HomeMy WebLinkAboutMiscellaneous - 29 MABLIN AVENUE 4/30/2018p C
TOWN OF NORTH ANDOVER
PERMIT FOR GAS IN§TALLATION
This certifies that **�A4yj------I** ............
. ........ ....
.............
Ias permission for gas installatio .....................................................
i the buildings of ....... S. ....................................................
n
at .... M41yj . ............................................. . North Andover, Mass.
Fee<.... �. ...... Lic. No . .... ............ ... ...............
GASINSPECTOR
Check# 6� I
O�920
11072
Date
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that ...... 0
L VIt o,
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.. .. .. . .... q
....... ......
........... .................................
has permission to perform ...... . &P,(Z- ................................................................
plumbing in the buildings of,:5wd(Cq .... .....................................
at,.)q .. /P.4G .4! .... 14 North Andover, Mass.
v
..................
Feq,2.0-..� \4-1� - I!,
.. ........... Lic. NO. .... .................................................................................
PLUMBING INSPECTOR
Check #
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING W6—RK
- rz . -
CITY MA DATE. 3AO�PERMIT#
�LV4 �15'
JOBSITE ADDRESS nl!� b /,�y A' v OWNER'S NAME' .5,4
jr OWNER ADDRESS TEL. )�664FAX:
TYPE OR OCCUPANCYTYPE COMMERCIAL.. EDUCATIONAL RESIDENTIAL::'�--.
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT:,���
I PLANS SUBMITTED: YW. NO9---
FIXTURES I FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM T
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR AREA DRAIN
INTERCEPTOR (INTERIOR)
i W
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING . ......
OTHER
.. . ..... ...
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES i-,��NO
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
C
LIABILITY INSURANCE POLICY OTHER TYPE OF 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.
CHECK ONE ONLY: OWNER 11"-' AGENT
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true p" accurate to the best of m)��nowledge
and that all plumbing work and installations performed under the permit issued for this application will be in coVky�with all Pertine,�kprovisi��? the
Massachusetts State Plumbing Code and Ch apter 142 of the General Laws.
PLUMBER'S NAME Peter G. Viens LICENSE # 1211 b SIGNATURE
MP, jP
CORPORATION 3631 C PARTNERSHIP: LLC #
COMPANYNAME Merrimack Valley Corporation ADDRESS 15 Aegean Drive, Unit #3
CITY Methuen STATE: MA ZIP 01844 TEL 978-689-0224
FAX 978-689-2206 CELL: 978-807-2819 EMAIL pviens@mvalleycorp.com
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
GOWNER
TYPE OR
PRINT
CLEARLY
CITY /J0-/,,jE-fL MA DATE 3 "P15- J J PERMIT #
JOBSITE ADDRESS OWNER'SNAME SA-JW/A.
ADDRESS TEL ZP'169 P 2 0 (6 114 FAX
OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL Ej RESIDENTIALV9-'
NEW: El RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES E] NO K,
APPLIANCES -1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM / SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES M NO
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY R] OTHER TYPE INDEMNITY F1 BOND F-1
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER El AGENT El
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true d accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compli n e with all PertinSpt pro n of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ff '- '7
PLUMBER-GASFITTER NAME Peter G. Viens LICENSE # 12116 SIGNATURIf
MP M MGF [-I JP E] JGF [:] LPGI [:1 CORPORATION KI # 3631 C PARTNERSHIP E] # LLC #
COMPANY NAME Merrimack Valley Corp ADDRESS 15 Aegean Drive Unit # 3
CITY Methuen STATE MA ZIP 01844 TEL (978) 68 -0224 VVI
FAX CELL EMAIL piensOnvalleVcorp.com
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f Th e COMM611 wealth of Massach usetts
Department of IndustrialAcciderits
Office ofInvestigations
600 Washington Street
B ostort, AM 02111
www. mass.gov1dia
Workers, C0MPCnS'Rfl6n11 InSUIr2nee Affidavit: Builders/Corntractors/Electricians/Piumbers
Please Frinll LtgLhly
Name (B usiness/orga nizat ion/] nd ivid ua 1): Z'�,
u/a Z -
Address:
�, I c " _y1f
City/Stale/Zlp: Phone 4:
Are you art employer? Check the appropriate box:
I am a employer with — 4. n I am a general contractor and I
employees (full and/o, have hired the sub-contTactors
I am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub -contractors have
working for ine in any capacity. employees and have workers'
[No workers' comp. insurance cornp. insuranceJ
required.]
3. El I am a homeowner doing all work
myself [No workers' comp.
insurance required.]
We are a Corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § )(4), and we have no
employees. [No workers'
comp. insurance required.1
Type of project (required):
6. F1 New construction
7. 0 Remodeling
8. E] Demolition
9. E] Building addition
I O.D Electrical repairs oi- additions
I I.El Plumbing repai=rs or additions
12TJ Roof repairs
13, F Other
'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
Homeovvners who submit this affidavit indicating they are doing all work and then hire outside contractors MLISI SUbmit a new affidavit indicatirl'.- such.
'Contractors th2i check this box must attached an additional shee'tshowing the name of the sub -contractors and State Whethl!T 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' compensation insitrancefor my employees. Below is the policy andjob site
information.
Insurance Company Name: /4/,
. VV5
Policy 4 Or Self -ins. Lic, 9:
Expi�ration Date:
Job Site Address: Ahklh�j A f- At 4^ A, -J 4- v- City/State/Zip: 0*1 q
Attach a cop), of the workers' compens2tion policy declaration page (showing the policy iriumber and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the h-riposition of criminal penalties of a
fine tip to S1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORX ORDER and a fine
of tip to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do herely certify iinder thepains andpenallies ofpeijuiy that the information provided above is true and correct
Phone#:
0 Official iise only. Do not write in this area, to be completed by cio; oi- lown official.
J_ "s,
c CiIN17 or- Town: Perm it[Liceflse
1 3
onl
y. Do no"
ority (cir
[rlsciting Authority (circle one):
--It _ ! - o
I LBo�aard of Health 2. Building Department 3. Cits,/Tovai Clerk 4. Electric2l Inspector- 5. Plumbing Inspector
o
6. Other
01.
-son:
cont2ct Pei Phone
�e Ers I
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. . . . . . . . . . r -A 1'.
m
"AND `GA T
PLUhBE`#-t'--'^ S
S- T,
SUES THE FOLLO
Is O'k 'i
L I -AS A J.OURNEY14AN Pl-Oft
BLUE91:7110- LANE
- IN
Commonwealth of Massachusetts
Department of Public Safety
Hoisting Engineer
License: HE -110323
PETER G VIENS-� ...
9 BLUEBI RD
4�'
ATKINSON NT03VFIIOII
954� Expiration:
Commissioner 11/1312015
State ofj
GAS FITTERS
NAME: PETER V
f
01.
ENDORSEMENTS
DATEISSUED: 1
.,�,Hampshire
I TP
2013
DATE EXPIRES: 1*1130/2015
LICENSE #:GFE0700587
1,certify that I have exami I' 1/ 4-" 1 F
ordance with the FederaMo - (
in acc ror Carrier Safety FVguI1i.ns-(,tg.11.41-391.49) and with knowledge
of the driving duties, I find this person Is qualified; and, if applicable, only when:
D wearing corrective lenses E] driving within an exempt intracity zone (49 CFR 391.62)
[I wearing hearing aid El accompanied by a Skill Performance Evaluation Certificate . (SPE)
C1 accompanied by a El qualified by operation of 49 CFR 391.64
warver/exemption
The information I have provided regarding this physical examination is true and complete. A complete examination
form with anv attachment embodies mv findings completely and correctly, arid is on file in my office.
-91GN—ATURE OF MEDICAL EXAMINER
Tj,�EP
V
0
DATE
ME91tAL EXAMINER'S NAME (PRINT)
El MD
I] Chiropractor
qqe-
ODO
dvanced
Xl�
Practice Nurse
MEDICAL EXAMINER'S LICENSE OR CERTIFICATE NO.
ISSUING STATE
0 Physician
Assistant
El Other
Practitioner
NATIONAL REGISTRY NO.
14—
le—�j
—
SIGNAT;U�R�07FIVER
I
CDL
YES AeNO
IRIVER'S LICENSE NO.
STATE
N
ADDRESS OF DRIVER 6 at.
it V)
la&.t�L16=te �
MEDICAL CERTIFICATION EXPIRATION DATE
0/i/X�'R
PLY 1 DRIVER PLY 2 MOTdR CARRIER
26520 (5/13)
,9,,,G0MMV.NWLALUn..vr
PDRIIIIIIII
L! -A
Commonwealth of Massachusetts
Department of Public Safety
Pipefitter Journeyman
License: PJ -028388
PETER G VIENS
9 BLUEBIRD Lt-�,r-
ATKINSON NH-,038fi
14
ti, nll�
Expiration:
Commissioner 11/13/2015
STATE OF NEW HAMPSHIRE
BUREAU OF BUILDING SAFETY & CONSTRUCTION
PLUMBING SAFETY SECTION
NAME: PETER QVIENS
LIC #: 3249 M
EXPIRES: 11/30/2014
AZ� "Y E E FZ
Peter Viens
Cert # 1023121001-12
Expires: 10/23/2015
Certification
N.F.P.A. 99-2012 ed.
ASSE 6010 Installer & ASME IX Brazer
�OSHA 600316337 40
US. DeWr-r'v - t LabiW-
-1 . qn of
Occupational Safety and Health Administration
Toter Viens
has successfully completed a 30 -hour Occupational Safety and Health
Training Course in
ConstructionSafety & Heafth
(TWAW qCwe 66873 7M/208)—
Date ... 71�1:5 . .....
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that p ..... 0 .... 6 .... e.�.p .... ...... ........
ve-
ha's permission for gas installation ........
in the buildings of .......... 7;.�/
........................................................................................................
at - C>2
..................................... ........................ A? ...................... . North Andover, Mass.
Feeo-A= ....... Lic. No. 3
... ............ .....................................................................
GASINSPECTOR
Check#
110 041
il,
1�4T's
h�'
MASSACHUSETTS UNIFORM APPLICAT ION FOR A PERMIT TO PERFORM GAS FITTING WORK
CT Y MA DATE PERMIT #
1 7 1 f
JOBSITE ADDRESS OWNER'S NAME
G
-U-t—
A
OWNER ADDRESS 1,44e. _TEL
TYPEOR
OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDEN�4AL
PRINT
CLEARLY
NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO
APPLIANCES'l FLOORS- 8SM 1 2 4 J. 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
OAR
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
led Ra—
DRYER law—
FIREPLACE
FRYOLATOR
FURNACE —=a== Lii�m& am �Wl—ammam-.
GENERATOR
GRILLE
INFRARED HEAT ER
LABORATORY COCKS
MAKEUP AIR UNIT
.OVEN
POOL HEATER
ROOM / SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
liability Insurance its the MGL. Ch. 142 YES 'T—IN 0
I have a current policy or substantial equivalent which meets requirements of
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY -Z^ OTHER TYPE INDEMNITY BOND
OWNER'S INSURANCE WAIVER: �am aware that the licensee ggoes not have the insurance coverage required by Chapter 142 of the
Massachusetts General Lawt, andthat my signature on this perm it application Wivjs this requirem ent.
CHECK ONE ONLY: OWNER -- AGENT
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are a an accurate t a est of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in m Ila withAall P i ant provision of As
�P,:FUe
Massachusetts State Plumbing Cod and Chapter 142 of the General Laws.
T
11 �EmAm A A 10
PLUMBER-GASFITTER NAME LICENSE IAM-
IC4 E
MID ZMGF -- JP — JGF LPGI CORPORATION PARTNERSHIP LLC
COMPANY NAM ffi�JR4-AI)DRESS
CITY 81 -ATE z IF
FAX CELL E AIL An
1�4T's
h�'
lk
The Comwnweafth of Mosachusells
Deparownt of IndustrialAccidents
I Congress streetp suite 106
-2017
Boston, MA 02114
wwmass.govldla
%Vorkersl Compensation insui-ance Affidavit: Buflders/Contraftm/Ekdriciid&tumli�16%
TO BE FILED WITH THE PERMITTING AUTHORITY.
AwIlantInformadon Plem Print Ltg[bly
NaMe (BUsineW0rS&ftiZW0rAndiVjdUal): dJ-
L-:!�2 41 IM4 mrh::�
A&Ms: k 2) u ki Y^a ut- 4
Phone
Are yw an employer? Check the appropriate 0111,
1.01 am a amployer with . ** ' _.Pnployas(fuU.8�diorpart-drm).*
2Q1 am a Sol$ pr*Mr Or PmmhiP and have no cmPl0Yfts working for me in
any "Wity. (No Workers' comp. insurance required.)
3.JJ 1 am a homowna doing all work myself. (No workas'comp. insurance required.) '
4,[]l am a homeowtiff SAdwill be hiring coatnictors to conduct all work on my property. lwill
go= do Wl contractors either have workers' compensation insurance or are sole
proprietors with no employees.
SC31 am a general conuutor and I have hind the sub-contm=rs listed on the attached shoet.
�7! sib-comractors have employees and have workers' comp. insurance.;
±e am a corporation and its officas have exercised their right of exemption per MOL c.
ls2, #1(41 and we have no employees. [No workas' comp. insurance requimd.]
-W k-". A -
Type of project (required):
7. [3 Now construction
8. [] Remodeling
9. [3 Demolition
10 0 Building addition
11.[3 Electrical repairs or additions
12. [] Plumbing repairs or additions
13.rlRoof repairs
14.00ther
*Any qVH= do cheicks box #1 mug also fIll out the $94tion below showing their workers' compensation policy informatioti.
t Homwwacirs who submit ft affidavit indicating they are doing all work, and dw hire outside contracton must submit a ww affidavit indicaini; such
ti0xichacm did alldc dds box must attached an additional sheet showing the name of the sub -contractors and state whathior or not thm enducs have
=0&yM ffft obwwractors have employees, they must provide their workers'oomp. policy number.
I= MX #Nlploygr that bprolpift worken'conyiensadon insmrancefor noy enVloyees. Belowkikepolkyandjobsfte
wormal"
Insurance Company Name:
Policy # or Self -ins. Lie. #: Expiration Date:
Job Site Address& city/State/zip
Attach a copy ofthe workers' compensation policy declaration page (showing the policy number and expiration date�
Fail= to secure covqrage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500-00
J
and/or one -you imprisomog5 as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a
doy against to vioiat�r.,,,� popy%, of this statement may be forwarded to the Office of Investigations of the DIA for insurance
covelm verification.
correct
..0
offleW we only. Do not wrke in thk 4reA to be completed by city op town offleld
City or Town: Permit/License
Iming Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector & Plumbing Inspector
6. Other
Contact Person: Phone #:,
COMMONWEALTH OF MASSACHUaligm
24MM"litis Wm
PLUMBERS 91W%%F ITTERS
ISSUES THE FOLLOWING LICENSE
LICENSED AS A MASTER PLUMBER
ROBERT A SAMMATARO
8 DUNRAVEN RD
WINDHAM NH 03087-1263
.933.11 05/01/116 226084 lz�
' ��;m t!7--7
JOMMONWEAIZU OF JdAIS&OURSETTS
0
R;N7,! I Z Y2,7M 6 f 0-1 Q j �Ml N
BOARD OF
PLUMBERS AND GASFITTERS
ISSUES THE FOLLOWING LICE 'S'
RECISTERED AS A PLUMBING C ORP
ROBERT A SAMMATARO
ROBERT A SAMMATARO P&H. INC
8 DUNRAVEN RD
WINDHAM NH 03087-1263
2373 05/01/16
221168
Check # I ;- 4 (
2 4 4L 6
Building Inspector
Location ;2�
No. ire-_ Date
TOWN OF NORTH
ANDOVER
0
Certificate of Occupancy
$
CHU
Building/Frame Permit Fee
$
Foundation Permit Fee
$
Other Permit Fee
$
TOTAL
$
Check # I ;- 4 (
2 4 4L 6
Building Inspector
j
V 7 a M (M
Building Permit Number.. 2195 Date June,
1976
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 29 Mablin Avenue
MAY BE OCCUPIED AS a Dwelling & 2—ca�r garage u'rider
ACCOR ANCE,
WITH THE PROVISIONS OF, TH'E BUILDING BY-LAW AND SUCH OTHER kEGULATIONSAS
P
M AY A,- PLY.
Santina Failla
CERTIFICATEISSUED TO
M.
ADDRESS 29 M -l' 1jLn Avenue, North Andover, 14ass.
Building Inspector
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APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS.
PAGE 1
INSTRUCTIONS
SEE BOTH SIDES
PAGE I FILL OUT SECTIONS 1 3
LOT NO.
2 RECORD OF OWNERSHIP DATE
BOOK �PAGE
ZON E
SUB DIV. LOT NO.
ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING
LOCATION 4_ 4.A,.4
PURPOSE OF 13UILDING
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
OWNER'S NAME S'
NO. OF STORIES Ille- slgzE 4-3'x'e
OWNER'S ADDRESS 'v fop -ix- -
BASEMENT OR SLAB
ARCHITECT'S NAME
SIZE OF FLOOR TIMOBERS IST 2ND
3RD
BUILDER'S NAME
SPAN
DISTANCE TO NEAREST BUILDING
DIMENSIONS OF SILLS ',o_
DISTANCE FROM STREET
POSTS 3 x
DISTANCE FROM LOT LINES - SIDES REAR A 4,
GIRDERS
16 x
AREA OF LOT FRONTAGE
HEIGHT OF FOUNDATION t 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 LINEIVS,_
INSTRUCTIONS
SEE BOTH SIDES
PAGE I FILL OUT SECTIONS 1 3
PAGE 2 FILL OUT SECTIONS 1 12
ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
DATE FILF-D
SIGNATURE10F OWNER OR AUTHORIZEET AGENT
F E E
PERMIT GRANTED
��65' 19
If f
3 PROPER-'ry INFQAMATION
LAND COST
EST. BLDG. COST
EST. BLDG. COST PER S(4. FT.
EST. BLDG. COST PER ROOM
waillilgWAC PERMIT NO.
4 APPROVED BY
BOARD OF HEALTH
PLANNING BOARD
BOARD OF SELECTMEN
BUILDING INSPECTOR
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Location c,27
No. 16 Date
A- IRO—�RTh. TOWN OF NORTH ANDOVER
Certificate of Occupancy $
CH Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL s
Check #
17595
Building InspeP, r
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
RENO
APPLICATION TO CONSTRUCT REPAI VATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
wdvoswy
BUILDING PEFMT N1 JMBER: DATE ISSUED:
I- A L
SIGNATURE. /fawr/amoo6.
Building Commissi ne ns tor of Buildings Date ? -106 _dV
SECTION 1- SITE INFORMATION
1. 1 Property Address:
yc-
1.2 Assessors Map and Parcel Number:
Map Number Parcel Number
Li
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Area (so Frontage (tt)
1.6 BUILDING SETBACKS (ft)
Front Yard Side Yard
Rear Yard
RegWred Provide ReqWred— Provided
Repired Provided
1.7 Water Supply M.G.L.C.40. §"54) 1.5. Flood Zone Information:
Public 0 Private 0 Zone Outside Flood Zone 0
1.8 Sewerage Disposal System:
1 Municipal 0 On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record
ap,!� o,� r, (-� ( 7— U
Name (Print) Address for Service —:
Signature Telephone
t
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Licen;ed Construction Supervisor:
fn�
Address
Signature Telephone
Not Applicable 0
License Number
>
Expiration Date
3.2 RegWred Home Improvement Contractor
4'(— C— Lj 4
Not Applicable 0
Registration Number
Company Name
Address
�2
Expiration Date
SignatuE�L I Telephone
1 11
U0
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z
0
0
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90
0
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SECTION 4 - WORKERS COMPENSATION (MLG.L C 152 4 2506)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes ....... 0 No ....... 0
SECTION 5 Description o Proposed Work (check
qpplicable)
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:
SECTION 6 - ESTIMATED CONSTRUCTION
COSTS
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
OMCIAL"USE ONLY
1. Building
r7 (5�
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plurnbing
Building Permit fee (a) x (b)
26>
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
T
I, 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
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
NO. OF STORIES SIZE,
BASEMENT OR SLAB
SU -E OF FLOOR TINIBERS IST 2 ND 3 RD
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMFNSIONS OF GIRDERS
f fEIGHT OF FOUNDATION THICKNESS
SVE OF FOOTING X
MATERLAd, OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED 1-0 NATURAL GAS LINE
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North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of IVIGL c 40 S 54, a condition of Building Permit
Number is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by IVIGL
c 11, Sl 50 A.
The debris will be disposed of in:
C--224L
Location of Facility)
natWWof Permit Applicant
�3 Z)/ Oq . ,
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through. the Office of the Building Inspector
. .........
The Commonwealth of Massachusetts
(.0 Department ofIndustrial Accidents
Office ofinvestigations
4h
600 Washington Street, Floor
Boston, Mass. 02111
orkers' Compensation Insurance Affidavit: Building/Plumbin2/Electrical Contractors
ease
RgiblV"'.
name:
city �-U-7j-,3 �
State: zip: 01Y -�'4 phone# 9 149 — 5�'-
work site location (full address): Izvn 4,/
,J Z -
I am a homeowner performing all work myself Project Type: El New ConstructionE]Reinodel
I am a sole proprietor and have no one working in any capacity. El Building Addition
I am an employer providing workers' compensation for my employees working on this job.
company name: AC. 611 -t -
address: C>
ci tv: phone
D0IiCV #
LJ I am a sole proprietor, general contractor, or homeowner (circle oize) and have hired the -cctrit"ra,ci o-r-,slis^t' e'd
the following workers' compensation polices:
comDanv name:
address:
city: phone 4:
insurance,co. DAM#
7
Ck
company name:
address:
city: #:
insurance co. lDolicv #
Attac4Uadi:d6iia0S6 1)1f,� i
t4ri,�
p,
V
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or
one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of $100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby
aiii/penalties ofperjury that the information provided above is trite and correct.
Date S/ 3 -/ Y
Print name C A, ZA Phone# 9,7�
official use only do not write in this area to be completed by city or town official
city or
0 check if immediate response is required
contact person:
(revised Sept. 2003)
permit/license # ElBuilding Department
ElLicensing Board
ElSelectmen's Office
E]Health Department
phone ElOther
I
ZIR, IL IL co M F2) M M
.. . .. . .. . .. . . .. . .. .. . .. . . .. . .. .. .. . .. . . .. . .. .. . .. . (M M IN IE (D (D IF
Chimneys Residential & Commercial Roofing All Types Of
Siding CHIMNEYS POINTED -REBUILT -CAPPED Expert Masonry Work
-Roof
ass Toll Free F* Leaks Experts * Licensed & Insured
1 -800 -WAIT -4 -US M Locally Owned & Operated Since 1976 ........ t License #034200
(924-8481) IKO VZozw or 9ohw Ml_ We Work Year Round
9
Proposal Submitted
844�1
Phone
?V-6alc)6�
Date
I
Street I
(99 A1171q-66120 V_C�
Job Name
City, State & Zip Code j.
4
Job Location
b Phone
We Propose hereby to furnish and labor in accordance with specifications below, for the sum of -
Dollars ($ IA& IQ)
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:
low involving extra costs will be executed only upon written orders, and will become an I V
extra charge over and above the estimate. All agreements contingent upon strikes, accidents
or delays beyond our control, Owner to carry fire, tornado and other necessary insurance. NOTE: This proposal may be
fully Workmen's withdrawn by us if not accepted within days.
Our workers are covered by Compensation Insurance.
We hereby submit specifications and estimates for:
let, 4 /q, 1-d
0/1'nstall 3 feet "Eave Seal"
of special ice and water barrier protection along all bottom edges of roof
and top to bottom in each valley. I 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 )perlinearft.
or( 6 )per sheet of plywood.
U(Install heavy gauge aluminum drip edges along every edge surface of each roofline
Z�/a, r
E(Cover entire roof (s) with IKO 25 year all asphalt, non -fiberglass, premium grade shi ngles
(Color of choice). cLd0-e_j CA~41,G�7 6� 94
dReplace all pipe boots where possible.
61"S'eal all flashings with clear Geo -Cel sealant. No black tar unless previously applied.
0"Remove all work-related debris.
Ercontractor warrants roof against all leaks due to defects in his workmanship for 12 years under
normal circumstances.
&Local current references and proof of workman's compensation insurance gladly given.
(2)
�_eKRemarks: CY7 4-&JPITI C66aA /?,��6,t Q�
(3) CIVT -TC--,C-
Acceptance of Proposal - The above prices, specifications
and conditions are satisfactory and are hereby accepted.
-�7
r
You are authorized to do the k "a S ecified. Payment Signatu e.
will be made as outlined above
r
Date of Acceptance, Signature:
I
OR
y
a
1)
P OL -"
Lfm itr)0" .,
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