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HomeMy WebLinkAboutMiscellaneous - 3 WALKER ROAD 4/30/2018 (2)0 0 N LL M.M M (1)0 U (6 U C N CO C oo N Y U)W o 0 > O ZE p U Z _ OC � 0 0 a - U � c o Q CL F � O L co E O U. 0 U 'o Z F— N cu m U N t O G Y 0 E0 vi N Z W cn Q 0-1 o 0 Q cn > o 7 F o o M m N = z Q Q co E U z° E U o o L m :c N 0) 0 a-U)c Q U O (a � N cn m J a) Q p L • i U U z N • cn U- i M U I-- c U 3 ca T 0 N M January 14, 2016 Michael Winston & Associates, LLC Innovative Risk Specialists POB 10721 Bedford, New Hampshire 03110 Tel: 603-494-2366 - Fax: 888-306-8106 - E-mail: michaelwinston@comcast.net Building Commissioner/Building Inspector Board of Selectman/Board of Health 1600 Osgood St. Suite 2043 North Andover, MA 01845 RE: John Larkin POB 383 North Andover, MA 01845 Type of Loss: Frozen Pipes Date of Loss: Janauary 8, 2016 Policy: BP21040018 Claim number: BOP53927 Our File #: MW 16-024 Location of Loss: 3 Walker Road, Unit 4, North Andover, MA 01845 To whom it may concern: The above captioned clam has been made involving damages or destruction of property which may exceed $1,000.00 or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139B is appropriate, please direct it to the attention of the undersigned and include a reference to the captioned insured, location, policy number, date of loss, cause of loss and claim or file number. On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above via first class mail. Sincerely, Michael Winston Adjuster 11 Location 3 /I FR %fid v No 6 6Q Date ,.0 � TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ J�C14Us Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 97-5,.6 i 8538 v- qU Iga(C', Building inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REP RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: { DATE ISSUED: SIGNATURE: eC.J Building Commissionedln for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Fs" d 00P-3 Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Regaired Provided ReqWred Provided 1.7 Water Supply M.G.L.C.40. 34) 1.5. Flood Zone Infomntion: Public ❑ Private 0 Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ on Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT NO 2.1 Owner of Record R —OL FE S Name (Print) Address for Service I-�?8-�s�- �35a Signature Telephone 2 2 Owner of Record: 31i4w �g Name Print fAddress for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: License Number Address Expiration Date Signature Telephone 3.2 egistered Home Improement Contractor Not Applicable ❑ G Company Name Registration Number I,r G2CESi�� s AddreZ�& I & — > — O \o Expiration Date SiTelephone 00 M X z 0 v n rn 0 z LTi 90 0 r rn r 000015 az 0 SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 25c(6) 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 ...... X No ....... 0 SECTION 5 Description of Proposed Work check all appHeable New Construction ❑ Existing Building 0 Repair(s) 0 Alterations(s) y�Y Addition 0 Accessory Bldg. ❑ Demolition 0 Other ❑ Specify Brief Description of Proposed Work: 9 ko/_ g 6 SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed brmit applicant OFFICIAL USE ONLY 1. Building 2 Q J 7 (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction [ / 7 3 Plumbing Building Permit fee (a) x tbl y� 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION 10 BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Si nature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION property Hereby declare that the statements and information on the foregoing and belief ,as Owner/Authorized Agent of subject application are true and accurate, to the best of my knowledge Print Name Si attire of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIIJBERS 1' 2ND3RD SPAN DIN ENSIONS OF SILLS DI1vIENSIONS OF POSTS DEyIENSIONS OF GIRDERS 1-iEIGHT OF FOUNDATION - THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND _ IS BUILDING CONNECTED TO NATURAL GAS LINE l4� 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 c11,S150A. 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 A I AT-HOME Installed S5RVOCRE Siding and Windows SM Board of Building Regulations and Standards HOME IMJ?.ROVEMENT CONTRACTOR Registrations 126893 xpCrafion 83/2006 60Type. .Supplement Card j THE Home Depl f,4t HAp ie Semi/` 9l1NROEUN CHHfIJ,== f t 3200 COBB GALLERIA ,Y420 ".....J".. ALTANTA, GA 30339 Administrator .Proudly sold, furnished and installed by RMA Home Services, Inc., a Home Depot authorized contractor. 345 Greenwood St. Unit 2 • Worcester, MA 01607. 508-756-6686 • Fax 508-756-2859 • Toll Free 800-657-5182 „FROM KIMBLY FAX NO. : 6033629679 Aug. 21 2005 03:39PM P4 HOME IMPROVEMENT CONTRACT Sold, Fumished and Installe4 by: Branch Name. S%(i/U Date:A* THD At -Home Services, Inc. d/b/a The Home Depot At -Home Services fioyg 145A Greenwood Street, Worcester, MA 01607 Branch Number: I Job #: ? Toll Free (800) 657-$192; Fax: 508.754-2859 Federal IDM 7S-2698460 W- Uc s C 02039 Rl Cold t.iea 16427 Cr Lie# 5655:2, MA Home ImprovementContractor Reg. 0126893 Q Installation Addresat City r State Zip Home Address: (If different from Installation Address) City State Zip Project InformadAq. I/We/You ("Purchaseel, the owners of the property located at the above installation address, offer to eonttact with home Depot U.S,A., Inc. (14ome Depot") to furnish, deliver and ammge for the installation of ail materials as dowfibed on the attached Spec Sheet #: , incorporated herein by reference and made a part hereof, Home Depot reserves the right to cancel this contract if,, upon ro-inspcctiou of the job. Home Depot determines that it cannot perform its obligations due to a structural problem with the home or because work required to complete the job was not included in the contract. DEPOSIT PAYMENT OPTIONS (Subject to fund verification and/or credit approval.) 1, Check, Cath1m Check or US Portal service Motmy Order (Made payable to The Home Depot). 2. Ctcdit Card* xWor other prym mt optica • Circle One gtlow Visa MsperCbrd Discover American Express The H6me lh@ot Horne Impr9veMent i Pen The Home Depot Credit Card Avallaelt Crealt: 9 , ( HIL & IMCC ONLY) Aoct#: 0" 96P. Date: Name *sitapp0monto+d:,.,,,,,f��S��QIiiC *Ry /oar cgnmne below. IAm agree to allow Home Depot to ehra.tht about re of it card the rrdicaud V1 °p 1 iii t HIL or HDCC Authori?xtion Codes Deposit Final Pa meat # 663 purchaser agrees that. immediately upon satisfactory completi n of tate work. Purchaser will execute a Completion Certificate ghlay any balance due. Purchaser also X=t to be'omfl d wally obli ted and liable hereunder. D ree /� 4 % z`t /�r S / 'G� n ht t � fit' E i nee a Thr and its attac lu i g any ng agreeme contain t e t o reetRant tween t e partes and Cart not be amended or modified unless in writing its a separate agreement signed by bot parties. NOTICE TO PURCHASER Do not sign this contract before yen read iL You are eatifl d to a eompktely fHled-in Mpy at the contract at the time you sign. Keepot it to protect your rights. Do not sign Completion Certitleate or agreement shfing i5at y” aft satbtkd with the entire project before this project b compleit LAW p�ibits ho®e repair coatraeton from n qu atiag or accepting a Completion Certi6tatt signed by the owner prior to the actust twmptetiou of the work to be performed under the contract. Yoa may cancel this iTsoxaetiad at any, time prior to midnight of the third batiaeu day after' the date of chit contract, See Notice of Cancellation ibr an expianatioa of this righ. There will be a service charge equal tp 25% or the contract amoaut if the job is cwocdkd by Purchaser AFTER the third bostatat 4ay, BY MY/OUR SIGNATURE BELOW, UWE AGREE TO BE BOUND BY THE TERMS Of TIjlS CONTRACT, UWE ACKNOWLEDGE RECEIPT OF A COPY OF THIS CONTRACT AND TWO COMPLETED COPIES Of THE NOTICE OF CANCELLATION. BY MY/OUR SIGNATURE BELOW, UWE UNMlIkSTAND THAT THE AGREEMENT IS SUBJECT TO REVIEW OF MYIOUR IREDrr HISTORY AND UWE AUTHORIZE HOME DEPOT AU HORIMI3 CONTRACTOR, To VF,R31-Y AND REVIEW MYJOUR CREDIT RECORD WITH AN INDEPENDENT CREDIT REPORTING AGENCY AND RELEASE. THEM FAOM ALL, LIABILITY INCURRED FROM INAD SSION lt ERRORS, DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK. SPACES. SUBMTI'1'6D BY: Date: c+� tent ACCEPTED BY: Data; e: n,rvnw,.r ' 140=8; ApomQXAL TERM& CONDTHONS AND WAaR NTIFS ARE STATED 0-1119 Rit'gRSF 51DE AND ARE PART OF TII15 CONTRACT White . aMUb File Yellow - C vW Me' Pian - Sales Coo v14-1 10-7-04 C -SC CONTRACT AMOUNT" S *LESS DEPOSIT $ BALANCE DUE ON COMPLETION $ Minimum 351/6 of Contract Amount due upon execution f this contrsct. lntlkate Payment Method For BALANCE DUE ON COMPLETION: DEPOSIT PAYMENT OPTIONS (Subject to fund verification and/or credit approval.) 1, Check, Cath1m Check or US Portal service Motmy Order (Made payable to The Home Depot). 2. Ctcdit Card* xWor other prym mt optica • Circle One gtlow Visa MsperCbrd Discover American Express The H6me lh@ot Horne Impr9veMent i Pen The Home Depot Credit Card Avallaelt Crealt: 9 , ( HIL & IMCC ONLY) Aoct#: 0" 96P. Date: Name *sitapp0monto+d:,.,,,,,f��S��QIiiC *Ry /oar cgnmne below. IAm agree to allow Home Depot to ehra.tht about re of it card the rrdicaud V1 °p 1 iii t HIL or HDCC Authori?xtion Codes Deposit Final Pa meat # 663 purchaser agrees that. immediately upon satisfactory completi n of tate work. Purchaser will execute a Completion Certificate ghlay any balance due. Purchaser also X=t to be'omfl d wally obli ted and liable hereunder. D ree /� 4 % z`t /�r S / 'G� n ht t � fit' E i nee a Thr and its attac lu i g any ng agreeme contain t e t o reetRant tween t e partes and Cart not be amended or modified unless in writing its a separate agreement signed by bot parties. NOTICE TO PURCHASER Do not sign this contract before yen read iL You are eatifl d to a eompktely fHled-in Mpy at the contract at the time you sign. Keepot it to protect your rights. Do not sign Completion Certitleate or agreement shfing i5at y” aft satbtkd with the entire project before this project b compleit LAW p�ibits ho®e repair coatraeton from n qu atiag or accepting a Completion Certi6tatt signed by the owner prior to the actust twmptetiou of the work to be performed under the contract. Yoa may cancel this iTsoxaetiad at any, time prior to midnight of the third batiaeu day after' the date of chit contract, See Notice of Cancellation ibr an expianatioa of this righ. There will be a service charge equal tp 25% or the contract amoaut if the job is cwocdkd by Purchaser AFTER the third bostatat 4ay, BY MY/OUR SIGNATURE BELOW, UWE AGREE TO BE BOUND BY THE TERMS Of TIjlS CONTRACT, UWE ACKNOWLEDGE RECEIPT OF A COPY OF THIS CONTRACT AND TWO COMPLETED COPIES Of THE NOTICE OF CANCELLATION. BY MY/OUR SIGNATURE BELOW, UWE UNMlIkSTAND THAT THE AGREEMENT IS SUBJECT TO REVIEW OF MYIOUR IREDrr HISTORY AND UWE AUTHORIZE HOME DEPOT AU HORIMI3 CONTRACTOR, To VF,R31-Y AND REVIEW MYJOUR CREDIT RECORD WITH AN INDEPENDENT CREDIT REPORTING AGENCY AND RELEASE. THEM FAOM ALL, LIABILITY INCURRED FROM INAD SSION lt ERRORS, DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK. SPACES. SUBMTI'1'6D BY: Date: c+� tent ACCEPTED BY: Data; e: n,rvnw,.r ' 140=8; ApomQXAL TERM& CONDTHONS AND WAaR NTIFS ARE STATED 0-1119 Rit'gRSF 51DE AND ARE PART OF TII15 CONTRACT White . aMUb File Yellow - C vW Me' Pian - Sales Coo v14-1 10-7-04 C -SC 11 cr) U-) L0 (Y') C\j .C\j !d W :3 SOW }z s n U-96392209 : 'o x ] k XZ 4j W— S I> : wodi ; 8 a rA W Cd 0 W o ;m o x c o� x A a v U w N U) cn Q a o w .o aG v � U � x w a a o 04 � w UM a w o w •� chi � w" x � 0�4 � w a w rA O � cn [ cn 0 W ;m o c o� 'ate CL= cccc m c �o m� O COL �M 3_ 0 _•� ,. m 3mc '' � o E IA om It 4 o y m3 co m � y O: _ y c y C O O 2 ca E m o L►aw� C, m _mm oo ac Olp c or- d y.C � m m caz oo d CC = o COL COD W C �r..�t t .... .y c •- W C H CLS Z LU 8,4D CD = w ` o O = aim � 0 W Date. 2 r TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .....�,1?ll. .`.................. . has permission to perform .....�!�! ...................... . plumbing in the buildings of . ................. at ............. North Andover, Mass. Fee. .....Lic. No.. . ...... .k..... . /�1......... PLUMBING INSPECTOR ' Check # 84u2 I I MASSACHUSETTS UNIFORM APPLICATION FOR.PERMIT TO DO PLUMBING (P int or Type Mass. }� _ - Dai 20Permit w �J New ❑ Renovation ❑ RP.-* _Type of Occupancy Replacemente FIXTURES Plans Submitted: Yes ❑ No D -SEPTIC # . Baa l nsta3ling Company Name f14Check ong: Certificate - ,ddress ❑ Corporation In ALH 0,31 p 1D d 3 U ❑ Partnership tusiness Tele hone L Jame of Licensed Plumber or Gas Fitter e INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL Ch. 142. Yes F/ Flo . D E If you have checkedyes• please indicate the type of coverage by checking the appropriate box. A liability insurance policy Other typeof indemnity ❑ Bond ❑ OWNER'S INSURNACE WAIVER: I am aware that the; licensee does not have the insurance coverage required by Chapter 942 of the Mass. General Laws, and that my signiiture on this permit application waives this requirement. Signature of Owner or Owner's Agent Check bne: Owner ❑ Agent ❑ hereby certify that all of the details and -information 1 have submitted entered) In above -application are true and accurate to the best of -y knowledge and that all plumbing work and installations performe nd r the permit iss for this application will be in compliance with .1 pertinent provisions of the Massachusetts State PlumSing Code a t 142 of the eral Laws. r' Avwp By 1 Si na ure of Licen ed lumber Tits: �� Ciry/Town I; Type of License: ID1IVlaster APPROVED (OFFICE USE ONLY) License Number ! ❑Journeyman ■ ■ l nsta3ling Company Name f14Check ong: Certificate - ,ddress ❑ Corporation In ALH 0,31 p 1D d 3 U ❑ Partnership tusiness Tele hone L Jame of Licensed Plumber or Gas Fitter e INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL Ch. 142. Yes F/ Flo . D E If you have checkedyes• please indicate the type of coverage by checking the appropriate box. A liability insurance policy Other typeof indemnity ❑ Bond ❑ OWNER'S INSURNACE WAIVER: I am aware that the; licensee does not have the insurance coverage required by Chapter 942 of the Mass. General Laws, and that my signiiture on this permit application waives this requirement. Signature of Owner or Owner's Agent Check bne: Owner ❑ Agent ❑ hereby certify that all of the details and -information 1 have submitted entered) In above -application are true and accurate to the best of -y knowledge and that all plumbing work and installations performe nd r the permit iss for this application will be in compliance with .1 pertinent provisions of the Massachusetts State PlumSing Code a t 142 of the eral Laws. r' Avwp By 1 Si na ure of Licen ed lumber Tits: �� Ciry/Town I; Type of License: ID1IVlaster APPROVED (OFFICE USE ONLY) License Number ! ❑Journeyman 'LOW Date. TOWN OF NORTH ANDOVER PERMM,FOR PLUMBING 7'7 o / This certifies that IP .... l ............................. has permission to perform .-:--:-7 � ........ plumbing in the buildings of .................. at ... ......... 77 North Andover, Mass. crs 1........ ....... Fee�. ..... Lic. No... . 3 PLUIM'S'l'. �N GI'NSPECTOR Check# 7473 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUM 13ING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location Of W/& --t7 Date D8 /3 07 Permit #�ct73 Amount New Renovation ❑ Replacement Plans Submitted Yes No L_J (Print or type) Check one: Certificate fInstalling Company Name o 4LLrV1f1,- F 11Corp. e�90� � Address /S 02r�iV /� R' � ❑Partner: Business Telephone7 G �'7 I.� r"�Co. Name ofLicensed Plumber. Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box Liability insurance policy ❑ Other type of indemnity 11 Bond ❑ Insurance Waiver I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations -peed under permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts hof the General Laws. r By: igna icens um er T e of Plumbing License Title 17; —,7/ City/Town icense N um er MasterJourneyman APPROVED (OFFICE USE ONLY Date. �/-- `t -0'(. . 00-5 TOWN OF N H ANDOVER 0 PERMI OR PLUMBING This certifies that .51A-1 ". A, � .'ry.`................... . has permission to perform .. ) ............................. plumbing in the buildings of C•L ............. at . . U�! f1. �/�..I�i�` . . �% ........... North Andover, Mass. Fee._?,?.—. . Lic. No. . ......... P MBING INSPECTOR Check # =ion 7 7055 MASSACHUSETTS UNIFORM APPLICATION FOR -PERMIT TO DO PLUMBING G�fJ (Print or ype) Mass. Da 2 Pe mit # 6 Building Location .Owner' a Type of Occupancy New ❑ Renovation ❑ Replacement(p/ Plans Submitted: Yes ❑ No ❑ FIXTURES B.P.-# SEWER # SEPTIC # z u, z Y Lr, cn z z F - Ile Ln tn Op z� Q w O~ z p LD to � w LU J to w to I = to H V W to u_ z - z CL U Z m _ to w LO >- ¢ F- to Y a a LL W O w Q Ln IY Q W to z a LL cn a O z z w u_Z) LLJ U S SUB-BSMT Q LLJ m o O BASEMENT 1ST FLOOR 2ND FLOOR -- 3RD FLOOR 4TH FLOOR-- STH FLOOR 9 6TH .FLOOR 7TH FLOOR 8TH FLO R nstalling Company Name Check ong: Certificate kddress s. Corporation 3usiness Telephone dame of Licensed Plumber or Gas Fitter ❑ Partnership ❑ Firm/C INSURANCE COVERAGE: I have a current 'ability insurance policy or its substantial equivalent, which meets the requirements of MGI -Ch. 142. Yes No . ❑ If you have checked es, please indicate the type of coverage by checking the appropriate box. A liability insurance polic)f— j Other tvna of inrior., ;f— n _ OWNER'S INSURNACE 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. Signature of Owner or Owner's Agent -iereby certify that all of the details and information I have submitte y knowledge and that all plumbing work and installations performe� I pertinent provisions of the Massachusetts State Plumbing Code a70 FTiti t yrlown i APPROVED (OFFICE USE ONLY) Check one: Owner ❑ Agent ❑ cation are true and accurate to the best of this application will be in compliance with Type of License: ZA s t e r ❑Journeyman License Number-- 7'n U,y S0 IZ TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVAT5 OR DEMOLISH A ONE OR TWO FAMILY DWELLING iC.te �. m1.2'3> .y '.'F. - `ki'tr a4.-- y � � '^�F —ya 3 � i ✓`� � � r BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioner/Inspector of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 3 W*lkc,v,- kd.4'11 ✓ oS3 0�l1 Map Number 'Parcel Number o. Ol�4S 1.3 Zoning Information: 1.4 Property Dimensions: C OnAO Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide ReqWred Provided ReqWred Provided 1.7 Water Supply M.GL.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2- PROPERTY OWNERSIIIPIAUTHORIZEDAGENT Historic District: Yes No 2.1 Owner of Record tit a,rK _3 Name (Print) Address for Service oY )�rD.Lk $ (,�q- Z06Z tQ . A" Aov-- `' a. dt 8LI5 Signa re Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: License Number Address Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ QNMA 46"A - Company Name Registration Number S�-. Mo,. o1601 3y5 �ce¢,rwoo� WoCC.eSU(-. 8.3 •oy Addre Expiration Date ,� _1 t -31 L Cel i) Signature Telephone T rn z O O z rn 90 O ae r rn r Z G) SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 & 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 buildin nnit. Signed affidavit Attached Yes ....... No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: V SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to befF`FICtAL Completed by permit applicant IISE.{?NLy 1. Building O O 3500 5 (a)»Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (e) X (b) O or 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 3 SOD Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I> , as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, P A,� ky ,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 � / P -'k V t4 Print Name Signature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TMERS 1 2ND 3RD SPAN DIMENSIONS OF SILLS DRAENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CH /INEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE s Location No. Check # 0 1j66i1 It Date =� TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Building Insp &qfo r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02 919 Workers' Compensation Insurance Affidavit Name Please Print Name: Location: _'�.. W * Kt, Glty ►y . persdloy-1-r Phone # 11701 689- 20 I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for rrly employees working on this job. ComRgpy name: Address_ Chit: Phone # Failure to secure coverage as required.. under Section 25A or MGL 152 can lead to the irnposifian of aiminal penalties of.a fine up to $1.500.00 and/or one years' imprisorurient_as_wa Las_coil4wnaltiesiolheiam d a—STOPYAORK-OFWJUndafineW-($I Dm)aidW--Kjoinstm, 1 understand that a copy of this statement may be\forwarded to the Office of Inws*jaWns of the DIA for coverage verification. / do hereby eertdy under Me 1 that the ir*mwtba provaled above is true and correct. rZI-Z Print Official use only do not write in this area to be completed by city or town offiaar A City or Town Permill:icensing � Building. Dept _ ©Check if immediate response is required I] LicenskV Board El Selectman's Office Contact Person. phone # L] Health Department Ei Other 0 NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-954 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 properly licensed solid waste disposal facility as defined by MGL Chapter 111, S 150 A. The debris will be disposed of in: W c.S (Location of Facility) MEMK11�21.1.,J��1111� -3 Q Signature of Permit Applicant I -S-0.3 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector f , 41 Date,! TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ... �. �` ... -�-t............... has permission to perform .... .. ...................... . plumbing in the buildings of ..C.I..- ? ........................ . at ....3.. .!?.`. ` ............ . North Andover, Mass. Fee.%.� ..'... Lic. No. J.v) c� 7. ......... .. ...... PLUMBING INSPECTOR Check # L� 5096 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (,Print or Type)) / br�h V • Mass. Gate /9///_20L_/Permit # ~0 ^E.l � Building LocatioZ 0-Whe r IM— Owner's Name -IL 1P r Telephone Type of Occupancy__L New 0 Renovation O Replacement T` Plans Submitted: Yes ❑ No U FIXTURES Check one: ❑ Corporation O Partnership Business Telephone �yc —�i5 4 S�%J�% X Frrnxo. Name of Licensed Plumber Cert)ficate INSURANCE COVERAGE: I have a curre• t liabiidy Insurance polity or its substantial equivalent which meets the requirements of MGI_ Ch. 142. Yes K ' No O If you have checked yes, please indicate the type coverage by checking the appropriate box A liability insurance policy 0 Other type of Indemnity O Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner 0 Agent O 1 hereby certify that all of the details and information I have submitted for entered) in above application are true and accurafls to the best of my knowledge and that all plurfibing work and installations performed under the permit iscu ►d for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the general taws. gnatuof cenPlumber / Ti _ Ue re City/Town Type of License: Master C] Journeyman ❑ 00 L License Number lo :3q I z z o A ►N- an J H o V< z z W W W Y A N} < • �' y O a N or � Q 0 H W y t- _� h V W N X< N � � 3 H X W cc 0 a Occ !- S W X. O 3r -1 9 .( W Y W Z 0 WO O 0 x4%W=< < 0 Z < C < O < H SUB—®SMT. BASEMENT IST FLOOR 2140 FLOOR SRO FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR aTHFLOOR Check one: ❑ Corporation O Partnership Business Telephone �yc —�i5 4 S�%J�% X Frrnxo. Name of Licensed Plumber Cert)ficate INSURANCE COVERAGE: I have a curre• t liabiidy Insurance polity or its substantial equivalent which meets the requirements of MGI_ Ch. 142. Yes K ' No O If you have checked yes, please indicate the type coverage by checking the appropriate box A liability insurance policy 0 Other type of Indemnity O Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner 0 Agent O 1 hereby certify that all of the details and information I have submitted for entered) in above application are true and accurafls to the best of my knowledge and that all plurfibing work and installations performed under the permit iscu ►d for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the general taws. gnatuof cenPlumber / Ti _ Ue re City/Town Type of License: Master C] Journeyman ❑ 00 L License Number lo :3q I XZZ ti 35SO Date..... )...� -j - o i ................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .......:..... has permission to perform ,: ...,:: �* ... wiring in the building of ......... ....-E�%c%............................................... at .......................................... � `�.�..�................... . North Andover, Mass. // Fee..l��.. ... Lic. No .............. ........ �r'.:�--�.rr.I,............... L / .BELE C'A'L INSPECTOR Check # it tr wfifv f ^'- '�-� �• �fcc-7�•ru� *���+t�e1r1 U111clul Use Only .Umarinwnl of }ira �aruicae Permit No. — (_:K��'t6 f BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked' [Rtv. 11/99) (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to he performed in accordance with the Nlassachuset s Electrical Code (MHC) 5-27 CNIR I3.00 (PLE:LSE PRINT IN INK OR "TYPE .'1!.L INFORM,11101V) Dnte: Jn�l City or 'Town of: A ►n �-h &)VP r To the Inspector of Wires: By this application the undersigned groes uottce of hs or- l�ileniton t )o perform the electrical work described below. Lucatiuu (StrI` eet .0 iull►her) .� l i�( .� Owner or -Tenant 4,11 Owner's Address (� Is this permit in conjunction Yvitlt n building permit" Purpose of Building; Existing Set•Ytcc New Service Yes No ❑ (Check Approprin(c Box) Utility Authorization No. \ntps / Volts Overhead ❑ Undgrd ❑ Anips oI(s Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: No. of (Meters No. of deters "", ur,u„ au,rca, or as required by the /nsi;ecfor of Waves. INSURANCE CO V1;1tAGE: Unless waived by the o\valcr, no permit fc r the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed op,. -ration" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited pro ,f of same to the permit issuing office. CHECKONE: iNSU2,�NCE ❑ BOND ❑ OTHER ❑ (Specify:1 Estimated Value of Electrical Work: (When requirm by nnnlici al olic \Vurk to Start: I cel-tifl-, urrdt•r 1-11" 1�IILA I N:\;lIE: , P P )•) (Expiration Date) luspections to be requested in accordal,ce with MEC Rule 10, and upon completion. Gins and pelrr Wes. of1jetfi ►•, that the information yr tlli application ix and complete. L:censcc: Sintl:tt LIC. NO.: (Ifapplicub wcr t, nrpi�,", •' h«nsc numbab line ) Address [� �')(lt( Ltl15l; l rnl� Bus. Tel. No.: "a[t.�t–IIJL — --I . + (rte V f X11 I. Tel. N o.. - OWNER'S lNSt�RA,'iCE NVAIVI,"R: I 3111 m awarc that the l icenscc doe. not have the liability insurance coverage normally required by la,x. 13v Inv siLtin Lme beluw, I hereby waive this requirement 1 3111 the (check onc) ❑ owner, ❑ owner's aernt. Siti11ntut'c I"ciclllnnlc \u" _._ PI.R,IfIT FLIT: S �3. �,•� w nc u„u,ving more urn$' be n•aived by Ilse fns rector o/fI'irrs. No. of Recessed Fixtures No. of Ceil.-Susp. (Paddle) Farts ! No. ° 'ota Transformers KVA Na of Lighting Outlets No. of glut Tubs Generators KNIA No. of Lighting Fixtures Swimming Poul Above ❑ Nn- ❑ ► o. o mergenc. ►g 1 1g1g rltd. r►d. BatteryUnits No. of Receptacle Outlets No. of Oil Burners FIRE ALAR11•IS No.. of Zoites No. of Switches No. of Gas Burners No. o etecttott and Initintin Devices No. of Ranges No. of Air Cond. Tons l No: of Alerting Devices No. of Waste Disposers Heat Purnp i,•uruber„ _. ons 170 . o e - nte onta Detection/Alerting Devices No. of Dishwashers Space/Area Fleating KW Local ❑ untctpa ❑Other Connection No. of Dryers Heating Appliances K1V ecurtySystems: No. of Vater No. o No. of No. of Devices or E uivalent Ilcat:t s K1V Signs Ballasts Uata Wiring: No. of Devices or Equivalent No. Hydrontnssane Bathtubs No. of Motors Total 1'i,, communtcattons NN it•tng: .tIP No. of Devices or Equivalent OTHER: "", ur,u„ au,rca, or as required by the /nsi;ecfor of Waves. INSURANCE CO V1;1tAGE: Unless waived by the o\valcr, no permit fc r the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed op,. -ration" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited pro ,f of same to the permit issuing office. CHECKONE: iNSU2,�NCE ❑ BOND ❑ OTHER ❑ (Specify:1 Estimated Value of Electrical Work: (When requirm by nnnlici al olic \Vurk to Start: I cel-tifl-, urrdt•r 1-11" 1�IILA I N:\;lIE: , P P )•) (Expiration Date) luspections to be requested in accordal,ce with MEC Rule 10, and upon completion. Gins and pelrr Wes. of1jetfi ►•, that the information yr tlli application ix and complete. L:censcc: Sintl:tt LIC. NO.: (Ifapplicub wcr t, nrpi�,", •' h«nsc numbab line ) Address [� �')(lt( Ltl15l; l rnl� Bus. Tel. No.: "a[t.�t–IIJL — --I . + (rte V f X11 I. Tel. N o.. - OWNER'S lNSt�RA,'iCE NVAIVI,"R: I 3111 m awarc that the l icenscc doe. not have the liability insurance coverage normally required by la,x. 13v Inv siLtin Lme beluw, I hereby waive this requirement 1 3111 the (check onc) ❑ owner, ❑ owner's aernt. Siti11ntut'c I"ciclllnnlc \u" _._ PI.R,IfIT FLIT: S �3.