HomeMy WebLinkAboutMiscellaneous - 30 LACY STREET 4/30/2018 (2)0 w
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TOWN OF NORTH ANDOVER
-----PtM�IT FOR PLUMBING
This certifies that
has permission to perform ... ................
plumbing in the buildings of .....................
- - .7. ��'
at ... .................... , North Andover, Mass.
Fee. Lic. No.. .......
APLUMBING INSPECTOR
Check #
6680
E -I
Date ... ........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ....... ..� 5��
........................ .................... .....
has permission to perf orm xvil/---"qI . . .....
wiring in the building of .... ................................
at ........
....... ........................... ............... . North Andover, Mass.
Lic. Nok//.2-1�/ ...
Fee. .............. .......... ili C ... NSP ..... R .................
Check # 17:7o-
7526
A
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No.
Occupancy and Fee Checked[09'J5 A.- 00
I[Rev. 1/071 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be perfonned in accordance with the Massachusetts Electrical Code (Mly), 527 CMR 12.00
(PLE,4 SE PRINT IN INK OR TYPEALL INFORMA TION) Date: -711-7/6 -7
City or Town of: NORTH ANDOVER To the Inspebo'r O'f Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) �,!J /—"f 6,�, S�,—
Owner or Tenant I�ILa;w &,�2 Telephone No.617%5-71-J-1�9
Owner's Address
Is this permit in conjunction with a building permit? Yes El No (Check Appropriate Box)
1 11/1
F urpose of Building t 7 Utility Authorization No.
I —
Existing Service 1,6Z) Amps ,P;Lo Volts Overhead Er Undgrd
New Service Amps I&Lz) 1,-2,2-6) Volts Overhead Undgrd
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
No. of Meters /
No. of Meters
Co lelion I �, , I.-
No. of Recessed Luminaires
L=- ... A
No. of Ceil.-Susp. (Paddle) Fans
—utc r1l"y — wul vifel by the inspector oj Pytres.
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above o In-
No. of Emergency Lighting
grnd. grnd.
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
INo. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiatin2 Devices
No. of Ranges
No. of Air Cond. Total
Tons 3
No. of Alerting Devices
No. of Waste Disposers
Heat Pu
Number
I Tons...
JKW
No. of Se-If--Co—ntained
Totals:
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
LocaIE:1 Mun'c'PP1 [:1 Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Water
No. of No -of—
No. of Devices or Equivalent
Heaters KW
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
[OTHER:
Attach additional detail Y -desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: -ZIJ — (When required by municipal policy.)
Work to Start: -711 7/J7__ Insp ections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE ICOVERAGE: 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 covefage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE V BOND 0 OTHER [] (Specify:)
I certify, under the pains andpenalties ofperjury, that the information on this application is true and complete.
FIRM NAME: LIC. NO.: All
Licensee: Sign iture LIC.
(Ifal)plicable, enter ex n the license nutn er ine.)
�Vipt i_ Bus. Tel. No.
Address _ Alt. Tel. No.;6/
*Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) [] owner 11 owner's agent.
Owner/Agent — — " I
Signature Telephone No. FPER7MIT FEE.- $
4/0'r
Re,d�q�,,
6 C-. ( ')
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
—� I —
Building Location
I
Owners Name 644'zw
Date
Permit#
91 Type of Occupancy A--5 /�000�/ ('4-L— Amount — 1:72 a-sle
New Renovation Replacement Plans Submitted Yes No
a . 1:1 0
FUTURES
(Print or type)
Installing Company Name. A7,0- Lj2j4a If, 91'"qAv
Check one: Certificate
Corp.
Partner.
Firm/Co.
Name of Licensed Plumber
Insurance Coverage: Indicatj& type of insurance coverage by checking the appropriate box:
Liability insurance policy 19 Other type of indemnity 0 Bond
Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner 11 Agent 1:1
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 installot d P i I pplication will be in
'Ons performed un Jer -e dss cd for this a
tpp I
s de 42
1
compliance with all pertinent provisions of the Massachu S te Plumbing C in
p ���e e eral Laws.
By: Signalure or Elconsea 'OV
T f Plumbil License
Title 7YOF
City/Town License Numoer Master Joumeyman4
APPROVED (oFwE USE orqLy
jv
62'12
Date .......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ......... ............ . ..... ...................... ?� .................... I
has permission to perform ...... ..... ............. .......
/ . ..............
wiring in the building f
.......................... .. ............. ... ..............
P 'Q RW/
at .... ........... . North Mdovei, Mass.
Fee .. .................. Lic. No. ..........
Check A 5-A ELEcrRICAL i�S'P"EC'TOR"
it -1 43:9
to " J iL 11 " ' 0 L *'� 1 .7 ' # # 'A
Perrni.t No.
Occupancy & Few Checked
AppuCAIIONFOR PERMITTO PERFORM ELECn?ICAL woRK
ALL WORKTO BE PERFORMED IN ACCORDANCEWUH THE MANACHUSMELECMICALCODE, 527 CmIt 112—.00
(pLEASE pRINT IN INK OR TYPE ALL INMRMAMON) Da
Town of North Andover To the Inspecto I Wires:
T'he undersiped applies for a permit to perform the electrical work described below.
Location (Street & Number) 5,�D S7 7
Owner or Tenant :S6 Aj�� i-1 C— A" T�> -T-0 �A
O*ner's Address
Ls this permit in conjunction with a building permit Yes[M No 0 (Check Appropritm BojL)
Purpose of Building
Utility Authorization No.
Exi3ting Service ... Amps
. . . L.Volts Overhead 9 UndergrourW No. of Meters
New Service Amps....L.Volts Overhead Underground No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work
ft of Usiming o0dws Ift of Hot TWo No. of Transbrnme TOW
rft of Ugams ru"Mme
'5-0, 00
QWUUMU% roun rum"
vound
rMou"W
No. of Receptscis Ou"
No. of ou Burners
No. of Ernerr;wt-joti-x Bel"
No. of Switch outlets
No. of Gas Burners
No. of Ranges 00
No. of Ak Cond.
ToNd
Tons
FIRE ALARM
No. of Dispossis
No. of Dishwashers
W
No. of Hem
ponys
Spece Arm Hewing
TOW
Tom
Total
Kw
Kw
No. of Deftcdon uW
Wdedne Devion
N& of SMURN DrAces
NO. Of SON Contained
No. of Dryers
Hewing Devices
Delecdon/Sou"M DrAces
LMW municipal
1:1 connectiom
I*, of W, He, I I I No. of
im Boilesis
No. Hydro Message Tube
W Of Moan
Total HP
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FIRMNAME
e -
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No. Of Zones
1612 YIN I�ND [D
Twulm, .., 'now oftwupby
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awmusMRANCEWAM*InmntmtdvLiondnmt do'
ardiligmylyancrithpMEM'611-1 d "W"aftliaghmal
(Pleasecheckone) Owner M ASM Te . lephone No. PERMrr FEE 2
Signalum or uwrdr or pig= — - I
L&MXnWW0FPEfflWS4FW Peradt NcL
B0AJtD0FF=PMVMWRB=AWMWGR,aW
I OccuPoxy & Fen ChmW
APPUCA77ONFORPERMITTOPEMORMELEcnz[CAL WORK
ALL W09A To BE PERFORMED IN ACCORDANCE WffH TM MASSACHUSSTS El-lXTRXAL CODE, 527 cmR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Daj.�L /6'
Town of North Andover To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number) '�3�D S7
owner or Tenant Z�cD C— A
Owner's Address M k=
Is this permit in conjunction with a budding permit Yes [:a NO [:3 (Check Appropride Box)
Purpose of Building i r-> iEF�� � k �— — � Utility Authorization No.
Exi3ting Service Amps /�Volta
Overhead Unilerground C3 No. of Meters
New Service Amps..../ .Volts Overhead Undeqpund C3 No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work -- V-�crcL-�L* k C) Q
No. of Llghft Outlft
Nm of Ho Tubs
No. of t��
Total
No, of Ughtird Flatwu
00 -7
Swbmdng Foot Abu"
)
13
Bebw
KVA
KVA
UQUA
growA
No. of Receptacle oudeft
No. of 011 Hunwe
No. of Lighti'll Jimmy Uiti
No. of Switch Outlets
<
No. of Gas Bamers
FIRE ALARMS No. of Zom
No. of Rmign op,4
NcL of Air Cond. Total
TOM
No. ofDaimcdoij uW
Nm of Disposals
N& of Had Total
Pumps
TOM
KW
laidating Deving
NO. of Smul" Davices
No. of Dishwashm
Spece Arm Heaft KW
ew
No. of Saff Cafthw
n -,, on)SOMMMM Onices
Local Mmicipal Ej
comactiew
Othw
No. of Dryan
Hoeft Devica KW
No. of Won Heaters Kw
No. Of Nm -d—
Simon
Bailside
No. Hydro Mauqp Tilis
N4L of bloom
Total HP
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OWrWSMJRANCEWAMRlummiateLizwdnmt dxja=aWMW(rjh&kWUW At Tel No,
(Please check one) 0wnW Agent E3 Te . lephone No,
aiignamm ol VWINFIr Of AgOlIff ...,PMWr FW
Location
No. Date
,40XT#j
TOWN OF NORTH ANDOVER
0 jajoijilfilk
16. AiffiwAik
4w
"WMW
Certificate of Occupancy
$
Building/Frame Permit Fee
$
Foundation Permit Fee
$
Other Permit Fee
$
TOTAL
s
Check #
18720
--Building lnspectqf�/
N
- _. . - - , 'T --*,- . .-. , I
1. 1 Property Address:
TOWN OF NORTH ANDOVER
1.2 Assessors Map and Parcel
Map Number
Number:
0,:S- 2—
Parcel Number
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAI$ RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
04
Frontage 4)
1.6 BUILDING SETBACKS (ft)
BUILDING PERMIT NU.11Br)
DATE ISSUED -
Front Yard
Side Yard
Rear Yard
SIGNATURE:
V
Building Cot�ssidner/IEWtor
of Buildings Date
- _. . - - , 'T --*,- . .-. , I
1. 1 Property Address:
1.2 Assessors Map and Parcel
Map Number
Number:
0,:S- 2—
Parcel Number
1.3 Zoning Information:
Zoning District Proposed Use
Property Dimensions:
Lot Area (sf)
Frontage 4)
1.6 BUILDING SETBACKS (ft)
Front Yard
Side Yard
Rear Yard
ReqWred Provide
R�red Provicw
Leg2ired
Provided
6)
1.7 Water Supply M.G.LC.40.
Public 0 Private D
1.5. Flood Zone Infonnation:
Zone Outside Flood Zone 0
1.8
Municipal
Sewerage Disposal System:
0 On Site Disposal System D
SECTION 2 -PROPERTY OWNERSIIIP/AUTHORIZED AGENT ----I
NtstorlcUfstrict-Y—es
No
.i or Kecora
Ixt 0- � i�-i , � � - . [ ( -- 30
-A�Ve (Print) Address for Servi&
-7
Signature Telephone
2.2 Owner of Record:
0 ox, n e 0 L ct c
Name Print iddre.s for Service:
SECTION 3 - CONSTRUCTION
I Licensed Construction Supervisor:
Licensed Construction Supervisor:
Address
Signature Telephone
3.2 Registered Home Improvement Contractor
Company Name
Address
Not Applicablebr
License Number
Expiration Date
Not Applicable 0
Regi _�on —Number
Expirati�n —Date
f
SECTION 4 - WORKERS COMPENSATION (MLG.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 ....... 0 No ....... 0
SECTION 5 Description of Proposed Work (check an applicabie
New Construction 0 1 Existing Building 0 1 Repair(s) 0 Alterations(s) Addition 0
Accessory Bldg. 0 Demolition 0 Other 11 Spj�cify
Brief Description of Proposed TVork:
-p- VL
I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I
Item Estimated Cost (Dollar) to be
Completed by permit applicani
OFVICIAL US9 ONLY
1. Building
? I I i
(a) Buildi g Permit Fee
Multiplier
2 Electrical
t r&�
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) x (b)
1� —
4 Mechanical (HVAC)
5 Fire Protection
6 Total (1+2+3+4+5) A:5-.
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMP�ETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR.BUILDING PERNUT
6 V�t 6L ?0'w' 4 1
as Owner/Authorized Agent of subject property
Hereby authorize '? f!:Jle r k -A P-4- A— to act on
My beha 1 all matter elative %ok honized by this building permit application.
VA z I A*u L t4 (+ -IC�PS-
KignatuTe`of6vner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
M4L as Owner/Authori7ed 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
0 AA, A-)
Print Name
oc�
SiLature of Owner/Apent Date
NO. OF STORIES SIZE
BASENIENT OR SLAB
SIZE OF FLOOR TDABERS I ST 2ND 3 RD
SPAN
DIMENSIONS OF SILLS
DWENSIONS OF POSTS
DMIENSIONS OF GIRDERS
HEIGHT OF FOUNDATION TIRCKNESS
SIZE OF FOOTING X
MATERIAL OF CHHVMY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
4q
9
IPUT
NAMI
TO:
From:
reter rLftnam
I I'l Rea 5trect
N. Andover, MA o 18+5
tel- (978) 685-6ZO8
email: 61cugateOcomcast.net
C o n t r a c t
Tom &JoAnne Farrill
3 o Lac,9 5t.
N. Andover, MA
Futnam Design
1 1 1 Kca,5t.
N. Andover, MA o 18+5
,5cptem6er22,2005
5COFE-OFWOK
1 - Renovate existing kitc6en including.
a) Kem ova I of existing kitcke n ca 6incts a nJ repla cc w itk new custom ca, 6inctrg.
Wall paper will 6c removed and walls prep pcJ and primed to accommodate new
ca6incts w6cre required.
$2,380
6) Tear out existing ceiling and replace wit6 new 6luc 6oarcl and smoot6 plaster.
c) Replace copper pipes in ceiling and plum6 new kitc6en and 6at6 fixtures (all
plum6ing related costs). Customer will provide all new fixtures in kitc6en and 6atk.
$3,2+5
J) Remove existing window a6ove sink and replace wit6 customer supplied 6ow
window. Construct roof for 6ow window wit6 asp6altskingles to matc6
residence. rinis6 interior and exterior accorclinglq- $1,800
c) Remove tile floor and retile wit6 customer provided tile and grout. Contactor will
provide tile ad6esive. $1)200
New -su6floor (if required). $ +60
0 install new recessed lig6ts in ceiling as required (up to 6 ca.), move electrical
outlets as required to accommodate new window, provide clectrical fcccl for new
stove and 6ang ceiling fan. All electrical requirements (except ceiling fan 6ut
including electrical permit) will 6c provided for b�q contractor.
$2,750
g) Futnaw Design will remove existing kitchen appliances (stove, refrigerator&
dishwasher) and install new appliances if required.
2- Kemodel 1/26atk on main floor including..
a) Kemove tile and retile with customer supp lied material. Contractor will provide
adhesive.
$ 500
6) Ke place 6atk room window with customer provided window. f inisk interior and
exterior according1,9-
$ 100
c) Flu m 6 new 6at6room sink and toilet. (Cost is included in kitchen detail.)
J) Dumpster Kental $ +00
ContractTotal $13,835
Futnam Design guarantees its workmanship for a period of up to onegear. However,
Futnam Design shall not 6c re5ponsi6le for ang pro6lem5 ari5ing out of or relating to defects
in manufacturers' products.
ncl
Note: Items not included in this contract are 6uilJing and plum6ing permit cosIn, final
paint. Allot6er costs are considered.
FAYMF—NT5CHF—DULF-
6 57b
I - One-third upon acceptance of this contract. , kk ) L4—Tb
Z- One-third after installation of ca6inet5ancl window, completion of rough C cectrLical iW02
rough plum6ing and kitchen ceiling.
5- One-tkircl upon completion of project. 3 Z�
FutnamDesign is a small compan,9 specializing in fine carpentrq and tilewor4LT6anL,9ou for
the opportunit.9 to provide services forgou.
5igned:
,5igned: -C> -
re er utnam/Autnam Design
Note: This drawing is an artistic
interpretation of the general appearance of
the design. It is not meant to be an exact
rendition.
!1'71,
20 "
Designed: 5/12/2005
Pri nted: 9/8/2005
BD45PARRML IBD45 PARRILL RESI�ENCE KIT 5-IL2-05-1-TDrawing #, I,
F 7
El El
El 0
El C]
Note: This drawing is an artistic
interpretation of the general appearance of
the design. It is not meant to be an exact
rendition.
!1'71,
20 "
Designed: 5/12/2005
Pri nted: 9/8/2005
BD45PARRML IBD45 PARRILL RESI�ENCE KIT 5-IL2-05-1-TDrawing #, I,
Note: This drawing is an artistic
interpretation ofthe general appearance of
the desigrL It is not meant to be an exact
rendition.
20 20 -,"2
TECHNOLOGIESU
Designed: 5/12/2005
Printed: 9/8/2005
BD45 PARRILL I BD45 PARMLL RESIDENCE KIT 5-12-05-1
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NORTH ANDOVER BUILDING DEPARTMENT
Tel: 978-689-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
at: -3 0 L -c- c -/ & -t , is that the debris resulting from this work shall be
disposed of im' a properly licensed solid waste disposal facility as defined by MGL
c 11, S 150 A.
Also, note Permits are required under Fire Prevention laws Chapter 148 Section
10A.
The debris will be disposed of in:
o f -j 9- VQA� b , �-z o r- jP-1D,-Q & h Ar
Fire Department Sign off-.
Dumpster Pennit
(Location of Facility)
Signature of Permit Applicant
Date
4�N
DI Department of InduaWd Accidents
Office of InvesrigmUns
600 Washington S&Cet
Bost014 M4 02111
kv wWw.mas&gov1d1a
. Workers" Compensadon Insurance Affidavit: Builders/Contractors/Electridanolumbers
ApipUcant Information Please Print Lerdbly
Name (Business/orguiaationtbdividuaw 7 k c, m,�j_ � H ,
— _14k
Address: 3 b L-ot��
I
City/State/Zip: N,) "Tk 6 V -0t , HA- 6 1.t� TPhone #:
Are you an employer? Check the, appropriate box: Type of project (required):
1. 0 1 am a employer with 4. 13 1 am 2 general contractor and 1 6. New construction
eMloycei (fall and/oTpart-time).* have hired tbc sub-com&aclm
2. CEf I am a sole proprietor or par=- listed on the attached sbeeL 7. Remodeling
ship and have no eirployces Ilese sub-contraClOrs have S. Demolition
working for me in any capacity. workers' con*. insurance. 9. Building addition
(No workers' comp. insurance 5. El We are a Corporation and its
required.] officers have exercised their 10-0 Electrical repairs or additions
3. 0 1 am a homeowner doing all work Tight of exemption per MGL I LO Plumbing repairs or additions
myself [No workers' cornp. C. 152, 11(4� and we have no 12.[:] Roof np,&g
insurance required.] t employees. [No wo*cn,
cww. hMU=ce reauire&1 13..[:] C)Mer
-Any NWKWAM6 %� G� VOIL M A MMM vano Tul am M lemon Below lmvftg ftk woltm I ompen"on Ucy in
t Hornwwom wim subma fte offideft oftaft 1hey am doing an wolk end then hire outode Po - fimmatiaw
tConvsclovs dw check du box me duched n eMbonal doet show" dw == of dw sobcon� subluft a new affidevit "cating such.
No hew wo*as, conv pormy tafmUntica
I am an employer d&W 6 pnmWns norkers ' compemadon IRSUFMCefOr my CMPARYM& Below Is dwpWky Madjob do
Informatim
Insurance Company Name:
Policy # or Self -ins. Lic. M
Expiration Date:
Job Site Address:-- city/stawaip:
Attack a copy of the workers' compensation policy declaradom Page (showing the Policy number and expiration date).
Failure to secure coverage as requiref under Section 25A of MGL c. 1*52 can lead to the hWsition of criminal penalties of a
fine up to S 1,500.00 =W�or one-year Imprisonmen% U wen 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 8 COPY Of this statement may be fbzwaTdcd tD die Office of
Investigations of the DIA for insurance coverage vMification.
Idoherebyeen*underthep", nd
a fPen Oer*rY thm the Infwmedon prvvMed abow Js &we md cotre"
signature: Z q ci-
Phone M
M
09kial use 0*. Do not wr*e In this area, to be complaed by e4 or mm o
.&igL
City or Town: Permlvucenu #
Inning Authority (circle one):
L Board of Heakh 2. Building Department 3. Ckytrown Clerk, 4. F
6. Other IecWcsl Inspector S. Plumbing Inspector
Contact Person: Phone*
o their emplo
Massachusetts General Laws chapter 152 requires all employers 10 Provide workers' cOmPmstiou f T yen'
an employee is deimed as "...every person in the service of another under my contract of hir%
Pursuant to this statuttv
express or implied, oral Or written-"
An empWer is defined as',n individual, partnership, association, corporation dr other legal entity, or any two or anote
of the foregoing capgod, in a joint enterprise, and including the legal representatives of a deceased employer, or the
recetver Or nustee of ali individual, partnership, association or other legal entity, employing employ=- HOwcvcf 60
owMT of a dwelling house having not more than three apartmentB and who resides therein, or the occupant of the
dwelling house of MOM 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 be deemed to be an enVloYcf."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the Issuance Or
renewal of a Hcelm or permit to operate a businm or to construct buildings In the commonwCAM for SnY
apPlicaut who bas not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neitber thecommonwcaft nor any of its political subdivisions shall
enter mtD my contract for die performance of public work until acceptable evidence of compliance with the inmuance:
requirements of this chapter have been presented to the contracting authority."
Applicants
please fill out the workers' mnpcnsation affidavit completely, by checking the boxes that apply 10 your situation and, if
necessary, supply sub-contractor(s) name(s), addms(es) and phone wmber(s) along with their certificate(s) of
insurance. Limited Li2bft COMp2nics (LLQ Or LimiW Liability Partnerships (LLP) with no employees other than the
Members Or partuerS, STC MM required 10 C8M WOTkCU' compensation insurance. If an LLC or LLP does have
a policy is roquhv& Be advised dial this affidavit may be submitted to the Department of Industrial
employees, g& . nre Mw A bould
Accidents for confirmation of insurance covera Also be to sign and date the affldavlL affida t s
or dw IM' mit or license is being request4 not the Department of
be TeMucd to the city Or town do 'he application f A
Indusmal Accidents. Should you have any questions regarding the law or if you arc required to obtam a workers'
conve=athn policy, pleaw call die Department at the mi P listed below Self-insured companies should enter theff
scif-ins�CCUCCON=W*aOnthc-------2
City or Town Offlclals
please be . sure that the affidavit is complete and printed lepbly. 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 reprding the applicauL
Flease be sure to fill in the permit/ficense number which will be used as a reference number. in addition, an applicant
4 .
that must submit multiple permi:t1license applications in any given yen, need only submit one affidavit indicating current
policy infbrmadon (if necessary) ad wmia -Job Site Aftm- die applicant should write "all locations is -(city Or
town)." A copy of the affidavit tb* has been officially sumbped or maAed by the city or town may be provided to the
applicant as proof &at a valid affilevit is on file for future 'permits or licenses. A new affidavit must be filled out each
yew. Where a home owner Or cid= is obtaining a licensi or permit not related to any business or commercial venture
(i.e. a dog license or Permit to bum leaves etc.) said person is NOT required to complete dds affidavit.
The Office of investigations would like to dumk you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a calL
The Department's address, telephone and fSK mmlbcr
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investlgatlo=
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406'or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-05 wwwjnau.gov/dia
D. Robert Nicetta,
Building Commissioner
Please vrint
TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
400 Osgood Street
North Andover, Massachusetts 0 1845
HOMEOWNER LICENSE EXEMPTION
DATE:- ), 4 — o c_+ - �_ qbs-
JOB LOCATION:—,S c,�Z a-�
Number Sdeet Address
HOMEOWNER —Qitf S_ 2-
Namd Home Phone
PRESENT MAILING ADDRESS 36 L&c-1 Sf,
Telephone (978) 688-95454
Fax (978) 688-9542
Map/Lot
9 -7r — q � q -6,?6_3
Work Phone
Nj)t_,rk_ Ae-�b�,jer -1A
V -
City Town State Zip Code
The current exemption for "homeowners" was extended to include owner -occupied dwellings to 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 HOMEOWNER
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 structures. A person who constructs more that one home in a two-year period shall not
be considered a homeowner.
The undersigned "homeowner" assumes responsibility for compliances 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 North Andover Building Department
minimum inspection procedures and requirements and that he/she will com I with said procedures and
I" com y
requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
BOARD OFAITHALS 688-9541 CONSERVATION 688-9530 HEALTH 689-9540 . I PLANNING 689-9535
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Location
No. 4:�:2 Date -ot
TOWN OF NORTH ANDOVER
Certificate of Occupancy $ — --
Building/Frame Permit Fee $ lc� C —
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # 9
t
Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
f6r: Offk ulk oily:
BUELDTNG PERNUT NUNMER: 1-2
1 DATE ISSUED:
SIGNATURE: 411
Building Comrrl-issioner/12�6tor of Buildings Date
SECTION I- SITE INFORMATION
1. 1 Property Address: 1.2 A--,s=ors Map and Parcel Number:
3 L,
Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning Di ct Proposed Use Lot Area (so Frontage (ft)
1.6 BUILDING SETBACKS (ft)
Front Yard Side Yard Rear Yard
Required Provide ReqWred Provided Reqwred Provided
1. 7 Water Supply M.G.L.C.40. 5 34) 1.5. Flood Zone Infornution: 1.8 Sewerage Disposal System:
Public 0 Prrvate 0 Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System S
SECTION 2 - PROPERTY OWNERSEEIP/AUTHOREED AGENT -7,
2.1 Owner of' Record 7-z5,.K?
7 3 S
AI/Z -L A2 12y, /`7 4 12111?, z Z, _Z
Name (Print) Address for Service
Signature Tele�hone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES 1
3.1 Licensed Construction Supervisor: Not Applicable 0
(770�—
Licensed Construction Supervisor:
License Number
Addres
7a ��2 Expiration Date
Signature Telephone
3.2 Registered Home Improvement Contractor Not Applicable 0
I+Z-Z-e,kl / o z9
Company Name Registration Number
�12 �-' Z�i W2- 41,4
Aqddress Z
1 /9 _C;l
9 7Z—�aFa7— �96 2E piration Date
Sipriature Teleplrone'
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I SECTION 4 - WORKERS COMEPENSATION (NLG.L C 152 � 2506) 1
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 applicable)
New Construction 0
Existing Building 0
Repair(s) 0
Alterations(s)
Addition 0
Accessory Bldg. 0
Demolition 0
Other 0 Specify
Brief Description of Proposed Work:
5 42—t (.19 Lk r . v-7
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k-rr /A�- 4,!2 si
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollar) to be
an
Completed by permit applic t
8')t 'Uj%-,L, Y"
4
1. Building
(a) Building Permit Fee
Multip ier
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 COMIPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUII-DING PERMIT 7
—J 72 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
b z4 d--72, as Owner/Authorized Agent of subject
property
Herebv declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
rin ame
C
Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TRVIBERS I ST 2 No 3RD
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FULED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
Town of North Andover tAORTk
0V .1"10 1
LO
Building Department 0
0
27 Charles Street
North Andover, Massachusetts 0 1845
(978) 688-9545 Fax. (978) 688-9542
TED
DEBRIS DISPOSAL FORM
In accordance with the provisions of MGL c 40 s 54, and a condition of
Building permit-# the debris resulting from the work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL cl *1, sl 56a.
The deb, ris will be disposed of in /at:
Z Z -
Facility location
Signature of Applicant
Date
NOTE: A demolition permit from the Town of North Andover must be obtained for thils
project through the Office of the Building Inspector.
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