t application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner Agent 0
I hereby certify that all of tfie (letaiis ana iniormation 1 nave NIJUHULMU kul rJIMICU) III atjvv� aFpj�aLIUJA Ul� — UIJU --- — Ll—
best of my knowledge and that all plumbing work and installations perfpm�ed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts S�a�aXode'and ChaptV42 of the General Laws.
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
[�Plurnber "96 S�/ -
Gas Fitter License NurnbeT
Master
Joumeyman
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North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance wi h he provision of IVIGL c 40 S 54, a condition of Building Permit
Number — d3Tq is that the debris resulting from this work shall be
disposed of in a'proper.ly licensed solid waste disposal facility as defined by MGL
c 11, S 150 A.,
The debris will be disposed of in:
(Location of Facility)
S�g6atur e of Permit Applica—nt
--0?
�Dat
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through.the Office of the Building Inspector
Tel: 978-688-9545
Town of North Andover
Building Department
27 Charles Street
North Andover MA 01845
HOMEOWNER LICENSE EXEMPTION
Please print. -
DATE L2 &) 3
JOB LOCATION 02P 2
Number Street Address Section of Town
"HOMEOWNER
N
Phone
PRESENT MAILING ADDRESS CE_
1j__
Work Phone
City Town State Zip Code
The current exemption for "homeowners" was extended to include owner -occupied dwellings
of six units. or less and to allow such homeowners to engage an individual for hire who does
not possess a license, provided that the owner acts as supervisor. (State Building Code Section 109.1.1)
DEFINITION OF HOMEWOWNER:
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which
there is, or is intended to be, a one to six family dwelling, attached or detached structures ac-
cessory to such use and and/or farm structures. A person who constructs more than one home in a
two-year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official,
a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the
building permit. (Section 109.1.1)
The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other
Applicable codes, by-laws, rules and regulations,
The undersigned "homeowner" certifies thajpb/she understands the Town of No. Andover
Building Department minimum inspection
,4yocedures and requirements and that he/she will
comply with said procedures and requiy�rfients. /,�-) , //
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Note: Three family dwelling 35,000 cubic feet, or larger, will be required to comply with
State Building Code Section 127.0 Construction Control.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Name LI -3 &10 41Z S --K) Please Print
Name: LA-.)Lgt2LzM
Location:
CitV �� - PM -7 Z>C,% At -2z-- Phone #
5;�l I am a homeowner performing all work myself.
F-1 I am a sole proprietor and have no one working in any capacity
F-1 I am an employer providing workers' compensation for my employees working on this job.
Company name:
Address
cibc. Phonet�
Insurance. Co. Polipy #
Company name -
Address
Cily: Phone#:
Insurance Co. Policv #
Failure to secure coverage as required under Section 25.A or MGL 152 can lead to the imposition of criminal penalties of.a fine up to $1,500.00
and/or one years' imprisonment-as-wefl-as-cb.Al-penalties in.1he Imn jdA-STOP.W-ORK-ORDER.zid.-a.fine -Of -($1.00M)-a Aay.againstme� I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
irt
I do h by cert'. under the pains d na Fes of pedury that the information provided above is true and correct.
/'5
�/Sign ur 7 r,,o 6��/ e?9
w,"Print name "b ne
Official use only do not write in this area to be completed by city or town official'
City or Town Permit/Licensing
Building Dept
ElCheck if immediate response is requy-ed 0 Licensing Board
n Selectman's Office
Contact person: Phone El Health Department
Ei Other