HomeMy WebLinkAboutMiscellaneous - 30 OAKES DRIVE 4/30/2018 (2)C)
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The Commonwealth ofMassachusetts
Department ofIndustrialAccidents
1 Congress Street, Suite 100
Boston, AM 02114-2 017
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectriciansIplumbers.
TO BE FILED WITH THE PEPJYHTTING AUTHORITY.
NaMe (Business/Organization/Individual):
Address:r_�.�_
City/State/Zip:
Are you an employer? Check &e appropnaie box:
Phone#: OK
ifIlarnaemployerwith - — ! employees (full and/or part-time).*
2.FJ I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3.FJ I am a homeowner doing all work myself. [No workers' comp..fi-isurance required.] t
4. F1 I am a homeowner and will be hiring contractors to conduct all work on my property. Iwill
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5.FJ I am a general contractor and I have hired t ' he sub -contractors listed on the attached sheet.
Thes'e sub -contractors fiav� er�ploye,e's and have workers' comp. insuranceJ
*f711W,e are a corporati n and its officers have exercised their right of 'exemption per MGL c.
.9 1 . ill 11 .
152, § 1(4), and we have no Fpploye�s. fN!D workers' comp. insurance required.]
Type of project (Tequired):
7. F1 New construction
8. El Remodeling
El Demolition
10 Building addition
11. E] Elect rical repairs or additions
12. FJ Plumbing repairs or additions
13 E] Ro 'of rep airs
14. E] Othbr
*Any applicantthat checks b6x#1 must also fill outthe section liclowshowing their workers' compensation policy inform.ation.
t lfomeowners,;�ho submit t�is affidavit indicating they are doing all work and then hire outside contractors must s0mit a new affidavit indicating such.
tContractors that check this box must -attached an additional sheet showing thq name of the sub -contractors and state whether or not, those entities have
employees. If the sub-cion6ci&s tave 6m`ploy*ees, icy' must provide their workers' comp. policy number.
lam an employer that is providing workers' compensation insuranceformy employees.' Below is thepolicy andjobsite
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' c . ompensation 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 hereby cerf* under th epainser4penalties ofperjury that th e information provided above is trqe and correct.
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. City/Town 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 hire,
expres's or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or' any two or more
of the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association 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 commonwealth 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 work until 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 the'boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and -phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLQ 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 Depaftment of Ifidustrial
Accidents fb� confirmation of insurance coverage. Also be sure to sign and date the aftidavit. The affidavit should
be returned to the city,or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you'are r6qu�ired to obtain a workers'
compensatioit'policy, please call the Department at the number listed below. Self-ib: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 pennit/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. A new 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 bum leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
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Date....
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ... 1 7—, c . ...........
.2'va
has permission to perform
wiring in the building of ..... ....................................
at ............ ........ 0. .......................... . North Andover, Mass.
Fee.. Lic. No. ......... P"." .....
ELEcrRICAL INSPECTOR
Check #
8267
J
I
Lommonwealth of Massachusetts Offici I Use 011-1y
Department of Fire Services Permit No. 92-67
-r 1
FOccupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS Elev. 110 3 —
�ev, 1/071
7
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massacbusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRW.DV DX OR TYPE ALL E&ORMA TION). Date:
City or Town of. NORTH ANDOVE-R- To the Ins ector q Wires:
r
---- ------------
By this application the undersigned]*ve-s ---t-i f —on to
noc- -1 --
or her intenti perform the electrical work described below.
Location (Street & Nun;�er) k"
Owner or Tenant YAt) �0 A -A. A^
Owner'sAddress
Telephone No.
Is this Permit in conjuncti wi h builling Perm—it? Yes No F-1
" t� I (Check Appropriate Box)
Purpose of Building WOe- J A d
I - ( V1- -- Utility Authorization No.
ExistingService 106 Amps (RW/Mhoits Overhead 0 Undgrd No. of Meters
New Service Amps volts Overhead Undgrd No. of Meten
Number of Feeders and Ampacity
Z
Location d N ture of Proposed Electrical Work: 11; ipl
P/
COM letiono thefollowin table may be waived b the Ins ector of Wires.
No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total
No. of Luminaire Outlets No. of Hot Tubs Transformers KVA
Generators KVA
No. of Luminaires
No. of Receptacle Outlets
No. of Switches --
No. of Ranges
No. of Waste Disposers
iNo. of Dishwashers
No. of Dryers
No. of a er
Heaters KW
No. Hydromassage Bathtubs
OTHER:
Swimming Pool Above
d.
No. of Oil Burners
No. of Gas Burners
No. of Air Cond. NEU--
Tons
Jur-mr UMP I I'N um
To Is- - ...Rber- Ton.s
Space/Area Heating KW
Heating Appliances KW
No. of No. ot
Signs Ballasts
No. of Motors Total HP
ALARIMS INo. of Zones
Of Alerting Devices
11 C`=cpt 0 other
Lo. -of bei
A Wiring:
No. of De,%
of Devices or
Estimated Value of Electrical Work --fl Attach additional detail if desired, or as required by the Inspector of Wz7r-e-s.
/M - - ('When required by municipal policy.)
Work to Start: 7-,� Inspections to be requested in accordance 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
under -signed certifies that such coverage is in force, and has exhibited proof of same to the permit issuing ofnce..
CHECK ONE: INSURANCE 0 BOND F-1 OTHER 0 (Specff�.-)
]"cm*fy, under the,"ns !qdpenaldes aClyrjur
F1RM NAO i y, that the information On this application is true and complete.
M- "n r A LIC. NO.:
Licensee:
(If applicabl Signature
e� filer exemvt in the Jicense pumber 1z;01 LIC. NO.-3j��114
Address: Le9 (e, A s. Tel. No.
*Per M.G.L c. 147, s. 57-61, security *efrk requires D AkLelv--� t. Tel. No.��
epartment of Public Safety I'S License: Lic
OWNER'S INSURANCE WAATR: I am aware that the Licensee does not have the liability ins . No.
required by law. By my signature below, I here . by waive this requirement I am the (c urance coverage normally
Owner/Agent heck one) 0 owner M owner's agent
Signature Telephone No. PERMT FEE: S
PY/A
qp64-9A
eq�Z ;7-;�,o- e§ PV
0 + - e - ?-25- - 0 B Az,,,P-
Vill
1 VU
The Conumnwea&k of Ajossachusetir
D epartnte nr of In dustrial A ccidents
QJf1ce of Investigations
600 Wzwkinoton Street
1,
Bovton, MA 02111
. 0 . www-nwssgov1dia
Workers, COMPensation Inskrance Affidavit-. Builders/ContmctorslMectrician
Rolicant Information 9/Plumbers
Plea fhh
�e Print Lem
NaM'e fRmin&_qdr) . � I ' A -A,-_
Ad&ess:'j0()
City/State/Zip-_&_&TY_)
�7c_
Phone k-
27 5 99q
Are you an employer? Check�l�e appropriate box:
.l.al'arnatmPloyerwith q
4. 1 am IL general contractor and I
employees (full and/or part-time).*
2. [3.1 am,asole proprietor or
have himd the sub -contractors
listed
partner_
an the attached sheet
ship and have no employees
7bese suj�_contractors have
working f6r me in any capacity.
[No workers' comp. insurance
workems' comp. insurance..
5. We
are a corporation and its
required.)
3, 1 am a homeowner doing
officems have exercised their
all work
right of exemption per MCM
MYse1E [No-workers'comp.
C. - L5Z § 1(4),'and we have no
insurance required.) t
employees, [No workers'
COMP. insurance rei3uhd-1
Type Of Preject (required):
6. New construction
7. Remodeling
9. Demolition
9. Building addition
10. Electrical repairs or additions
I 1 -11 Plumbing repairs or addifions
12. koof repairs.
1317 Other
*Any applicant that checks boie # I MUM RISD f9l out the seetion beioW C their worked' compensation I policy in . formatiotL
T HomeownOn who submit this alffidavit indicati
'Contractors that chcok this bo I ng they art doing R11 wO* and then hire -outside contructon must submit a new affidavit indicating such.
K Must &=Chad an additional sheet showing the: munc of fie sub_m� and their work=' COMP. Policy infDMIdliaft.
am an emplo
.per j*ai.js.prqvidj,
inforwzadom in workers'COMperzsadoninsuranceforngenployeeL Below iS. the peficy andjob *e
7 k (\ I
insurance Company Nam
Policy 9 or Self -ins. Lie.. #: ExPirlition Date:
Job Site Address city/statezip
_-A-4 -4 ��
Attach a copy of the workerst com tion poll &Z:4�e 4 .
Penn . . cy declaration page (showing the policy number and expiration date�
Failure to secure coverage as required under Sextion 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 R STOP W0RK ORDER and a fine
of up to $250.00 a day against the vioiatDr. Be advised that a C.
investigations of the DIA for insurance coverage verification. OPY Of this statement may be forwarded to the Office of
I do hereby th
Pam= p I en OfPerjurYXhar the informafion oWded above is true and corre
Pr
Date. -
"hone 4:
12
Offichd use only. Do not wrile Mi thk area I , it be
conrleted by do or town official
City or Town: ---------- Permit/License 9
Issuing Authority (circle one):
1. Board Of Health 2_ Building Department 3. CitY/Town Clerk 4. Electrical Inspector 5. Plumbina
6. Other Inspector
Contact Person:
Phone #:
Information. and Instructions
Massachusetts General Laws chapter 152 requires all emp I oyers to provide wor* ken' compensation for their employees.
Pursuant to this statute, an enployee is defined as "...evcr_v person in the service of another under any contract of hire,
express or implied, oral or writt="
An employer is defined as "an individual, partnership, assaidiation, corporation or other logal entity, or any two ormore
of the'fantgoing engaged in ajoint enterprise, and including the legal mprftcritatives of a deceased employer, or the
receiver or trUStCe 'of an individual, partnership, association or other legal entity, employing employees. 'However the
owner. of a dwelling house having not more than thr= apaxtmants and who resides thereK or the occupant of the
dwelling house of another who employs persons to do ma-intarmce, construction or repair w&k on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be dcemed to be an employer."
MGL chapter 152, PC(6) also states *mt 'every state oir local fic6using agency shall withhold the issuance or
renewal of a license or permit to operate a busmiess or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence.of compliance wilth the insumnce coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither t3he commanwe� nor any of its political subdivisions shall
enter into any contract for the pcifornmee of public work until -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 complotely, by checking the boxes that apply to your situation and, if
ri=essary, supply sub-contradtir(s) name(s), address(es) Emd phone number(s) along with their certificate(s)'of
insumnee. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' corripensation insurance. If an LLC. or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accident for confmation of insurance coverage.. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city. or town that the application for the pe m*it or license is being requested, not'the Department of
industrial Accidents. Should you have any questions regm-ding the law or if you.we requirted to obtain a workers!
compensation policy, plzastcall the Delmirtment at the-nurnber listed below. Self-insured companies should enterther
self-insuranc'e'licenst ziumber on ffie'approjoriate. li=.
City or Town Officinis
Please be sure that the affidavit is complete and printed legibly. The Department his provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to cont= you regarding the applicant
Pie= be sure to fill in the parnittlicense number which will be used as a reference number. In addition, an a0plicant
that. in ust submit multiple permitAicanse applications in any given yW, need only submit one affidavit indicatiripcurrertt
policy information (if necmary) and under "Job Site Address" the applicant should write "all locations in city or
town)." A copy ofthe affidavit that has been officially starnped or marked by the cit y or'town may be provided to the
applicant as proof that a valid affida,& is on file for futum permits or licenses. A new affidavit must be filled out each
yew. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
0-C. EL dog license of permit to burn leaves etc.) said person is NOT required to complete this affida-A
The Offica of Investigations would Itle to thank 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, Wephone and. fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Mee of Investiggations
600 Wadiington Str�et
Bosion., MA 0211*1
TeL # 617-7274900 6xt 406 or 1-977-MASSAFF-
P.evised 5-26-05 Fax # 617-727-7744
wwwman.gov/dia
Date .... z
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies ........................
has permission to perform ...............
plumbing yinhe buildings of
...............................
......... .......... North Andover, Mass.
Fee'4��. Lic. Nor)'�
OLUMBIN6,11Y P'ECTOR
Check # -3901 L/ L�
7792
MASSACHUSETTS UNIFORNI APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOvER, MASSACHUS=S
D
Building Location. k,� Owners Name
Amount C
Type of Occupancv
New RenovationNVPD Replacement Plans Submitted Yes No
. 1:1 11
(Print or type) I
j4agk-_o�e: Certificate
Installing Company Name 14��ZA
Partner.
Firm/Co.
Name of Licensed Plumber:
Insurance Coveracre: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of I indemnity Bond F1
Insurance Waiver: L the undersigned, have been made aware that
three insurance the licensee of this ' application does not have any one of the above
Signature — owner
I hereby certify that all of the details and information I have subm�*i
best of my knowledge and that all plumbing work and ins
compliance with all pertinent provisions of the Massac US S
By:
bign re 0�'Ljomse
Title 5�f Plumbb
r
City/Town P2- 1�0
1,APPROVED (omm usE oNLY T7;enSt114UMDtr —
0 Agent ri
ted (or entered) in above application are true and accurate to the
?erformqdAtrrffe?Pqrmit Issued for this application will be in
5W"6I-ng Cyfe-�OCtapter 142 of the General Laws.
Master C17 Journeyman
Location
e -
N o%' Date
ft
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Iry
Other Permit Fee,/�,,- $
Sewer Connection Fee $ --------------
Water Connection Fee $
'49
TOTAL $
Building ln���
Div. Public Works
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Castricone Roofing & Siding E W "
-\kj
REPAIRS FREE ESTIMATES
Telephone (978) 682-4266
MARIO CASTRICONE
31 Court Street, North Andover, Mass. 01845
I/we, the owner (s) of the premises mentioned below, hereby contract with and authorize you as contractor, to furnish all necessary
materials, labor and workmanship, to install, construct and place the improvements according to the following specifications, terms and
conditions, on.Dremis b low described:
...... ...
CKXJ1 . .........
Owner's Name ......... .............. ....... — .. .... ....... .. ........ ..... ......................... * ..... ....... ......
Job Address ..... In ....... �Q.C.—.. vi� �X r-�Ackao
... . .............. 0".&t ..... ...State ....... . ..... . ...............................
KIES SPECIFICATIONS
..... .......
.AdQ�
...........
. ....... ............
....... .... ........ . ........................ ...............
..........
....................................... ......................................
........... .. .. ....... . .......... ....... ....
................ ... . .. ......
\A
..........................
.............
..............
*IAA�� ..................
.... ... .... .
............ ..... .... ....
... ...............
....... ............................. .................................. ........ ji ........ V .................................. *** .................................................................... ....... ... ..................
....... ... . .. ........ y .... .......... ** ...... ............ .............. . t� ........ ....... . .. . . ............. ................
.. Ty . ........... ....... ................................................................................................................
i . .... .......... Q ................. . ...... ...
..... Y ... ................... .
V. .. ... ........ Y- C . . ................ ...............................................
........................................................................................................... . ..................................................... ... ......................................................................................
. ....................
Materials and labor to cost $ .... illcvl ........................... Payable e -.'y\.. .............................. and balance in ............
monthly installments of $ .......................................... each, payable on ........................................ day of each and every month thereafter until paid
in full ( .............. % charge per year is to be added to above cost of labor and materials and is included in monthly payments.)
Contractor will do all of said work in a good workmanlike manner.
Upon completion of above work, all undersigned agree to execute and deliver to contractor, their joint note in accordance with his (their) above obligation and a
completion as requested by the contractor. Upon refusal to do so, contractor may at its option declare the entire contract price or so much as then remains unpaid
immediately due and payable. It is agreed that if permitted by law contractor shall be paid by the owner(s), all reasonable costs, attorney fees and expenses, in
addition to the amount due and unpaid, that shall be incurred in enforcing the terms.and conditions of this contract and/or any lien in connection therewith.
It is further agreed that this contract may be assigned by contractor; and also that the obligations hereof shall bind and apply to their heirs, successors or estates
of the parties.
The undersigned warrant(s) that he is (they are) the owner(s) of the above mentioned premises and that legal title thereto stands of record in his (their) name(s).
PROVISO: This contract shall be void and of no effort if credit approved of owner(s) is refused.
There are no representations, guaranties or warranties, except such as may be herein incorporated, if any, nor any agreements collateral hereto, nor is this
contract dependent upon or subject to any conditions not herein stated. Any subsequent agreement in reference hereto shall be binding only if in writing and signed
by all parties.
Cover attic storage cleaning not included.
Receipt of a copy of this contract is hereby acknowledged, and it is further acknowledged by the undersigned that the foregoing provisions have been read and
the contents thereof understood and that no representation or agree mient not herein contained shall be binding upon the parties and that all of the agreements and
understandings of said parties are contained herein.
Owner or Owners are not responsible for Property Damage or Liability while job is in operation
IN WITNESS WHEREOF, the parties have hereunto signed their names this .................... X. ...day Ofo.. ... I ...... ..... ........
Accepted: ��Z'
Signed........ .. ... . .. .................. ..................
4: Owner
(OWNER HAS 3 DAYS IN WHICH TO CANCEL CONTRACT) &,)1_ #&--D -QR201-,�
Signed......................................................................................
Owner
.. .................. ......... .......................
....... Signed ...................................................... ..................
�— zw—�Clcp ....
Representative
4'
Location
� 2 -7
No.
Date
401tTpI
TOWN OF NORTH ANDOVER
-4
Certificate of Occupancy $ -
Building/Frame Permit Fee $ 2
S AC
#bundation Permit Fee $
Othe� Permi,t,F,ee $
Sewer Connect , ion Fee $
Water Connection Fee $
TOTAL $ -024 L)
4i -I.
Building IrTspector
Div. Public Works
PE:Rlfff N(�..
1
P/
APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1
MAP +40.
"Ilk
ZON E
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
DATE FILED hIA-Y 2-1
1 -7 ra4cf-,
SIGNATURE OF OWNER OR AUTHORIZED AGENTV
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WL&A4,311 9
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CONTR. TEL.
CONTR. LIC.
3 PROPERTY INFORMATION
LAND COST
EST. BLDG. COST
EST. BLDG. COST PER SQ. IrT.
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO. ly A ,
4 APPROVED BY
BOARD OF HEALTH
PLANNING BOARD
BOARD OF SELECTMEN
c5L
LOT NO.
2 RECORD OF OWNERSHIP IDATE
BOOK 'PAGE
SUB DIV. LOT NO.
LOCATION
30 Allzs
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PURPOSE OF BUILDING im-Nen AL.
6 0 KA
OWNER'S NAME
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NO. OF STORIES s lzk 2-4— Z
OWNER'S ADDRESS ; o 0,4i<es
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BASEMENT OR SLAB 5AS&14eN*r
ARCHITECT'S NAME c- 4L)4:!,K-
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SIZE OF FLOOR TIMBERS IST 2ND
3RD
BUILDER'S NAME J -AV '
AUZK6
SPAN --n
DIMENSIONS OF SILLS IV
DISTANCE TO NEAREST BUILDING
DISTANCE FROM STREET
POSTS
DISTANCE FROM LOT LINES - SIDES REAR 44
r
GIRDERS
AREA OF LOT q
FRONTAGE
3aa
HEIGHT OF FOUNDATION 0 THICKNESS
IS BUILDING NEW
SIZE OF FOOTING I, x
IS BUILDING ADDITION
MATERIAL OF CHIMNEY IR I c ic-
IS BUILDING ALTERATION
IS BUILDING ON SOLID OR FILLED LAND o
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 0
IS BUILDING CONNECTED TO NATURAL GAS LINE A
MAP +40.
"Ilk
ZON E
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
DATE FILED hIA-Y 2-1
1 -7 ra4cf-,
SIGNATURE OF OWNER OR AUTHORIZED AGENTV
pen
F E E w V� '!��
PERMIT GRANTEW*
WL&A4,311 9
G
OWNER TEL. #--
CONTR. TEL.
CONTR. LIC.
3 PROPERTY INFORMATION
LAND COST
EST. BLDG. COST
EST. BLDG. COST PER SQ. IrT.
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO. ly A ,
4 APPROVED BY
BOARD OF HEALTH
PLANNING BOARD
BOARD OF SELECTMEN
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FORM U
TOWN OF NORTH ANDOVER
LOT RELEASE FORM
SUBDIVISION
ASSESSORS MAP
SUBDIVISION LOT(S)
PERMANENT ADDRESS
STREET 0
8IGNED BY D.P.W.)
(A
APPLICANT ?Cu�
PHONE
DATE OF APPLICATION
1 I/Y(11
TOWN
USE BELOW THIS LINE
PLANNING BOARD
Y4LOzo"�
DATE
APPROVED
TOWA LANNER
DATE
REJECTED
CONSERVATION COMMISSION
Tlm-�ff
,oe
D4TE
APPROVED Le
CONSERVATION ADMIN.
/11'ATE
REJECTED
BOARD OF L
DATE APPROVED
HEALTH SiUITARXn DATE REJECIED
DEPARTMENT OF PUBLIC WORKS
DRIVEWAY PERMIT (+
SEWER/WATER CONNECTIONS
FIRE DEPT. kP_0tj I ke�, Smo
P 0 ) � �M�A I -� L,�e, 12, -TL-S
RECEIVED BY BUILDING INSPECT10N
DATE
Ar)fL—i
I r,%,o 4.,,,
1�
This form shall be signed by the agents of the Planning and Health Boards,
the Conservation Commission prior to the issuance of any building permits
for the subject lot. This form shall not releive the applicant from tile
compliance of any applicable Town requirement or Bylaw.
i's
CER TIFIED FOUNDA TION PL AN
LOCATED IN Ooi--riA 4,j -,Dv
SCALE.7"-- (.o' DATE.-_-* �,sg.
S L. GIL ES R. L. S.
LAWRENCEa NORTHANDOVER
5 AJ 1 -J 5 BA -J K..
.-rk's L -0-r is. �Ja-r �j F Fx- A.
Al
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THE
CERTIFY THAT OFFSETS SHOWN ARE FOR THE USE OF
OFFSETS SHOWN THE SUIL DING INSPECTOR O1VL Y, 8 SUCH
CONFORM TO THE USE IS FOR DETERMINATION OFZ01VING
ZONINGS Y L A W OF CONFORMITY OR NON CONFORMITY
WHEN TAKEN.
"/, -W
kOe) I (c e i&:T
lluet LO*f -
TOWN OF NORTH ANDOVER, MASSACHUSETTS
OFFICE OF
DIVISION OF FINANCE
120 MAIN STREET. 01845
KEVIN F. MAHONEY
FINANCE DIRECTOR
November 14, 1991
Mr. James V. Carroll
100 Johnnycake Road
North Andover, MA 01845
Dear Mr. Carroll:
f:C7
TELEPHONE 682-6483
Please be advised that check #278 issued by you on August
2e, 1991, in the amount of $27.50 has been returned by your bank
and cannot be redeposited.
Under Chapter 432 of the acts of 1989, Commonwealth of
Massachusetts General Laws Chapter 60, Section 57A, the PENALTY
FOR TENDERING AN INSUFFICIENT FUNDS CHECK AS PAYMENT FOR A
MUNICIPAL ASSESSMENT OR SERVICE is $25.00.
Please remit a bank check for $52.50 to the above address in
payment of this charge. If payment is not received within seven
(7) days, this matter will be referred to the North Andover
Police Department to issue a complaint.
Should you have any questions, Please call 682-6483,
extension 16.
Sincerely
Kevin F. Mahoney
Treasurer
V cc: R. Nicetta
Building Inspector
:L t, Gallagher
0. . ' Andover Police Dept.
NW151991 1�
JILDI NG DEPARTW
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