HomeMy WebLinkAboutMiscellaneous - 29 BUCKINGHAM ROAD 4/30/2018-0
P
Date ..... Y - -3r) -
..................................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that
....... ...................... ..........
has pennission to perfonn ............ 6,9,-6 ---
............................................. ..................................
wiring in the building of ........ .................. ..............
................ .. . .....................................
at zl�k, - -4
...... e . .... ................. .... . North Ando , m
onn Andover
. . ...... Lic. No.
. ..............
. ............... . ............. ...... .. ........ . .....
AECTRICAL INSPECTOR
OA'heck # ?)
13 2 73.
a/ Madjachwaffi
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
PermitNo.
Occupancy and Fee Checked
Dlev. 1/071 (leave blank-)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
AU work- to be perforined in accordance witli 01a Massnrhusetts Electrical Code (MY -C), P-7 CMR 12.00
(PLF-4SE PRNTfjVRVY OR TYPB.AU LVF01MUTION) Date:
C44-twTown ok Z9 ayl� e" TO tile Pectal. Of Wires,
By this application the undersigned gives nofice of his or her intengon to perform the elerAlcal work described below.
Location (Street& Number)_
Owner or Tenant :22 4 Telephone No.
Owner's Address 4/ 71eq
Is this permit in conj-unctni with a building permit? Yes
Purpose of Buildin
N o L�J, (Ch eck Appropriate Box)
Utility Authorization
Existing Service Amps Volts OverheadEl Undgrd 0
New Service Amps Volts Overhead 1:1 Undgrd 1:1
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Warla
No. of Meters
No. or Meters
Cm -1011011 "f"'I", r -1/n. , I.Al. , 1. -j
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
-'--? LF)JIneinspectorq111
No. of Total
Transrormers ICVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators ICVA
No. of Luminaires
Swimming Pool Above E] In- D
— grnd. rud.
N65--aTT-m—ergency ig ing
Batte!y Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of zoncs
No. of Switches
No. of Gas Burners
No. of Detection and
-Initiating Devices
No. of Ranges
Total
No. of AJr Cond. Tons
No. of Alerting Devices
No. of Waste Disposers
Hent Pump
Totnts:
I Number
ITD115 11CW—No.ofSelf-Containe
Datettion/Alerting, Devices
I—F-1
No. of Dishwashers
Space/Area Heating IuY
I
LocalEl 'CY oun'ne'ePtino'n 0-0ther
No. of Dryers
N o. of Water
Heaters lay
Heating Appliances XW
No. of No. of
Signs Ballasts
security Systems:,
NO. of Devices or Enuivnient
Data Wiring:
No. of Device �rp U�ivnlent
No. Hydromassnge Bathtubs
No. of Motors Total HP
I
I-elecommunicritions wiring:
No. of Devices or E, quivalent
TH E R:
.411ach addilional detail if desired, I)r as required bji the III -Spector of Wires.
Estimated Value of Electrical Work. (When required by municipal policy.)
Work to Starc & - inspections to be requ- ested in accordance with MEC Rule 10, and upon completion.
-.-....-.......--�--,.-....".-..-.-FNSURANCE-CO.V.'E,RAG'L-:-Unless-,.vaived-by-the�oNvncri-no.permit-for-die-performahceof-cle-dtr.icnl-wbrie-may-Wu6urlless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalenL The
undersigned certifies that such covampe is in force, and has exhibited proof of same to the permit issuing office_
CHECK ONE: INSURANCE IK BOND E] OTHER [I (Spar-Lfy:)
I Cardfir, Under d1opullis allapanaldes ofPerjury, that the h1rarma Oil Oil 1111S application is trite and coniplete-
FIRM NA3=,: _:7_> 91
zelr�e LTC. No.:i
Licensee: �Z>'r e!�,-wx-g 0 Signature
Wapplicable, enter " metupt " in the license nuniber line.) LIC. No.:
I azd2L zgzqaa t'
Address: // Z��_ Bus. Te
04 A I T, � M !1. -z
*Per 14G.L. c. 147, s. 57-61, security work Aquires Doartme-at of?6b)ic Safity "S" Lfcvn'se: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee dDes not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement I am tile (check one) [] owner El owner's a t.
,Owner/Agent ,e,,L
Signature Telephone No. FEE: S
j
0
The Counnonwealth of Massachusetts
Department of Industrial Accidents
0 e ofInvestigations
fflic
600 �Vashington Street
Boston, MA 02111
wwminass.govIdia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
DDlicant Information Please Print LeLyibl,
Name (Business/Organization/Individual):
City/State/Zip:
Phone.#:
Are you an employdr? Check the appropriate box:
i. n I am a employer with )-� 4. E] I am a general contractor and I
I AJ I A IF ,
have hired the sub -contractors
Cn1p GYeCs � an or part -t e).
2.E1 I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
31� I am a homeowner doing all work
myself [No workers' comp.
insurance required.] t
listed on the attached sheet.
These sub -contractors have
employees and have workers'
comp. insuranceJ
5. R We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
insurance recittired.
Type of project (required):'
6. F� New construction
7. E] Remodeling
8. F� Demolition
9. F� Building addition
10.[FE'lectrical repairs or additions
11. n Plumbing repairs or additions
12.E:] Roof repairs
13.n Other
I *Any applicant that checks box #1 must also fill out tile section below showing their workers' compensation policy information.
it Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such,
TContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' conipensation insurancefor nty eniployees. Below is the policy andjob site
information.
Insurance Company Name:
� ;�av 6,w 7,-,/ 4 &
1!!5_1
Policy # or Self -ins. Lic. 4: " 0" e VV 1,44:rZ — Expiration Date: /- _A�
Job Site Address: 966��,Oa Aow ffd M P, 49 4,; City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiratioli 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
Inv6stigations of the DIA for insurance coverage verification,
I dq hereby certify under the pains and penalties o i that the inforination provided above is true and correct.
Sii4nature: Date: 4e -
Phone #: f_ -7 9 — ile .0 , � --,;:? /
Use
City or Town:
not write in this area, to be completed by city or town official
Pern-iit/License #
Issuing Authority (circle one):
t,
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone#:
Date ..... ........
11113
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that ........................................................... I
has permission to perform ... . ...... vv�w.? .................................................
..... ........ ... ..... ........... ..
plumbing in the buildings of ....................................................
at ... 2:� ...... -Y LA �.A AA
3AAO.. ............ . �1 .......... ......................... North Andover, Mass.
Fee..:P.�. ...... Lic. 1'40.
..................... .................................................................................
PLUMBING INSPECTOR
Check #
fVj A
—Cr.JSETTS UNIFORM APPLICATION FOP, A PERMIT TO PERFORM PLUN11BING VVORK
C!7Y
DAIEJ PERMIT
;i JOBSITE IDDRESS OWN ER'S NA ME
r%
pb
OWNERADDRESS,j
__7TEL:
TYPE OR I — FAX.-
- ! OCCUPA'INICY TYPE T
P RENI T COMMERCIAL E DU CAI I ONAL RE Sl DEN TIAL
CLEARLY NEAi:
RENCYATION: ED RFP
LACEiMiEl, 1.
PLANS SUBMITTED: YES NO
FIXLJ I
FLOORS— j 1 1 1 � I A
CONN �DE\�ICE
I DEDICATED SPECIA_L'�IVASTE SYS
�EE�DICI ED
DEDICATED GRE A
ASE SYSTEM
DEDICATED G
DEDICATED AIATER RffSE —S, S
-D I SH VVA S-H, E iR,
DRINKING FOUNTA�Nf
FOOD WASTE GRINDER, 0\17
FLOOR/ AREL
L RR,'JOR
�11\1 TIERCEPTOR I'N �Tl
VA I Ur�y
,7uur- J�WN
SERVICE /MOP �J�
NK
URINAL
WASHING IVIACHINE -ONNECTIO
N
WATER H,-ATEJ� AL�; TYPE Q 6� -
M' ( tt� HIHING I T
10 1 11 LI -12
! 13 1 14
INSURANCE
I have a current liit��jnsurance policy nr i's substantial eQuivalent which meets the requirements O1'MGL, Ch. 142 YES VN0
If you have checked YES please indicate -,-ie �,pe Of coverage by checking the appropriate box below.
LIANBILITY INSURAN.,E POLICY J_v_�� OTHER TYPE INDEMNITY E] BOND L7
j
OWNER'S INSURANCE WAIVER: lam awa'e that the licensee does not have tt . he insurance coverage requirid by Chapter 142 of 'he
Massachusett's Geneial Laws, and that m y.-'
I L -Ignature on this permit application �� this require-ment. L
SIGNATURE OF OWNER OR AGENT
CHECK ONE ONLY: OWNER [] AGENT 1_--jl
J hereby certify t,Iaj all of the details and inflorn-lation'i have'submitted,'Or erileed) regarding this I'
Knowledge and that 21i Plumbing work and ins',allations performed under the permit issued for th�s app icall. ue and accurate 'Lo the best of my
Provision of the Wssachuset1is State Plumbing Code and C>api i- -a , @'Lion wil e in complian with all P -
PLUMBER NAME- 142 offhe Genera,l L2VVS. ertL"
L i C E t q S E -#, ffLkA i
COMPANv N4,11-: aja(E] SIGNATURE
LVA L) L IE 11YL91 ADDRE S:
S R
L STATE:
X �112 1! P:
FAX.
'El:
L 103- Q _3'� - Eh/iAll_
MASTER R' JOURNEYMAN 17_ ':ORPORATION PARTNERSHIP
F7
31,
Date ....... 4 . .... I
.......................
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that .... vxl ...... " . —1 ......................................
.............. . ........ .... .. .....
ha�permission, for gas nstallation �9ai'l
int�e buildings of ... .....................................................................................
at ....... :;m ......... North Andover, Mass.
Fee...... . Lic. No. .......... ....................................................................
Check #I AtH
09951
GASINSPECTOR
TYPE OR
PRINT
CLEARLY
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY MA. DATE PERMIT#-.
JOBSITE ADIDRESS 1 01 OWNER'S NAME
OWNER ADDRESS. [ TEL: E:!�-�� FAX: E==
OCCUPANCY TYPE: COMMERCIAL E] EDUCATIONAL [I RESIDENTIAL 5;/'
NEW: D RENOVATION: 0 REPLACEMENT: &?"0'
TRES -Finnp
E R
BOOSTER
C
CONVERSION BURNER
COOKSTOVE
DIRECT VENT HEATER
LDRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
LABORATORY �COCKS
MAKEUP AK UNIT'
OVEN
POOL HEATER
ROOM / SPA -
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
2 � 3 F4 1 5
PLANSSUBMITTED: YESO NOE]
=-MEM-M=�
N=M�w
�# INSURANCE COVERAGE
I have a current i[��insurance policy or its substantial equivalent which meets the. requirements of MGL. Ch. 142 YES El NO 0
If Youiln-ave checked YES, please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY S?� OTHER TYPE INDEMNITY [] 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.
SIGNATURE OF OWNEROR A -GENT
CHECK ONE ONLY: OWNER D AGENT F
hereby cert4 tha�t all of the details and information I have submitted (or entered) regarding this application are true and accu rate to the best of my
.Knowledge and that all Plumbing work and inst,:Ilations performed under the permit issued for this appl' tion ill be ii compliance with all Peftjio�
provision of the Massachusetts State Plumbinc'Code and Chapter 142 of the General Laws.
PLUMBER/GASFiTTER NAME: A) LICENSE #���3
3a SI NATURE
COMPANY NAME: 7 + H
CITY: STATE: ZW ZIP: ADDRESS:
TEL CELL FAX:
F4� �"�ilE - EMAIL:
MASTER R'JOURNEYMAN [I LP INSTALLER CORPORATION 11,� �aPARTNERSHIP
LLC E] #
LLC 0 #=4
Workers' Compensati ' on Insurance Affidavit: Builders/Contractors/Elec ' tricians/Plumbers.
TO BE, FILED VnTH THE PERNHTTING AUTHORITY.
Nalne (Business/Organizat'ion/Individud):
+ tf
Address: � z?)_11
City/State/Zip: sayvw_ Phone #: 7 612 Z//
Are you an employer? Check &e appropriate box:
l.J;JVam a employer with __� employees (M and/or part-time).*
IF] I am a sole proprieto-r or partnership' and have no e mployees - working for mein
any capacity. [No workers' comp. insurance required.]
3. n I am a homeowner doing all work myself. [No workers' comp. insurance required.] t
4.F] I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
prop;lriet�rs with no em�loyees.
5.FJ I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
�he�b s�b-contraic'toris'b��; qn�ploy'ee's and have workers' comp. insurance.$
6. We are a corporation and its officers have exercised their right of 'exemption per MGL c.
11 � .1 4-1 , I
l52,§l(4),andwehaye.noe loyees. [No workers' cpmp. insurance required.]
Type of project (Tpquired):
7. E] New construction
8. E] Remodeling
F1 Demolition
10 F1 Building addition
I i. FJ Electrical repairs or additions
li E])Plumbing repairs or additions
13.Fl Roof repairs
14.E]'Otlfer
*Any applicant that checks box# I must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit IMS affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. if the sub-c6n'tra-cit o`rsh�.ave employees, 1hey must provide their workers' comp. policy number.
lam" an employer thai ispiovidiizgwork�rs'compensation insurancefor my emplbyees.'Below is thepolicy and)oh site
information.
Insurance Company Name:
Policy # or Self -ins, Lie. 9:-/ /,_�_00_1 Expiration Date:
Job Site Address. -41 9 City/State/Zip:&4A0" A,�
Attach a copy of the workers' 60111pens4lon policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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 $250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance,
coverage verification.
I do h ereby certify under the pains andpenalties ofpeijury that the information provided above is true and correct
Signature: Date:
Phone #:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License 9
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. Cityrfown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
The�Cbmmonwealth of Massachusetts
Department of IndustrialAccidents
I Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov1d1a
Workers' Compensati ' on Insurance Affidavit: Builders/Contractors/Elec ' tricians/Plumbers.
TO BE, FILED VnTH THE PERNHTTING AUTHORITY.
Nalne (Business/Organizat'ion/Individud):
+ tf
Address: � z?)_11
City/State/Zip: sayvw_ Phone #: 7 612 Z//
Are you an employer? Check &e appropriate box:
l.J;JVam a employer with __� employees (M and/or part-time).*
IF] I am a sole proprieto-r or partnership' and have no e mployees - working for mein
any capacity. [No workers' comp. insurance required.]
3. n I am a homeowner doing all work myself. [No workers' comp. insurance required.] t
4.F] I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
prop;lriet�rs with no em�loyees.
5.FJ I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
�he�b s�b-contraic'toris'b��; qn�ploy'ee's and have workers' comp. insurance.$
6. We are a corporation and its officers have exercised their right of 'exemption per MGL c.
11 � .1 4-1 , I
l52,§l(4),andwehaye.noe loyees. [No workers' cpmp. insurance required.]
Type of project (Tpquired):
7. E] New construction
8. E] Remodeling
F1 Demolition
10 F1 Building addition
I i. FJ Electrical repairs or additions
li E])Plumbing repairs or additions
13.Fl Roof repairs
14.E]'Otlfer
*Any applicant that checks box# I must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit IMS affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. if the sub-c6n'tra-cit o`rsh�.ave employees, 1hey must provide their workers' comp. policy number.
lam" an employer thai ispiovidiizgwork�rs'compensation insurancefor my emplbyees.'Below is thepolicy and)oh site
information.
Insurance Company Name:
Policy # or Self -ins, Lie. 9:-/ /,_�_00_1 Expiration Date:
Job Site Address. -41 9 City/State/Zip:&4A0" A,�
Attach a copy of the workers' 60111pens4lon policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance,
coverage verification.
I do h ereby certify under the pains andpenalties ofpeijury that the information provided above is true and correct
Signature: Date:
Phone #:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License 9
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. Cityrfown 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 lVfe,
expres's or implied, oral or written."
An employer is defined as "an indiviidual, partnersWp, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, associa ' tion 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 work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment b6 deemed to be an employer."
MGL 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 to construct buildings in the commonNyeaIth 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 any of its political subdivisions shall.
enter into any contract for the performance of public workuntil 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 - tho'boxes that apply to your situation and, if
necessary, supply sub-'contractoi(s) name(s), address(es) and -phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. lie advised that this affidavit may be submitted to the DepaAment of Ifidustrial
Accidents fbi confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be retained to the city.or town that the application for the permit or license is being requ�sted, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are requ�red to obtain a workers"
compensatioti..'policy, please call the Department at the number listed below. Self-in�sured companies should'enter their
self-insurance. license number 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 affidavit 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 permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/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
town)." A copy of the affidavit that has been officially stamped or marked by the city or ' town may be provided to the
applicant as proof that a valid affidavit is on file for future 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 to burn leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
Revised 02-23-15
The Conunonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-NMSSAFE
Fax # 617-727-7749
www.mass.gov/dia
R M K AON L IlAlr-
Date.
40RTN
TOWN OF NORTH ANDOVER
0
PERMIT FOR GAS INSTALLATION
CHUS
This certifies that ...
...... .....................
has permission for gas installation . . .................
in the buildings of ...
...........................
at 0
........... ' North Andover, Mass.
Fee... ? Lic'. No..0 Y.�'/ .. ..... I .........
GASINSPECTOR
Check #
5913
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
Mass. Date �2_ 20 - ;7 Permit #
Budding Location c�2 9 6c,,y7 4, 6,4o��q �41 /P6, Owner's Nam'e
Owner Tel# 6-? r - 6 d-? - 6 / �? 7 Type of
New 0 Renovation 0
Replacement 0
FIXTUREJ
1�
//C 141"
A
Plan Submitted: Yes El No 0
- Installing CompanyN'ame
4y2jL
1�9 ,,- 1v
Address /0,
cl
16
E
MEN
MEN
MENEENE
No
NONE
EMEENE
0
0
MENEEMENES
OR �
NEENNEENEENEE
ONNEEN
NEESE
ENNEEMENNEEN
ONEEMENEENEEM
00
NONE
NOMENNEENEEN
NONE
MEN
- Installing CompanyN'ame
4y2jL
1�9 ,,- 1v
Address /0,
cl
16
oIF6
Business Telephone #
Name of Licensed Plumber or Gas Fitter— a-64-2�7_ �C.
Check one: Certificate
11 Corporation
0 Partnership
E�Firm/Co.
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes �P' No 0
If you have checked yes, please indicate the type covera e by checking the appropriate box.
9
A liability insurance policy �9 Other type of indemnity o Bond El
OWN ER'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.
Check one:
Owner 0 Agent 0
I h * ereby certify that all of the details and information I h—av-e submitted (or entered) in above 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 -ill K , V
CityfTown
APPROVED (OFFICE USE ONLY)
e in GOM lance WILH all
State Gas Code and Chapter 142 of the GeneLal-6bW.
TypeofLicense:
a4lu-mber &gnature OT Llcensed Plumber or GasrFifter
c3 Gas fitter
&Ma'ster License Number 5
o Journeyman
Date...
....... .. .......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that .......... �77 .....
..... . ................. ..............
.5 77,6t:�I—
has permission to perform ...... 51.01.k .............
wiring in the building of. . ................ �441. ..................................
at ............
orth Andover, Mass.
Fee... 3.. Lic. No . ...... ... (X ............... .. .. ....... ............ ..........
ELEC-ATRICAL� INSPECTOR IV
Check #
7076
N
�a\- Commonwealth of Massachusetts Official Use Only
Permit No. 7P �12
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS l[Rev.9/051 (leaveblank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
X11 work to be performed in accordance with the Massachusetts Electrical Code (MEC), $7 CMV2.00
(PLEASE PRINTIN INK OR TY A L 0
INXRJ4 TION) Date:- 111,9�210 6
City or Town of.- NA
i ak/-r/0, To the Inspector of Wires.t
By this application the undersigned gives notice his o herintent, n to perform the electrical work described below.
Location (Street & Number)
;0, , A -
t�00-,d Telephone N r
Owner or Tenant
Owner's Address
Is this peimit in conjunn with a Vililding permit? Yes No (Check Appropriate Box)
i
Purpose of Building n Utilit Authorization No.
y
Existing Service Amps — Volts Overhead Undgrd No. of Meters
New Service Amps Volts Overhead Undgrd No. of Meters
Number of Feeders and Ampacity
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
"'"Y V. �"' Vc" Uy grit: j ect Ur uj tres.
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
.Above <an--
Swimming Pool grnd. E] grnd.�� 13
No. of Emergency Lightin—g
Battgy Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners —7�>
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Tota
I T21�
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Total5FF
NR!P.P9:
ll�p§ ..........
I I
1.
No. of Self-C—ontained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local o Munic El Othe
Conne 171)
No. of Dryers
No. of Water
Heaters
Heating Appliances
No. of No
Signs Baila,(s s�
Securit S t
Yf Ls ems:
No. o evices or Equiva
Data Wiring:
No. of Devices or Equivalent.,,)
No. Hydromassage Bathtubs
No. of Motors Tota I H
-
Telecommunications Wiring:
No. of Devices or Equiv le
OTHER:
,I cc,-, A trach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of glectr�tal Work: XO (When required by municipal policy.)
F
Work to Start:&/,2-?/a6- Inspections to be requested in dccordance 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 t e permit iss ing office.
CHECK ONE: INSURANCE Z BOND [:] OTHERE] pe Iff)
Icer% under thepains andpenalties ofperjury, that the infior�ms o th * a lication te.
FIRM NAME: Castle Electric. Inc.
Jul%-. NO.: AID 191
rnatur LTC. NO.: 26186E
Bus. Tel. No.; 781-762-9891
Alt. Tel. No.:
applicable, enter the license number here:
e Licensee does not have the liability insurance coverage normally
this requirement. I am the (check one) El owner 1-1 owner's agent.
r,"ULure Telephone No. I PERMIT FEE.- $) �., �:j
Licensee: James R. Prescott S
(Yapplicabie, —enter "exempt" in the license number line)
Address: Bldg. # 2 1. Endicott Street. Norwood, MA. 0
*Security System Contractor License required for this v
OWNER'S INSURANCE WAIVER: I am aware tha�
required by law. By my signature below, I hereby waiv
owner/Agent
IN
0 #-/�t/C,5rtte�- 6 -
/Vo � �,
7-- e;(S /�y
ri
Date..P.-A.-... d. )e-0,
.. ..........
TOWN OF NORTH ANDOVER
I
Ime PERMIT FOR WIRING
This certifies that .......... :7: ......
........................................................
has permission to per(c
wiring in the building of ............
. .........................................
at ... g;2 ......... . ................ I ........................ ...... NTh>-?AQndover, Mass.
0 -
Fee ... Lic. No ... .......... . .
...... . ......
ELECTRICAL INSPE* R
Check #
5509
TRE COAMOArREALTH OF M-4SS4 CHUSEITS Office Use only
C Hy
DEPARTIVIEW a—'-P^,,UBL1C -�t No.
Pern -5
E:r- -up
B OA W OF ME PRE VE Vff',,O, ULAH0NS527CWJ2.M
U
t,
Total
Tons
(P) ccup ancy & Fee s Checked
APPLICATIONFORPERARTTO
(VNVI,
-V( ELE=CAL WORK
RFORM
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH M SACHUSSTS ELECTRICAL CODE, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION)
Date 0: 6--t—
Town of North Andover
To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work
scribed below.
Location (Street & Number)
Bucl Ve,
Owner or Tenant IMIAm 4-
V
Owner's Address
Is this pennit in conjunction with a buildin,; permit: YesM
No (Check Appropriate Box)
Purpose of Building
Utility Authorization No.
Existing Service Amps Volts
Overhead Underground No. of Meters
New Servic Amps I Volts
Overhead M Underground No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work
2,4136 IdM
No. of Lighting Outlets No. of Hot Tubs
1
t-/ No. of Transforffiers . Total
.2-
KVA
No. of Lighting Fixtures Swimming Pool Above
Below Generators KVA
ground
ground
No. of Receptacle Outlets No. of Oil Burners
No. of Emergency Ligliting Battery Units
No. of Switch Outlets
of Ranges
No. of Disposals
N(? of Dishwashers
No. of Dryers
No. of Water Heaters
No. Hydro Massage �Tubs
THER-
I No. of Gas Burners
No. of Zones.
No. of Air Cond.
Total
Tons
No. of Heat
Pumps
Total
Tons
Space Area Heating
Heating Devices
KW No. of -
Signs
No. of
Bailasis
No. of Motors
Total HP
XTMWCoVMgft PursuarittMhe OfM
aw a current Liability BC��]Udiflg Con
aw submilted vdEd sanrolheOffim YES
SURANCE BOND F-1
)rk to S�rt
rjedurKIA�PdAescfpajury.
A4NAMP-
FIRE ALARMS
No. of Zones.
Total No. of'Detection and
KW Initiating Devices
KW Ng...,pf Sounding Devices
,
No�' F bfSelf Contained
De��'-bti o�n/Sounding Devices
Local Municip.al
M
Othe-,
Connections
YES [77/r No 71
M
0 015 file q I
F,
y1sce \1 V If L,-- � J4X/%-)4Lt LicerwNo
oil I/ BusinessTel.No.
hes� 06 U �=
AIL Tel No.
N�R'SINSLT-AM--EWAIVER,la 1warethatteT Joensedoesnothave ftiLqnr=covmWorit3aibsu-Aal Muivalentasrepredbylviassactiusen Gei� Lam
d-mt mysignatimon (hispeirnit application waives ft mquiienynt
�ase check one) Owner Acent
Telephone No. PERMIT FEE 136
7ignarure 5T Owner or Tgent
q0i
Ith",o
The CommonWea - if Mas s*achusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation insurance Affidavit
FN—ame Please Print
Name:
Location:
city Phone #
I am'a homeowner performing all work myself
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
City: Phone #:
Insurance. Co. Policv #
Company name:
Address
Cily: Phone#:
Insurance Co. Policv #
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to $1,500.00
and/or one years' impiisonment-as-we.U-as-ci%nl.penaftiesin-theforrn-cf-a-S-TOP.W.ORK-ORDER.-an.d-a.fine -of .($1DR-00)-a-dayagainst.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 certify under the pains and penalties of peilury that the infonnation provided above is true and conect.
Signature —Date
Print name Phone
Official use only do not write in this area to be completed by city or town official'
City or Town Permit/Licensing
Building Dept
F-lCheck if immediate response is required Licensing Board
Selectman's Office
Contact person: Phone E] Health Department
F� Other
ThECOADIOAME4LTHOF
B0AR.00FFT?EPREWW6XJ
APPLICATIONFORPERARTTO
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH I
T
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION)
Town of North Andover
lie undersigned applies for a permit to perfonn the electrical wo k
BUC
Q
Location (Street & Number) 4r- 11
Owner or Tenant ff 4-
V
owner's Address
Is this pern-dt in conj unction with a buildina permut: Yes
Purpose of Building
Existing Ser.viqe Amps Volts
New Servic Amps Volts
Number of Feeders and Ampacity
Loc ation and Nature of Proposed Electrical Wo rk
No. of Lighting Outlets 2- No. of Hot Tubs
No. of Lighting Fixtures
No. of Receptacle Outlets
-,Df Switch Outlets
f Ranges
co�i--lp,0--A
i Dishwashers
Dryers
Water Heaters
�dro Massage Tubs
- ISwimming Pool Above
ground
I No. of Oil Burners
WHUSE7TS Office Use only
117Y Permit No.
7YONS527CAR12M
ccupancy & Fees Checked
)RMELE=CAL WORK
S ELECTRICAL..CODE, 527 CMR 12:00
Date
To the Inspector of Wires:
below.
No (Check Appropriate Box) I 1 -7- . ?7?
Utility Authorization No.
Overhead M Underground M No. of Meters
Overhead Underground r --j No. of Meters
chi
—nll 71U
No.
Below r-" I Generators
iNo. or zmergency Lignting Battery Units
No. of Air Cond.
Total
FIRE ALARMS
Tons
No. of Heat
Total
Total
No. of Detection and
. . Pumps
Tons
KW
Initiating Devices
Space Area Heating
KW
N9. ofSouh�ing Devices
No.,P?,,Self C�o,n-tained
Delt ttion/Sounding Devices
Heating Devices
KW
Local Municipal
Connections
KW No -of.
No. of
Signs � ,
(.Bailasis'.
No. of Motors
Total HP
'GDVW
dgft RMIaritV11B Of IV
"Liability . fiqiwJudbgCor
6tledvalidproof sametodleoffl= Ya
' the
NC�
BOND
Per�esofpeljuly:
Total
KVA
KVA
No. of Zones
YEs FL—,;f NO M
Other
offkc"Wbik $
Rough Fird
LicmseNo.
Signature
LicffwNo
Busir�s Tel No.
At Tel No.
N�-,�]Nk-��CEWAIVEP,Ix4warp-diatdrL=wdoeSDotbavedrn,a==oDw-t�-corits%bst�aINMIdlellasmTmedbyMassaLtu-,eMC-e�l-aws
thamysignakmon thispennitapplicationwaiws this m9mernent.
�ase check one) Owner Aaent
Telephone No. PERMIT FEE $
7ignature ot Owner
�n �n
K
11-1�/ IV A i- (- A f2 t: kt ) c rll_ — t- 3 1- 6 5- - Pv'l*l
N
vt C,
M
A
5PAVkc
EVTOFPUBLII
61TEMONN
61 T -To
H M SA
14 SA
VA 8Crjt
wz�rlk scrit
WHUSE77S Office Use only
Permit No.
YI0NSM7GWRJ2.-00
Occupancy & Fees Checked. -
)RMELE=CAL WORK
rs ELECTRICAL CODE, 527 CMR 12:00
Date
To the Inspector of Wires:
below.
/774
'es No (Check Appropriate Box)
Utility Authorization No.
Overhead Underground No. of Meters
M
Overhead Underground No. of Meters
a V6 014cl U�l
M -PIM CA4
,ocation and Nature of Proposed Electrical Work M"M .1 IF 4
No. of Hot Tubs C71 No. of TransfoOers Total
No. of Lighting Outlets 2, H KVA
------------ SwimEm-ing Pool Above Below Generators KVA
No. of Lighting Fixtures
f Oi
No. of Receptacle Outlets No. of Oil Bumers No. of Emergency Ligfiting Battery Units
J� nf Switch Outlel
C,i—.n�ge
I . —
f DisposalT
Dishwashers
Dryers
':Water Heaters
dro Massage I
R
Cc)mnr Pa
kentuabilityl
.1
S I — .11' 1 0
1
No. of Gas Burners
No. of Air Cond.
Toft
—,fHat
TO,
—F4,.
Total
Pumps
Tons
Space Area Heating
Heating Devices
No. of
No. of
Sig . T
Bailasis
No. of ivfo—t rs
Total Hl
'GO
�Mwtotheoffim YES
BOND 09=specify)
R
\IER'S INSURANCEWAMT, lafnfiwafeda drLmm does nothai
v my �gngmon fhispeff6tapplicadon waives [his m#aml
ase check one) Owner Agent
Signature ot Clwffe—ror Agent
AL�S� No. I Zones
Total— N Det.Lhn%
Ila
KW Initiating Devices, dA!;
K W ?ftof Soukrig D�vices?
NfJ-.'fSelf C6atained
_B69Uibri/Sounding Devices
KW Local Municipal Other
F1 Connections L --j
Apn7iim1prit W.", M NO F1
fill . 1 0. 1 &. V a
I FA
Bus="o
I No.
AkTelNo. e,
,-,!�orits
.,f mbsfantial eqzalffft as mpred by Nbsmclms Gffrd Lam
Telephone 149. PERIMIT FEE $ 135
Castle Electric, Inc.
Norwood Commerce Center
Bldg. #21 Endicott Street
Norwood, MA 02062
781-762-9891
Fax# 781-762-9116
December 20, 2006
Mr. Peter Murphy, Wiring Inspector
Town of North Andover
400 Osgood Street
North Andover, MA 01845
Dear Mr. Murphy:
Please cancel the electrical permit that was filed on November 22, 2006,
for 29 Buckingham Road, North Andover. This job was cancelled.
Thank you.
I
icere y rs
James R. Prescott
C k Rd
Location
0.
N Date
Th
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee
MU
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ I ao
Check # C)
7565' Ik At
Building Inspector
TOWN OF NORTH'ANDOVER
BUILDING DEPARTMENT
"PLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUELDING PERM[IT NUMBER: ISSUED:
SIGNATURE:
Building Commig'sioner/InspQuor of Buildings Date
SECTION I- SITE INFORMATION . I-
1. 1 Property Address:
1.2 Assessors Map and Parcel Number:
L/
Map Number Parcel Number
1.3 Zoning Information:
1.4 Property Dimensions:
Zoning IN46d Proposed Use
Lot Area (sf) Frontage (fl)
1.6 BURDING SETBACKS (ft)
Front Yard Side Yard
Rear Yard
Required Provide Required Provided
Required Provided
1.7 Water Supply M.G.L.C.40. 54) 1.5. Rood Zone Information:
1.8 Sewerage Disposal System:
Public 0 Private 0 Zone Outside Flood Zone 0
Municipal 0 On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
Nistuit Distrim: Yes —No
2.1 Owner of Record
,-2—
111 Sn't V.
#7 (-1 a_ M + -
Name (P n�int) Address for Service
Signature'
Telepho 7 -2
2.2 Owner of Record:
Name Print Address for Service:
Signature Tel It
222T-
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable e
Licensed Construction Supervisor:
License Number
Address
Expiration Date
Signature Telephone
3.2 Registered Home Improvement Contractor
Not Applicable ;?
0_0
Company, Name
liegistration Number
Address
Expiration Date
Signature Telephone
Ma
M
X
ic
__4 .
z
0
M
N
t\
J�
0
z
M
0
mn
ic
L&SPE
SECTION 4 - WORKERS COMPENSA TION (NLG.L C 152 6 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted %ith this application. Failure to provide this affidavit vVill result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes ....... 0 No ....... 0
SECTION 5 Description o Proposed Work (check
applileable)
New Construction 0
Existing Building 0
Repair(s) 0
17�1� ations(s) 0 T�
0
Accessory Bldg. 0
Demolition 0
Other 0 Specify
Brief Description of Proposed Work:
-7x
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollar) to Ix
Completed by permit applicant
C IALUSE�ON LY �T
FR
1. Building
(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
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERY[IT
as Owner/Authorized Agent of subject property
Hereby authorize LAO )ne,
r7, r to act on
My beham 11 matters relati )�o this building permit application.
�rkorized by
- ' � 11, ' V C- /
-Sig riature'6f Owner - _V_ Date i
SECTION 7b OWNERATITHORIZED AGENT DECLARATION I
1, 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 Owner/Agent Date
Eggs=
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TDvMERS I ST 2 ND 3 RD
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HIHGHT OF FOUNDATION THICKNESS
SIZE OF FOOT]NG X
MATERIAL OF CHEVMY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
I
LOT 15A'
MAP 15 PARCEL 24
LOT4'A'
MAP 15 PARCEL 14
CERTIFIED PLOT PLAN
LOCATED IN NORTH ANDOVER, MASS.
SCALE. 1 "=20' DATE 6/18/2004
Scofft. Giles R.P.L.S.
Frank. S. Giles R.P.L.S.
50 Deer Meadow Road
North Andover, Mass.
BUCKINGHAM
OFFSETS SHOWN ARE FOR THE USE
OF THE BUILDING INSPECTOR ONLY
AND SUCH USE IS FOR THE
DETERMINA TfON OF ZONING
CONFORMITY OR NON -CONFORMITY
WHEN CONSTRUCTED.
LOT 17A'
MAP 15 PARCEL 26
LOT 2
MAP 15 PARCEL 121
THE A VERAGE FRONT SETBACK 250'
EACH SIDE'OF- THIS LOCUS IS 12'. 0
D. Robert Nicetta
Building Commissioner
(978) 688-9545
(978) 688-9542. Fax
Please print.
DATE
JOB LOCATION
Number
HOMEOWNER
Name
PRESENT MAILING ADDRESS
Town of North Andover
Building Department
27 Charles Street
North Andover, MA. 01845
City Town
HOMEOWNER LICENSE EXEMPTION
4 a- rv_ Pj -
eet Address
q7r
Home Phone
State
Map / lot
Work Phone
Zip Code
The current exemption for "home6wners" was extended to include owner -occupied dwellings
of two 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 108.3.5. 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 or two family dwelling, attached or detached structures ac-
cessory to such use and/or farm structures. A person who constructs more than one home in a
two-year period shall not be considered a homeowner.
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 that he/she understands the Town of No. Andover
Building Department minimum inspection procedures and requirements and that he/she will
comply with said procedures and requirements.
HOMEOWNER'S SIGNATURE_,��
APPROVAL OF BUILDING OFFICIAL
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 150 A.
The debris will be disposed of in:
(Location of Facility)
Signature of Permit Applicant
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of, the Building Inspector
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Location
No. Date
V40RT
Ot TOWN.OF NORTH ANDOVE�
0 Certificate of Occupancy $
Building/Fralme Permit Fee $
A Foundation Permit Fee
Other Permit FeeV
$
Sewer Connection Fee
Water Connection Fee
'TOTAL
Building Inspector
Div. Public Works
PERMIT NO. APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS.
r
PAGE I
MAP +40.
LOT NO.
2 RECORD OF OWNERSHIP IDATE
BOOK PAGE
ZONE
SUB DIV. LOT NO.
I
LOCATION
sockliz P -6A -l-)
PURPOSE OF BUILDING k VZ
, __,_
OWNER*S NAME Tltwso-t #-/
NO. OF STORIES SIZE
OWNER'S ADDRESS
BASEMENT OR SLAB
ARCHITECT'S NAME
SIZE OF FLOOR TIMBERS IST 2ND 3RD
BUILDER'S NAME
SPAN
DISTANCE TO NEAREST BUILDING
DIMENSIONS OF SILLS
DISTANCE FROM STREET
POSTS
DISTANCE FROM LOT LINES - SIDES REAR
GIRDERS
AREA OF LOT S-11) a :5�.o FRONTAGE
HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW J')b
SIZE OF FOOTING x
IS BUILDING ADDITION
MATER:AL OF CHIMNEY
IS BUILDING ALTERATION /V 0
IS BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE Y4
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
F E E
PERMIT GRANTED
6-1 19 1& Ile,
3 PROPERTY INFORMATION
LAND COST
EST. BLDG. COST ?�b-bo
EST. BLDG. COST PER SQ. FT.
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
SUILDING ImeracTolt
- s -z
OWNERTEL# b?,)Q �7-z—
CONTR. TEL. #
CONTR. LIC. #
H.I.C.# 4/,5 Afft4
BUILDING RECORD
I OCC UPANCY 12 f,
SINGLE FAMILY
S I-ORIES I
MULTI. FAMILY
OFFICES
APARTMENTS
CONSTRUCTION
2 FOUNDATION
—
8 INTERIOR FINISH
a 1 2 13
PINE
CONCRETE
—
CONCRETE BL K.
BRICK OR STONE
HARDW D
PIERS
PLASTER
-6RY WALL
UNFIN.
3 BASEMENT
AREA FULL
FIN. B M T AREA
V, 1/2 1/1
FIN. ATTIC AREA
t!O 8 M T
FIRE PLACES
HEAD ROOM
MODERN KITCHEN
4 WALLS 9 FLOORS
CLAPBOARDS
DROP SIDING
WOOD SHINGL�S
ASPHALT SIDIWG
ASBESTOS SIDING
B
1
2 3
_EONCRETE
�ARTH
-�TARDIWD
COMMCN
VERT. SIDING
-;�SPH TILE
STUCCO ON MASONRY
STUCCO ON FRAME
BRICK ON MASONRY
BRICK ON FRAME
ATTIC STRS. & FLOOR
CONC. OR CINDER BLK.
WIRING
STONE ON MASONRY
STONE ON FRAME
SUPERIO EOCR
ADEQUA!T, NONE
5 ROOF
10 PLUMBING
GABLE —
GAMBREL]L]
I
I HIP_
MANSARD
BATH 13 FIX.)
TOILET RM. (2 FIX.)
FL—ATJ
-�IHED
WATER CLOSET
ASPHALT SHINGLES
LAVATORY
WOOD SHINGES
KITCHEN SINK
SLATE
NO PLUMBING
TAR & GRAVEL
STALL SHOWER
ROLL ROOFING
MODERN FIXTURES
TILE FLOOR
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
AS
OIL
B'M*T 2nd
lo 3 I
I ELECTRIC
1 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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I TOWN of NORTH ANDOVER
AFFIDAVIT
Hmie hPmYeaffit Cat=tcr law
awiment to penit tgAimum
t6 -7 We 11W.]
me- W, $Maio 1'9�zvcl 0
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Type of Wbrk:_�4-)L!,-1k' Est. Cost Z 0 0
Address of Work ) �- A' 1/ 6 P-)) �--/ k 0
Owner Name:- (2— v A J -6
Date of Permit Application:
I hereby certify tbat:
Registration is not required for the following reason(s):
Work excluded by law
Job under � $1, 000
Building not owner -occupied
Owner,pulling own permit
Other (specify)
Notice is hereby given that:
Rr office Use Oftly
Rmdt
Date
OWNERS PULLING THEIR OWN PERMIT OR DEALING WIM UNREGISTERED 00NTR&C10RS---'
FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRA-
TION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A.
Signed uxler pemlties of perjLxy:
I hereby apply for a permit as the agent of the owner:
Date Contractor Name
OR:
Registration No.
Notwithstanding the above notice, I hereby apply for a permit as the
owner of the above property: A /)
'2T)
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MAY -24-95 WED 01:39 PM BEVERLY
MAY -24-95 WED 01:40 PM BEVERLY FIRE DEPT 922 1879 P.02
OEM== ------ p -
C U T L I'S T
'C'USTOMER --
DATE:
E-
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R E F s i F\ - I Lm- S. --
LAPEL
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MAY -24-95 WED 01:40 PM BEVERLY FIRE DEPT
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PL�AN VIEW
CUSTOMER --
DATE:
3�1
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t-
RE:F SIRIOS2
922 1879 P.03
L,oad cand zuppc-r-
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Q;n UOP Of b;-za-r-,s. 1.c,-, -"L) Centc-r,
Ee sure -Lo Fc:�ijcw the c4ec:,
T
your
71,1& dGStq,-, r,=qU,r r --.s knee br=s.s� be -a7, spiTcas -and'
between, jcis+s. Your materials, nc-cessary ,1619ms.
The Ezi
t c
design i's no riiiris.,-�ed bU*,-,ldng picn. Yc--, 'are
measuram�� ts be--nq corrs:-t For vc-rify�ng +11L,"ot
the dc -sign (u,,d Substtu-t.-,,cr-,s or, r,)c,�j;p,
*cns that
all local bullding co -des anci �-eqzt
To ver-Fy thQt
t
�7)e S:L-=e2+=d
,J�� C:GSFq:Q. and cmy
t W'
dP--=I*gn witi-j z'tr- revIetv
you�-
COrls-'ructic-n and procer
C4
Location Ce I
No Date
VkORTPI TtiWKI nC Klf%DTU AKMMIUM
0 Certificate of Occupancy $
41
Building/Frame Permit Fee $
CU
Foundation Permit Fee $
ACH
Other Permit F� $
Sewer Connection Fee
Water Connection Fee
TOTAL
Building Inspector
Div. Public Works
XTO
8172
0
PER'MIT NO. APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS.
10
4
PAGE 1
MAP ilO.
LOT NO.
2 RECORD OF OWNERSHIP IDATE
BOOK ;PAGE
ZONE
SUB DIV. LOT NO.
4
A
LOC �T,Ov vv- [5:!� �, q
f, -I< q
,.�:e "&
PURPOSE OF BUILDING If
OWNER'S NAME
NO. OF STORIES SIZE
OWNER'S ADDRESS
BASEMENT OR SLAB
ARCHITECT'S NAME
SIZE OF FLOOR TIMBERS IST 2ND 3RD
BUILDER'S NAME
SPAN
DISTANCE TO NEAREST 6-UILDING
DIMENSIONS OF SILLS
POSTS
DISTANCE FROM STREET
DISTANCE FROM LOT LINES - SIDES
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
WILL 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 ND APPROVED BY BUILDING INSPECTOR
DATE FILED / elq-�)
PERMIT GRANTED
to
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
BUILDING INSIPRCTOR
OWNER TEL. #
11-714
CONTR. TEL. # 7 0-b
CONTR. LIC. # (9,3!( d il
H. I. C. # Zo,3:3 17
BUILDING RECORD
OCCUPANCY 12
SINGLE FAMILY
I
I SiORIES
MULTI.
OFFICES
APARTMENTS
CONSTRUCTION
2 FOUNDATION
8 INTERIOR FINISH
3 1 2 13
PINE
CONCRETE
CONCRETE BL*K.
BRICK OR STONE
HARDW D
PIERS
PLASTER
DRY WALL
--6NFIN
3 BASEMENT
AREA FULL
FIN. B M -T AREA__
114 '/2
FIN. ATTIC AREA
t!O 8 M T
FIRE PLACES
HEAD ROOM
MODERN KITCHEN
4 WALL$ 9 FLOORS
CLAPBOARDS
B
1
2
3
DROP SIDING
WOOD SHINGLES
ASPHALT SIDING
ASBESTOS SIDING
VERT. SIDING
CONCRETE
EARTH
HARDNIJ'D
COM/,ACN
ASPH. TILE
STUCCO ON MASONRY
STUCCO ON FRAME
BRICK ON MASONRY
BRICK ON FRAME
ATTIC STRS. & FLOOR
CONC. OR CINDER BILK.
WIRING
STONE ON MASONRY
STONE ON FRAME
SUPERIO! 1__� POOR
ADEQUATE NONE
5 ROOF
10 PLUMBING
GABLE
2
G_AMB.REL]_d
I
I HIP
BATH (3 FIX.)
MANSARD
TOILET RM. (2 FIX.)
L ---
F AT
'�HED
WATER CLOSET
ASPHALT SHINGLES
LAVATORY
WOOD SHINGES
KITCHEN SINK
SLATE
NO PLUMBING
TAR & GRAVEL
STALL SHOWER
ROLL ROOFING
MODERN FIXTURES
TILE FLOOR
TILE DADO
IA
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
ELECTRIC
I st I 3rd
NO HEATING
THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND oDISTANCE FROM
LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA -
;ES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN.
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Date..f.-./ ........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
'�-o
..................
4� . . .................. ..........................
This certifies that ..................
has permission to perform ...............................................................................
wiring in the building of ..........
......................................................................
.......... North Andover, Mass.
......... Lic. Noxi -.7 ...................
ELECTR ICAL INSPECTOR
Check # -? /%.)
4683
`7
Com nfotlwaaftif nfwoassac�usemT
Departaferif 01-F-irr, Servi,-Cps
1
G!z FIRE PREVENTION REGULATIONS nd Fm Checked �3
LIP"elf Qeavc blaak,
APPUCATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work tobeparforyped inacccrdance wilt, qw-MM96usetts Eledrical Code QZ-C), 52'01CW. 12.00
1JVK 01?-1YjT4tL IIVFORA-917jm-� Date: 9/1�)/O-�>
city or -town Of.- N-4\rlaaw-f To the MsActor' of Wires:
13y JJ,� applicaton the urdotlaicl �s notice ef his or!Fer —int,.-afion to perorm the
elect6cat vyotk described below.
i,ocaiioct (Sri-cet & Nunibex;) �241
Ownerf,rTenant
Ownt,r's Address _qj 10&3
Of
is t.hl-.s permit in co.tjtInction Witb & b-lilding pertnit? Yes No W (Cbecl, Appropriate Box)
Purpose -of Rttlldiog--QQZL-A����_ Utility AvOorization No.
Er.iwkig Ser%iCCQ4ja— Amps (QO I --�4cyou--. Overhead Undgrd ('I
�ew —ScMjc� Ampi
__�_Volts OverhepLd Undgrd
Numkr of Feeders andUVacity
Location and Nature of Proposed'Elt-Arical Work:
\N
No. of 14tiers.
Am of Meters
,pierto" omefollowing table may iw waived by Me Inspedor z1virw.
1-a. or Recessed FixtaTes j No. of Total
I.No. of Ceil.4vsp. (Pjkddk) Fans ITransfomers K -VA
No. , of LighfingOAets
0
IND. offfot Tubs
e in-_
,08 Vb �G b
SwImming Pool
Generators KVA
No. of RemptAde Outten
40 'of O_
11
No. of OR Borsers
of 2a 'net
No. of Svv Itches
IN0. of Ranges
No. d Gas Bwrners
No. of Air Cond.
Total
Toms
I
initiating EWEN
No.,of AlertiRgDevices
-No, of Waste b1spoSers
Pump
Totals:
j_4VMVjTaos
jjgL
No. of gel=ntaln—a
Detection/Alerthm DMce--
=.—T
_
Ni,, of Dishwashers
NO. of Dryer$
o, o Water
Heaters KW
SpacclAtealleafing KW
HeafinzApplianocs KW
a No. of
S!m ftlasts
Odier
becutlt� Syaem:
No.of1wica- 6r f1suivalent
Dab Virilin
No. of Lkes or Eanivalkni
r-za. ilydromamage Bathtubs
No. of Motors
Total UP
Telecommunka"ons Whum:
N& DeAces or Fmulv'Ment
-of
Aftch additionaldesad irdah*4 or aj reqtdred bv do ImvedororWim,
LNISt!"NCIE COVIER&GE. Unless waived by the owncr, no pennit fer the performarim of clecuical Work Toidy issat uAfts
th;?� ficrm:ee- Pluvides proofef VabilitV insitraum induding'compteW opemon7 cmmg.- or ils substsatial equimLent. The
wi&-rsi,,medcerUfits t1Wmmho0YVW. is inforve, aMbas "ibitedpwofef sa= to the pumt im&g office.
(I-MCKONE: INSUKANCE Rr 13DIND [] M7M [] (Spej;jfy.)6ferLjed YN�&Q .9*4 1c4
a tim3ted Value of RlaAn4 Vork: , %0- C2__ (Vftett req*od by lnunioipal policy.) (Ei(pimfi&DO)
wbi-�- to Start:-2�N/b 3 11wections to be Tequcftd irk Hccordancx witin NEC Rale to, vd -,Ipon cmup'etioa.
I emo, under file pa&r and pfflabi&-i qfFzrjujy, fkat the in
� fonndion on thij applicadon is hwe and LW"Pk-A'
FIRM Nkl;trnwe-A Lie. NO.,. 15 11 101A
Signature 9 q
Li J () -4/—/t-��-7 LIC. NO.! 5 1 A
M*i-T-lica , gas. Tel. No.,17EZ
Azic 0
!�=Zv:tj 3 41t. Tlel'
r P1
!..r
mo�
OlAiNEI�'5�11U.&WArVER.: I am aware that the Licensm does no; ha%4 die liability 1mjvapre Lm--etage nor
requiTed bylaw. By nY signalffebeltiw, I hereby noahe this MamirmnL I am" ,check one) L-] owner Ujcmnex-sas t.
!1witer,'Age-ni - a
4ij:jl�iurt __ Telephone Wo. FE: S &O-OLY I
LOT 15A'
MAP 15 PARCEL 24
LOT4'A' to
MAP 15PARCEL 14 c)
rV
)
ct
CERTIRED PLOT PLAN
LOCATED IN NORTH ANDOVER, MASS.
SCALE. 1 "=20' DA TE. 612312003
ScottL. Giles R.P.L.S.
Frank. S. Giles R.P.L.S.
50 Deer Meadow Road
North Andover, Mass.
LOT 16A'
MAP 15 PARCEL 25
73.74'
LOT 17A'
MAP 15 PARCEL 26
LOT 3A
LANDCOURT PLAN 8813 M
6152 S. F
ASSESSORS MAP 15 PARCEL 13
- W-509. 61"
EXIST 1 112 STY.
W.F. DWELL.
.14
BUCKINGHAM
OFFSETS SHOWN ARE FOR THE USE
OF THE BUILDING INSPECTOR ONLY
AND SUCH USE IS FOR THE
DETERMINATION OF ZONING
CONFORMITY OR NON -CONFORMITY
WHEN CONSTRUCTED.
#29
LOT2
MAP 15 PARCEL 121
GARAGE
I STY
L=65. 33,
ROAD
Zoning Bylaw Review Form
Town Of North Andover Building Department
27 Charles St. North Andover. MA. 01845
Phone 978-688-9645 Fax 978-688-9542
-Street-.-.
Item
Map/Lot:
Site Plan Review Special Permit
Applicant:
/,/,a i" Sm, -/-A --7-7111 _174-1- 7
Request:
P,621e )ax ao
Date:
r%
F
F_ ca�c tic CIUVI.Seu Liiat ayEer review OT your Application and Plans that your Application is
DENIED , for the following Zoning Bylaw reasons:
Zoning R -
Remedy for the above is checked below
Item # Special Permits Planning Board _-Iiem#
Item
Notes
Site Plan Review Special Permit
Item
Notes
A
Lot Area
Parking Variance,
F
Frontage
Lot Area Variance
I
Lot area Insufficient
Height Variance
1
Frontage InsufficWn—t
Variance )r Si n
2
Lot Area Preexisting
Ll e- S
2
Frontage Complies
3
Lot Area Complies
3
1 Pre xisting frontage
—insufficient
Lf e- S7
4
Insufficient Information
4
T information
B
use
5
No access over Frontage
I
2'
Allowed
Not Allowed
G
I
Contiguous Building Area
Insufficient Area
3
Use Preexisting
2
Complies
4
Special Permit Required
e- _S
3
Preexisting CBA
5
Insufficientr Information
4
Insufficient Information
C
I Setback
H
Building Height
I
All setbacks comply
1
Height Exceeds Maximum
2
Front Insufficient
2
1 Complies
3
Left Side Insufficient
3
Preexisting Height
4
6
Right Side Insufficient
Rear Insufficient
—4-i—nsufficient
I
Information
Building Coverage
L-1 P_
6
Preexisting setback(s)
e- t-,
1
Coverage exceeds —m—ax—im—um
7
Insufficient Information
2
Coverage Complies
D
I
Watershed
Not in Watershed
Ll e- 5
3
_4
—Coverage Preexisting
Insufficient Information
Lj
2
3
In Watershed
Lot prior to 10/24/94
j
1
Sign
Sign not allowed
4
zone to be Determined
2
Sign Complies
5
Insufficient Information
3
Insufficient Information
E
I
2
Historic District
In District review required
Not in district
K
I
2
_�_a_rking
More Parking Required
Parking Complies
sufficient Information
3
InsufficieEntinformation
—pr', - --n MadkEg
xisti g P
,E EEF
Remedy for the above is checked below
Item # Special Permits Planning Board _-Iiem#
Variance
Site Plan Review Special Permit
C-4-5-
Setback Variance
Access other than Frontage Special Permit--.
Parking Variance,
Frontage Exception Lot Special Permit
Lot Area Variance
Common Driveway Special Permit
Height Variance
Congregate Housing Special Permit
Variance )r Si n
Continuing Care Retirement Special Permit—
Independent Elderly Housing Special Permit
Large Estate Condo Special Permit —
Planned Development District Special Permit
Planned Residential Special Permit
R-6 Density Special Permit
—
Special Permits Zoning -B—oard
Special Permit Non -Conforming Use ZBA
Earth Removal Special Permit ZBA
Special Permit Use not Listed but Similar
Special Permit for —Sign
Special permit for preexisting
nonconforming
Watershed Special Permit
The above review and attached explanation of such is based on the plans and information submitted. No definitive review and
or advice shall be based on verbal explanations by the applicant nor shall such verbal explanations by the applicant serve to
provide definitive answers to the above reasons for Any inaccuracies, misleading information, or other subsequent
changes to the information submitted by the applicant shall be grounds for this review to be voided at the discretion of the
Building Department. The attached document titled "Plan Review Narrative" shall be attached hereto and incorporated herein
by reference. The building department will retain all plans and documentation for the above file. You must file a new permit
application form and begin the permitting process.
Am(6", 2- - (q - co -3 2-(8-
El-uilding Department Official Signat Application Received Appli iiion -Denied
Plan Review Narrative
The following narrative is provided to further explain the . reasons for DENIAL for the
APPLICATION for the property indicated on the reverse side:
Referred To:
Fire
m4ptEg
SV
Zoninq Board
/&e 'U- Ct,(A- lork, e)f
Department of Public Works
C410 AJ 61 C�, 73 1A v-1
Historical Commission
Other
rtment
A C le�, 0 r S/,
fZ /-.e- C) d A.' 1!�j 6L/
Referred To:
Fire
Health
Police
Zoninq Board
Conservation
Department of Public Works
Planning
Historical Commission
Other
rtment
. ...... Zoning Bylaw Review Form
Town Of North Andover Building Department
27 Charles St. North Andover
MA. 01845
Phone 978-688-gs4S Fax 978-688-9542
Streett
Map/Lot: 15-1 /3
Applicant:
Request: e)(t,6Af�g a
Date:
Please be advised that after review of your Application and Plans that your Application is
DENIED � for the following Zoning Bylaw reasons:
Zoning A-4
Item Notes Item Notes
A Lot Area F Frontage
I Lot area Insufficient Frontage Insufficient
2 Lot Area Prepy'istinn
Ll e- S 2 Frontage Complies
Lot Area Complies 3 Preexisting frontage— Lf e
4 Insufficient Information Insufficient Infor
B Use mation
1 Allowed 5 No access over Frontage
G Contiguous uilding Area
2 Not Allowed 1 Insufficient Area PJ/81
3 Use Preexisting -i— Complies
4 Special Permit Required Lj e, -S 3 Pree (isting CBA
5 Insufficient Information 4 Insufficient Informatio-n--
C Setback H Building He
I —
I All setbacks comply _L__ Height Exceeds Ma-m-m—um
2 Front Insufficient 2 Compli�es-
3 Left Side Insufficient -i— Preexisting Height
4 Right Side Insufficient— o?o —ey4e-siv--� 4 Insufficient lnformatio�-- —1-1e-
5 Rear Insufficient — c, %,, c-_ -- - I
Building Coverage
6 Preexisting setback(s) 1 Coverage exceeds maximum -
7 Insufficient Information 2 Coverage Complies
D Watershed -i-- Cov rage Preexisting
1 Not in Watershed 4 Insufficient Information
2 In Watershed J Sign
3 Lot priorto 10/24/94 1 Sign not allowed
4 Zone to be Determined _L_. Sign Complies
6 Insufficient Information 3 Insufficient Information
E Histor c District' K Parking
I In District review required -T--Wo-re Parking Required A)
2 Not in district G(e- s 2 Parking Complies
3 Insufficient Information Insu 'icient Inform"
ation
Remedy for the above is checked below.
Item # Special Permits Planning Board Item #. Variance
Srt -1an Review Special Permit -c- 4 —_5 - Setback ariance
Access other than Frontage Special Permit Parki —
Frontage Exception Lot Special Permit Lot Area variance
Common Driveway Special Perm7it-- r1ei nt variance
Congregate Housing Special Permit variance for S'
Continuing Care Retirement
Independent -§Pec'al Permit Special Permits Zoning Board
kderly Housing Special Permit
1__§ ecial PermitCNIon-Conifor-ming Use ZBA
Larg ? Estate
Condo Special Permit _ji I P ��-i n
_Earth Remova 11 6 ecial Permit ZBA
Planned Development District edial —Permit
a��,�In �!S S ecial Permit Use not -Liste butSimilar
-Zp2 ia! �ermit Use not I-isted
Planned Residentiaill ecial Permit
R-6 Density special Permit Special Permit for Sign
Special permit for preexistin�
Watershed Special Pprmit nonconformina 9
The above review and attached explanation of such is based on the plans and information submitted. No definitive review and
or advice shall be based on verbal explanations by the applicant nor shall such verbal explanations by the applicant serve to
provide definitive answers to the above reasons for Any inaccuracies, misleading information, or other subsequent
changes to the information submitted by the applicant shall be grounds for this review to be voided at the discretion of the
Building Department. The attached document titled "Plan Review Narrative" shall be attached hereto and incorporated herein
by reference. The building department will retain all plans and documentation for the above file. You must file a new permit
application form and begin the permitting process.
(14 - CO 75 -8 0
Building Department Official Signat
Application Receive
Tpplicati� Denied
Plan Review Narrative
The following narrative is provided to further explain the reasons for DENIAL for the
APPLIbATION for the property indicated on 'the reverse side:
Referred To:
t -ire —qe—a —It h—
Police
rvii�, oning Board
Conse on Department of Public Works
Planning
Other �IstOri�calCom�missionn
–guil �inq 5`eDartm�en��
3 2-
0( Ct V
FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary 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 or requirements.
[.-.*****************************APPLICANT FILLS OUT THIS SECTION-**********************
APPLICANT PHONE 612?
LOCATION: Assessor's Map N6rnber PARCEL -j&
SUBDIVISION LOT (S)
STREET-Atirki'a''2, ST. NUMBER
USE
RECOMMENDATIONS OF TOWN AGENTS:
----------------------------------------------------------
CONSERVATION ADMINISTRATOR DATE APPROVED
DATE REJECTED
COMMENTS
TOWN PLANNER
DATE APPROVED
DATE REJECTED
COMMENTS
FOOD INSPECTOR -HEALTH
DATE APPROVED
DATE REJECTED
SEPTIC INSPECTOR -HEALTH
DATEAPPROVED
DATE REJECTED
COMMENT
PUBLIC WORKS - SEWER/WATER CONNECTIONS.
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR —DATE—
Revised 9\97 jm
I * , , . A, 2/ jV16 -�
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
e 'o
BUELDING PERM[IT NUMBER:
DATE ISSUED:
SIGNATURE:
Building Commissioner/12�eEtor of Buildings Date
cri—rinpi i eirry irmur%rix., �Y�., I
1.1 Property Address: 1.2 Assessors Map and Parcel Number:
f3ao k q
Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area (sf) Frontage (ft)
1.6 BUILDING SETBACKS (ft)
Front Yard Side Yard Rear Yard
Required Provide Required Provided Required
Provided
+
1.7 Water Supply M.G.L.C.440.1- 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System:
Public 0 Private 0 Zone Outside, Flood Zone 0 Municipal 0 On Site Disposal System. 0
SECTION 2 - PROPERTY OWNERSIRP/AUTHORIZED AGENT
2.1 Owner of Record
ba 0 1. j T I I Y)
Name (Print) ress for S��Ice-
7k -6ff 3
1'gigiia6re 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
Licensed Construction Supervisor:
License Number
Address
Signature Telephone Expiration Date
3.2 Registered Home Improvement Contractor Not Applicable 0
Company Name
Registration Number
Address
Signalu -e Telephone Expiration Date
T
M
z
0
0
z
M
go
0
mn
ic
M
z
G)
[MECTION 4 - WORKERS COMEPENSATION (NLG.L C 152 § 25c(6)
"U1 "Ib %'uJ11P4;nSULion insurance arlicavit must t)e 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 o pyoposed Work (check applicable)
New Construction 0
Existing Building 0
Repair(s) 0
Alterations(s)
0
Accessory Bldg. 0
Demolition 0
Other 0 Specify
Brief Description of Proposed Work:
V1 e
y t'� lo &_�LJ n.J4'r-W6'e i�A_ _'ca -m -e L06 rIA47,
X I -e Y1. 9 TV,
V1
SECTION,d- ESTIMATED COfATRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
OFFICIAL USE ONLY_
I . Building
(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
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, , as 0,Aqier/Authofized 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
1, 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 beliet'
Print Name
i ature of Owner/A I ent Date
-NO. OF STOTT s SIZE
-BASEMENT OR SLAB
-SIZE OF FLOOR TffvMERS iST 2 No 3 RD
SPAN
-DIMENSIONS OF SILLS
-DIMENSIONS OF POSTS ----
-DIMENSIONS OF GIRDERS
I IF IG HT OF FOUNDATION THICKNESS
-SIZE OF FOOTING X
-MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUELDING CONNECTED TO NATURAL GAS LINE
MORTGAGE INSPECTION PLOT PLAN
NORTHERN ASSOCIATES, INC.
630 7*U1?NPIKE STREEr N. ANDOVER MA 7*EL. (508) 975-7117
MOR T&A SOM DA VXD V. 49 MIRIAM 0. 5Mr7H DEED REF. 55 / 157
L OCA TXON.* 29 BUCKINGHAM ROAD PLAN REF. 0 8813 M
T Y. S T4 TE., NORTH ANDOVER MA SCALE., 1- 20'
DA M. 11117193 JOB ik 931 0914B
L01
LOrS JOA & 17A
L3 [I(-,< 1 N6 IJA "
CERrXFXED rO.' SHAMMUT MORWASE
NOTE: This mortgage inspection was prepared
specifically for mortgage purpo as only and
is no t to be relied upon a: a Nnd or property
iine survey. Building loc tion and offsets
shown are specifically for zoning determination
only and not to be used to establish property
lin ' cThe I;nd.:hown hereon is based on
ref:'ren ed I n or tion noted and may be subject
to furthe r takings and easements. Northern
Associates, rnc. accepts no responsibility for
damages resulting from said reliance by anyone
other than the said mortgage* and its assigns in
connection with its proposed mortgage financing
to said mortgagor.
I" OF ,
JA ES J.
C3 ABELY -4
-4
NO. 28520 en
r
P -e
e—
�Zo 0 011,
This mortgage inspection was prepared in accordance
with he Technical Standards for Mortgage Loan
,".P.!
_tJ one an adopted by the Massachusetts Board of
Registration of Professional Engineers and Land
Surveyors 250 CHR 605.
1 furth 11 rt:tate that in my professional opinion that
th u
.: Ttr c ras shown conform with
t ocal zoninq horizontal dimensional setback
requirements at the time of construction or are
exempt under provisions of M.G.L. CH. 40-A Sec. 7.
I.Property/House is not In a Flood H82ard.
2.Property/House is in a Flood Hazard Area.
03.Information is insufficient to determine
Flood Hazard.
Flood Hazard determined ftfla�W ood
Insurance Zat* Map Panel
�kDate_
OR
li
4-
tv
0