HomeMy WebLinkAboutMiscellaneous - 30 PENNI LANE 4/30/201810
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North Andover Board of Assessors Public Access
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Summary
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s1roperty Record Card
Location: 30PENNILANE
Owner Name: SMITH, JOSEPH E
LYNN D SMITH
Owner Address: 30PENNILANE
City: NORTH ANDOVER State: MA Zip: 01845
Neighborhood: 7 - 7 Land Area: 1.13 acres
�Use Code: 101-SNGL-FAM-RES Total Finished Area: 2500 sqft
ASSESSMENTS CURRENT YEAR PREVIOUS YEAR
Total Value: 507,000 507,000
Building Value: 280,400 280,400
Land Value: 226,600 226,600
Market Land Value: 226,600
Chapter Land Value:
http://csc-ma.us/PROPAPP/display.do?linkld=1 896674&town=NandoverPubAcc 5/17/2012
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Liberty Mutual.
INSURANCE
March 10, 2015
Town of North Andover
Attn: Building Inspector
120 Main Street
North Andover, MA 01845
Liberty Mutual Insurance
New England Region Central Property Unit
75 Sylvan Street
Danvers, NM 01923
Tel: (800)566-0323
Re: Property Address: 30 Penni Lane, North Andover, Ma 01845
Policy Number: H3221812461812
Underwriting Company: Liberty Mutual Fire Insurance Company
Claim Number: 031478778-0001
Date of Loss: 2/18/2015
Attn: Town/City Official
Pursuant to M.G.L. c. 139, § 3B, please be aware that a homeowners insurance claim has been made
involving loss, damage or destruction of the above captioned property, which may either exceed
$1,000.00 or causes the condition of a building or other structure to render Mass. General Laws, Ch.
143, � 6 applicable. You are required to notify Liberty Mutual by certified mail in accordance with
Mass. General Laws Ch. 175, 599, if you intend to initiate proceedings designed to perfect a lien
pursuant to Mass. General Laws, Ch. 139, � 3A & B, or Mass. General Laws, Ch. 143, � 9, or Mass.
General Laws, Ch. 111, § 127B.
This letter should not be construed as a waiver or estoppel of any of the terms, conditions or
defenses afforded by the policy or applicable law.
Please direct your notice to the attention of the undersigned and include a reference to the above
captioned property address, policy number, claim number, and date of loss.
Sincerely,
Liberty Mutual Support
Liberty Mutual Insurance
New England Region Central Property Unit
1-800-566-0323
September 12,2014
Town of North Andover
Attn: Building Inspector
120 Main Street
North Andover, MA 01845
Liberty Mutual Insurance
New England Region Central Property Unit
75 Sylvan Street
Danvers, MA 01923
Tel: (800)566-0323
Re: Property Address: 30 Penni Lane, North Andover, Ma 01845
Policy Number: H3221812461812
Underwriting Company: Liberty Mutual Fire Insurance Company
Claim Number: 030515721-0001
Date of Loss: 8/3/2014
Attn: Town/City Official
Pursuant to M.G.L.. c. 139, � 313, please be aware that a homeowners insurance claim has been made
involving loss, damage or destruction of the above captioned property, which may either exceed
$1,000.00 or causes.the condition of a building or other structure to render Mass. General Laws, Ch.
143, � 6 applicable. You are required to notify Liberty Mutual by certified mail in accordance with
Mass. General Laws Ch. 175, �99, if you intend to initiate proceedings designed to perfect a lien
pursuant to Mass. General Laws, Ch. 139, � 3A & B, or Mass. General Laws, Ch. 143, 5 9, or Mass.
General Laws, Ch. 111, § 127B.
This letter should not be construed as a waiver or estoppel of any of the terms, conditions or
defenses afforded by the policy or applicable law.
Please direct your notice to the attention of the undersigned and include a reference to the above
captioned property address, policy number, claim number, and date of loss.
Sincerely,
Liberty Mutual Support
Liberty Mutual Insurance
New England Region Central Property Unit
1-800-566-0323
"ORT�"
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
Thiscertifiesth
haspermissionto ......................
------------------
wiring in the building of ..... . .. ....................................................
at .............................. ... �.�e .......... ............. North Anddver, Mass.
ic. Nort�.� ..............
Fee 4�P� ............. L
E LE"C'r
RICA'*L* IN**S'P'E**' O**R
Check
7962
411, Commonwealth of Massachusetts Official Use Only
MEW Department of Fire Services Permit No.-...
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code ( EC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL XFORMA TION) Date: /, �� a (J�'
City or Town oh NORTH ANDOVER To the Inspecto of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
R
2=/(t
Location (Street & Number) A1 1-111V
r Tenant J0 /_-_ 15r 11,A_ e Telephone No. qr7e-2 73-4aZ8
Owner's Address SA /-,4
Is this permit in conjunction w , th a building permit? Yes E] No (Check Appropriate Box)
Purpose of Building_ 7C/77__e__ Utility Authorization No.
Existing Service Amps Volts Overhead F -I ' UndgrdF_� No. of Meters
New ServiEe Amps Volts Overhead Undgrd No. -of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
/V/ &r e�e- r— 7,v -o, Z e�,, -c &
Coninletion of thp &IInwino, tnhlp mmy ho inniVedbu pho Im o�fnv niWi
No. of Recessed Luminaires 17
No. of Cefl.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets 7
No. of Hot Tubs
Generators KVA
No. of Luminaires )7
Swimming Pool Above o In- F�
grnd. grnd.
No. of Emergency Lighting
BatteEy Units
No. of Receptacle Outlets 4-1
No. of Off Burners
7�
FIRE ALARMS
lNo. of Zones
No. of Switches 4;7_
No. of . Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
I umb�r.fj�q!j�
F-- ... *
...........
J.KW ..........
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local E] gu—nicipal [I Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water
Heaters KW
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
I
Telecommunications Wirin
No. of Deviceq or Equivalent
OTHER: 54A -c— ee 5 r/ 4 C y
Estimated Value of lectr Attach additional detail if desired, or as required by the Inspector of Wires.
_ I ical Work: (When required by municipal policy.)
\7 -
Work to Start: 6,g�� Inspections 'to be requested in accordance with MEC Rule 10, and upon completion.
Z
INSURANCE OVERAGE: —Unless waived.by the owner, no permit for the performance of electrical work may issue uffless
the licensee provides proof of 1i bility ncluding "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such c e, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE OTHER F1 (Specify:)
IceyWft, under th�&ns andpenalties Qfperjury, thaofie in o atio on this application is "nd complete.
FIRM NAME: Z . IC. NO.: 2�2_ /A
;Z ;W�. I Of e
Licensee: Signaturel2reA%/�,-�_ LIC. NO.:L45 -4
(Ifapplicable, enter i - n the hcens� gnum er line.) A_1
Aus. Tel.
Address: Alt. Tel. No.:
*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) n owner wrier's agent.
El o
Owner/Agent
Signature Telephone No. E
FP7"IT FEE. $
R,f k C9 4, / - ?- z -- ae P-7
�,tjo f" (--'
The Commonwealth of Alassackusefts
Ile Department of Industrial Accidents
QJf1ce of Investigations
600 Washington Street
Boston, M4 02111
www.nzass.go v1dia
Workers' Compensation Imiwance Affidavit: Builders/Contraci
Name (Business/Organization/Individual):
Address:
City/State/Zip: 0 / e-4-1 Phone #: - 9 X�--Vz'
Are you an employer? Check the appropriate box:
1. D I am a employer with Z/0'
4. [1 1 am a general contractor and I
employees (full and/or par -time).*
2.[] 1 am asole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet I
ship and have no employees
These sub -contractors have
working for mein any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. We are a corporation and its
required.]
3. 1 am a homeowner doing all work
officers have exercised their
right of exemption per MGL
myself [No-worke'rs'comp.
c. 1.52, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insw-ance required.]
C
Type of project (required):
6. [] Ne construction
7. Wemodeiig
8. 0 Dernol ition
9. D Building addition
10 . &9leclrical repairs or additions
I 1 -0 Plumbing repairs or additions
12-EIRoof repairs
13.[] Other
-ftnY11PP11GRnT1natC11eCk9bo)[#1 must also fill out the section below showing their workers'6D:npensation policy informatiotL
I Homeowners who submit this affidavit indicating they am doing all work and then hire outside contractors must submit a new affidavit indicating such.
lcontmctors tiat check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. Policy information.
I am an employer that is prpriding workers I compensation insurancefor my employees, Below is the policy andjob site
information.
Insurance Company Name:
Policy # or Self -ins. Lie Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' . compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500-00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby c n thepains a dpen p Y
'66 that lite information provided abo e is true d correct
Date.- �6
Phone V/
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License 4,
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk
6. Other
4. Electrical Inspector 5. Plumbing Inspector
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,
express or implied, oral or written."
An employer is defined as "an individual�, partnership, assodiation, corporation or other legal entity, or any two or more
of the'foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
r6ceiver 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 w6rk on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MOL chapter 152, §25C(6) also states that "every i 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,ot compliance with the insurancecoverage 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 compliaince with the insurance
reqwrements 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 (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirtnation 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 permit or license is being requested, nofthe Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
Self' insurance license number on the'appropriate line,
City or Town Officiais
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 permittlicense 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 burn leaves etc.) said person is NOT required to complete this affidavit
The Office of Investiptions would like 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, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investiggations
600 Washington Street
Boston, MA 021-11
Tel. # 617-7274900 6xt 406 or 1-8.77-MASSAFE
Fax # 617-727-7744
Revised 5-26-05 www.mass.gov/dia
December 6, 2007
Doyle Lumber Co.
Attn: Chipper Roberts
43 River Rd.
Andover MA 0 18 10
F 7
LLL�
Attached are TJ-Beam� calculations based upon design information provided by Doyle Lumber Co. These
calculations can be identified by the following date and time in the upper left hand comer of each sheet:
DESIGN DATEMME
12/6/2007 @ 4:01:35 PM
12/6/2007 @ 4:02:47 PM
The professional engineer's stamp on this letter verifies that the U-Beame analyses for the member(s) shown
conform to accepted engineering practice and use code accepted product design values. Each analysis reflects that
the iLevel by Weyerhaeuser products, as shown, have adequate capacity for the loading conditions indicated. The
input has not been produced nor reviewed for completeness or accuracy by a professional engineer.
All notes, figures and design load information shown on these calculations must be reviewed to ensure the design
loads, spans, bearing conditions and deflection criteria are accegtable for the specific application. Also, please
verify that the products installed have the "Silent Flooe", "TJI "', "Microllamo LVL", "Parallam� PSL", or
"Timberstrane LSL" markings to confirni. that this letter is valid for the products used.
Please feel free to contact me if there are any questions regarding the analyses.
Sincerely,
Ka J. Do e , P.E.
Structural Fra ngineer
NE TC# 58280
"OF
KATHY j.
DOUGHERTY
STRUCTURAL
N0.40203
IONAL
Northeast Technical Support +360 Route 101, Suite 2 * Bedford, NH 03110 * Phone 866-295-2170 * Fax 603-218-6167
Pg I of 3
b I y Weyorhae . user 4 Pcs of 13/4" x 9 1/4" 1.9E Microllam@ LVL
TJ -Beam@) 6.30 Serial Number: 700
User: 4 12/6/2007 4:01:35 PM fffff PRODUCT MEETS OR EXCEEDS THE SET DESIGN CONTROLS FOR THE
Page 1 Engine Version: 6.30.14 APPLICATION AND LOADS LISTED
12' 3" F21
Product Diagram is Conceptual,
LOADS:
Analysis is for a Header (Flush
Beam) Member. Tributary Load Width:
Primary Load Group - Residential - Living Areas (psf): 40.0 Live at 100 % duration, 12.0 Dead
Vertical Loads:
Type Class
Live Dead Location Application Comment
Uniform(plf) Floor(l.00)
40.0 14.0 0 To 12'3" Replaces
Uniform(plq Floor(l.00)
210.0 70.0 0 To 12'3" Adds To
Uniform(plf) Floor(1.00)
40.0 14.0 0 To 12'3" Adds To
Uniform(plq Floor(1.00)
0.0 80.0 0 To 12'3", Adds To
Uniform(piq Floor(I.00)
0.0 60.0 0 To 12'3" Adds To
Point(lbs) Floor(l.00)
4620 2310 2' 7"
SUPPORTS:
Input
Bearing Vertical Reactions (lbs) Detail Other
Width
Length Live/Dead/UplfftiTotal
1 Wood column 3.50"
1.691, 5459 340910 8868 LI: Blocking 1 Ply 1 3/4" x 9 1/4" 1.9E Microllam@ LVL
2 Wood column 3.50"
1.50" 2713 2036 / 0 4749 Ll: Blocking 1 Ply 1 3/4"x 9 1/4" 1.9E Mcrollam@ LVL
-See iLevel@ Specifiers/Builder's Guide for detail(s): 1_11: Blocking
DESIGN CONTROLS:
Maximum Design Control Result Location
Shear (lbs) 8777
8288 12303 Passed (67%) Lt. end Span 1 under Floor loading
Moment (Ft -Lbs) 19873
19873 22408 Passed (89%) MID Span 1 under Floor loading
Live Load Defl (in)
0.357 0.397 Passed (U400) MID Span 1 under Floor loading
Total Load Defl (in)
0.596 0.596 Passed (U240) MID Span 1 under Floor loading
-Deflection Criteria: MIN IMUM(LL:L/360,TL:L1240).
-Standard (Level@ Criteria) deflection has been exceeded.
-Bracing(Lu): All compression edges (top and bottom) must be braced at 12' 3" o/c unless detailed otherwise. Proper attachment and positioning of lateral bracing is required to achieve member stability.
ADDITIONAL NOTES:
-IMPORTANT! The analysis presented is output from software developed by iLevel@. Allowable product values shown are inac�r%2e �,,t��urrent iLevel@ materials and code accepted design values.
iLevel@ Engineering has verified the analysis. The input loads and dimensions have been provided by others C)Q and must be verified and approved for the
specific application by the design professional for the project.
-THIS ANALYSIS FOR iLevelO PRODUCTS ONLY! PRODUCT SUBSTITUTION VOIDS THIS ANALYSIS.
-Allowable Stress Design methodology was used for Building Code IBC analyzing the iLevelD Distribution product listed above.
-Note: See LeveI5 Specifier's/Builders Guide for multiple ply connection.
Operator Notes:
SEE SHEET ONE FOR ADDITIONAL INFORMATION
PROJECT INFORMATION: OPERATOR INFORMATION
Dave Apostoloff Kristina Tacito-Hansen
Lynn and Joe Smith iLEVEL by Weyerhaeuser (KTH)
30 Penni Lane 360 Route 101,Suite 2
North Andover, MA Bedford, NH 03110
Phone: (603)-472-6730
Copyright 0 2007 by iLevelO, Federal Way, WA. 21:t'
microllamO is a registered trademark of iLevelO.
S:\ENG\TCD\ProjeCt Files\50000-59999\58000-58999\58200-58299\58280\apostoloff 071205.sms
by Weyerhaeuser 2 Pcs of 13/4" x 117/8" 1.9E Microllam@ LVL
TJ�Bean-0 6.30 Serial Number: 700'fffff PRODUCT MEETS OR EXCEEDS THE SET DESIGN CONTROLS FOR THE
User: 4 12/6/2007 4:02:47 PM
Page 1 Engine Version: 6.30.14 APPLICATION AND LOADS LISTED
17-7
R2
6'4"
LOADS:
Analysis is for a
Header (Flush
Beam) Member. Tributary Load Width: 1'
Primary Load Group
- Residential - Living Areas (psf):
40.0 Live at 100 % duration, 12.0 Dead
Vertical Loads:
Type
Class
Live
Dead
Location
Application Comment
Uniform(plf)
Floor(l.00)
120.0
60.0
0 To 6'4"
Replaces
Uniform(plf)
Snow(1.15)
210.0
60.0
0 To 6'4"
Adds To
Uniform(piq
Floor(I.00)
0.0
80.0
0 To 6'4"
Adds To
Uniform(plo
Ftoor(l.00)
180.0
60.0
0 To 4'2"
Adds To
Uniform(plo
Floor(I.00)
180.0
60.0
0 To 4'2"
Adds To
Uniform(plo
Snow(l. 15)
390.0
130.0
0 To 4'2"
Adds To
Point(lbs)
Floor(1.00)
5289
3285
4'2"
-
SUPPORTS:
Input Bearing Vertical Reactions (Ibs)
Width Length Live/Dead/Uplift/Total
I Stud we] 1 4.88" 4.86" 4827 2406 / 0 7233
2 Stud wall 6.00" 6.01" 5677 3260 / 0 8937
-See !Level@) SpecifierstBuilders Guide for detail(s): Al: Blocking
DESIGN CONTROLS:
Maximum
Shear (lbs) -8734
Moment (Ft -Lbs) 14780
Live Load Defl (in)
Total Load Defl (in)
Detail Other
Al: Blocking I Ply 1 3/4" x 11 7/8" 1.9E Microllarn@ LVL
Al: Blocking 1 Ply 1 3/4" x 11 7/8" 1.9E Microllam@ LVIL
Design Control Result
-7250 7897 Passed (92%)
13120 17M Passed (74%)
0.079 0.189 Passed (U864)
0.122 0.284 Passed (U559)
Location
Rt. end Span 1 under Floor loading
MID Span I under Floor loading
MID Span I under Snow loading
MID Span 1 under Snow loading
Product Diagram is Conceptual,
-Deflection Criteria: MINIMUM(LL:L/360,TL:L/240).
-Bracing(Lu): All compression edges (top and bottom) must be braced at 6' 4" o/c unless detailed otherwise. Proper attachment and positioning of lateral bracing is required to achieve member stability.
ADDITIONAL NOTES:
-IMPORTANT! The analysis presented is output from software developed by iLevei@. Allowable product values shown are in accordance with current i Level@ materials and code accepted design values.
iLevelO Engineering has verified the analysis. The input loads and dimensions have been provided by others Y\ 1 9 ?_'�,r rjz�;bey and must be verified and approved for the
specific application by the design professional for the project.
-THIS ANALYSIS FOR i Level@ PRODUCTS ONLY! PRODUCT SUBSTITUTION VOIDS THIS ANALYSIS.
-Allowable Stress Design methodology was used for Building Code IBC analyzing the !Level& Distribution product listed above.
-Note: See iLevel@ Specifier's/Builder's Guide for multiple ply connection.
Operator Notes:
SEE SHEET ONE FOR ADDITIONAL INFORMATION
PROJECT INFORMATION: OPERATOR INFORMATION:
Dave Apostoloff Kristina Tacito-Hansen
Lynn and Joe Smith iLEVEL by Weyerhaeuser (KTH)
30 Penni Lane 360 Route 101,Suite 2
North Andover, MA Bedford, NH 03110
Phone: (603)-472-6730
Copyright 0 2007 by iLevelO, Federal Way, WA.
MicrollamO is a registered trademark of iLevelO.
S:\ENG\TCD\Project Files\50000-59999\58000-58999\56200-58299\58280\apostoloff 071206.sms
25C9
Date....
0 ...........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ....... . P.).i .............. 6z�c
has permission to perform ............. 4--1 ....................................................
� 411, 't�?
wiring in the building of ............... ..................................................................
L A/ ov M
at ........ ........ . .................................. No;rthn And ass.
4 OV
"_.A
�ro
Fel�., Lic. No. .. ............. . ....... ....... . .......
A
L RIC INSPECrO
Check # L/
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
Commonweahk ol Vam�cltu6effi
0 19
13 10
BOARD OF FIR E PREVENTION REGULATIONS
Official Use Only
Permit No.
Occupancy and Fee Checked
[Rev. 11199] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be perrornicd in accordance with the Massachusctts Electricnl Code (iNIEQ, 527 CNIR 12.00
(PLE11 SE PRINT 1jV INK OR TYT)E.4 LL IWORiVA TION) Mite: —0 0
City or Town of: To the Inspector of Wires:
By this application die undersigned sivcs notice of his or her intention t—o perform the electrical work described below.
Location (Street & Number)
Owner or Tenant Telephone No.
Owner's Address
Is this perinit in conjunction with a building permit? Yes El No 0'
(Check Appropriate Box)
Ilurj�ose or Building _51" Utility Audiorization No.
Existing Service Anips Volts Overhead Undurd
No. of Meters
New Service Anips Volts OvcrheadEJ UndgrdEJ No. of Meters. .
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Comoletion of the follaivine table may he ht. tho nr tv;,-e
No. of Recessed Fixtures
No. of Ceil.-Susp. (Paddld) Fans
No. of
Transformers KVA
No. of Lighting Outlets
tp
No. of Hot Tubs
Generators KVA
No. of Lighting Fixtures
Above In-
Swininfing Pool grnd. grnd.
I Emergency Lighting
Batter� Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALAPLAIS
FNo- of Zones
No. of Switches
No. of Gas Burners
No. of DeFeetion and
Initiating Devices
No. of Ranves
No. of Air Cond. Total
Tons ,
No. of Alerting Devices
No. of Waste Disposers
HeltPunip
N�j k�LjTons.
I.L
KW
ontained
Totals:
Detection/Alerting. Devices
No. of Dishwashers
Space/Area Heating KW
Loc 11 El f�lun'c'Pfil [1 Other
Connection
No. of Dryers
Healing. Appliances KW
6ecurity Systems:
No. ofbevices or Equivalent.
No. of Water KW
No. of INO. of
Data Wiring:
Heiters
S10,11s Ballasts
No. of Devices or Equivalent
No. Hydroinassage Bathtubs
No. of Motors p Total HP
"Ielecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Attach additional deiail ifdesired. or as required by the Inspector of wires.
INSURANCE COVERAGE' Unless waived by the o%%rner, no permit for the performance of electrical work may issue unless
the licensee provides proofof liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such cover is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANC �toeND El 91 -HER Ll (Specify:)
-(Expiration Date)
Estimated Value of Electrical Work:' (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
I certify, Itilder thumt . its altilpenalties or ry that the information on this alylilication is true aml complete.
V IL t -A "
MUNI NAME: 1471ZP CC LIC. NO.:- A 1317 7 -
Signature LIC. NO- 6 3Lt
�icensee: :STE77(,E2--) a��S" — 0 — _—,
0
(If applicabie-, entcr - Ix I " in Lhe lice", qybe * te. Bus. Tel. NO.- n-xv
Address: 1�11,790. Mn(e Lf n Alt. Tel. No.: --
OWNER'S INSURANCE WAIVE, R: I am aware that the Licem-ree does not have the liability insurance coverage normally
required by law. By iny signature below, I hereby waive (his requirement. I am the (check one) E] owner [] ovnicr's agent.
Owner/Agent -Rj111T r- E E : S
Signature Telephone No. F
I
0
Location 0
-7Q!?No. C> Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check#
"i 7748
Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
177-7
,e "T,
BUELDING PERMIT NUMBER: �Cp /7 DATE ISSUED:
SIGN 6--�
Building Colnn-dsgp�rnn� Ltor of Buildings Date
.RE
SECTION I -SITE INFORMATION
1.1 Property Address:
pcoi)l tape-
1.2 Amessors Map and Parcel Number:
/ 0!2--D
Map 1�umber Parcel Numb�r
vol .-1 X)d (0 v e— v
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Area (sf) Frontage (ft)
1.6 BIJUDING SETBACKS (ft)
Front Yard Side Yard
Rear Yard
Regaired Provide Required Provided
Rejjr�ed Provided
1.7 Water SupplyM.G.L.C.40.1- 34) 1.5. Flood Zone Information:
Public 0 Private 0 zone Outside Flood Zone 0
1.9 Sewerage Disposal System:
Municipal 0 On Site Disposal System 0
1
SECTION 2 - PROPERTY OWNERSEIIP/AUTHORIZED AGENT
rict: y6s Pqr)
2.1 Owner of Record
S rm f Ttf- W." Ile
�(Pt) Address for Service
Signature Telephone
2.1, Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
�icensed Construction Supervisor:
Address
Signature Telephone
Not Applicable 0
License Number
Expiration Date
3.2 R4stered Home Improvement Contractor
Not Applicable 0
Company Name
Registration Number
Address
Expiration Date
Siignature Telephone
Mo
M
X
z
0
M
Q�
0
z
M
90
0
M
z
Q
SECTION 4 - WORKERS COMPENSATION (NtG.L C 152 § 25c(6) I
Workers Compensation Insurance affidavit must be completed and submitted with this application. Faili
.in the denial of the issuance of the building permit.
Signed affidavit Attached Yes ....... 0 No ....... 0
SECTION 5 Description o Proposed Work (check app]llcable)
New Construction 0 Existing Building 0 Repair(s) 0 terations(s) , 0
Accessory Bldg. 0 Demolition 0 Other 0 Specify
Bri f cription of Proposed Work:
. R42 Ple Qe -E=u-) -6mi-npi-S L" c ci 4!!Z -
I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I
to provide this affidavit will result
Addition 0
Item Estimated Cost (Dollar) to be
Qompleted by permit applicant
OMCIALUSE ONLY
1. Building
(a) Building Permit Fee
lier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) x (b)
—4 Mechanical (HVAQ
5 Fire Protection
6 Total (1+2+3+4+5)
Check Number
5Eq-JLJ1VfN 12 UWARK AU InUMLAIMA M BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUELDING PERMIT
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 ofOwner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
I as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
Print Name
Signature of Owner/Agent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 1 2 ND 3M
SPAN
DIMENSIONS OF SILLS
DEVIENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHRVINEY
IS BUILDING ON SOLID OR FILED LAND
IS BUILDING CONNECTED TO NAfUOI GAS LINE
0
1p
0
I
rl=-
Page No. Of Pages
FUENTES GENERAL CONSTRUCTION
Aft Masonry* Decks* Roofing* Painting
..JM 85 Central Avenue
CHELSEA, MA 02150
M n 5 (617) 817-5473
PR0PdSAL SUBMITTED TO
PHONE
DATE
Authorized
Signature 4L�U:4-
Z 0 n I
(q F e (9 4
charge over and above the estimate. All agreements contingent upon strikes, accidents
C. V
STREET
JOBNAME
Our workers are fully covered by Workman's Compensation Insurance.
�j
CITY. STATE and ZIP CODE
JOB LOCATION
and conditions are satisfactory and are hereby accepted. You are authorized
Signatu e
CA o C
ARCHITECT
DATE OF PLANS
Date of Acceptance:
JOBPHONE
117 k6y3201
Wit pruplil[St hereby to furnish material and labor — complete in accordance with above specifications, for the sum of:
Payment to be made as follows: dollars($_j Z3 Soo
501. --FicsT -bo�-Qf) Ta*icn-eh-T OnJ annf Hcc- 50/4
Lj e rX -r- no k -1-S
All material is guaranteed to be as specified. All work to be completed in a workmanlike
manner according to standard practices. Any alteration or deviation from above specifications
Authorized
Signature 4L�U:4-
involving extra costs will be executed only upon written orders, and will become an extra
charge over and above the estimate. All agreements contingent upon strikes, accidents
C. V
or delays beyond our control. Owner to carry fire, tornado and other necessary insurance.
Note: This proposal may be
Our workers are fully covered by Workman's Compensation Insurance.
withdrawn by us if not accepted within days.
Arreptunre of Proposal— The above prices, specifications
and conditions are satisfactory and are hereby accepted. You are authorized
Signatu e
to do the work as specified. Payment will be made as outlined above.
2L &r�—t
Date of Acceptance:
Signature
To Reorder:
V �
North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of IVIGL c 40 S 54, a condition of Building Permit
Number is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by IVIGL
c 11, S 150 A.
The debris will be disposed of in: �P-56� -Zg?,4-
(Location of F—acility)
rVI
Wrl,
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
ids jihfi�wn
oard of Buildihg )Ilegula
HOME IMPROVEMENT CONTRACTOR
Registration: 134108
Expiration: 9125/2005,
Type: DBA,-
6ENTES HOME IMPROVEMEigifQONTARCTORSL
MARIO FUENTES
t: P5 CENTRAL AVE.
CHE - LSEA, MA 02150 Administr0or
0
BOARD OF BUILDING. REGULATIONS
License: CONSTRUCTION SUPE -R VISOR
Number: CS 086369
Birthdate: 01/22/1976
Expires:. 01/2 212007 Tr. no:. 86369
MARIOU FUENTES
85 CENTRAL AVE #1:
CHELSEA- MA 02150 Admini trator
IeA N
C, —
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111 -
Workers'Compensation Insurance Affidavit
Name Please Print
Name:
Location:
ci!y I am a homeowner performing all work myself. Phone
I am a sole proprietor and have no one working in any capacity
I am an employer providing workers' compensation for my employees working on this job.
Company name:
Address
CRY Phone
Insurance Co. Policv
Compa!]y name:
Address
Cily: Phone
Insurance Co. P licv #
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of.a fine up to $1,500.01)
andlor one years' imprisonment -as welas -civil.,penalties in 1he fan da.STOP.W.ORK.DRDER,.and..a.fine.of.(.$100.00.).a jday againstme. I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
do hereby certify under the pains and penalties of peoury that the information provided above is true and coffect.
Signature A - zaemz Date
-JP. 0 4-
Printname Phone# (2L- 9/2 - �;4
ZW A -
Official use only do not write in this area to be completed by city or town official'
City or Town —Permit/Ucensina
Building Dept
[]Check if immediate response is required 0 Licensing Board
ri Selectman's Office
Contact person: Phone #.- Health Department
Other
Town of North Andover
Building Department
27 Charles Street
.,roe Xf
North Andover, MA. 01845 AlIc jjs
D. Robert Nicetta
Building Commissioner
�9'78) 688-9545
( 78) 688-9542. Fax
HOMEOWNER LICENSE EXEMPTION
Please print.
DATE
JOB LOCATION
Number
"HOMEOWNER
Name
PRESENT MAILING ADDRESS\
City Town
Street Address
Home Phone
State
map i iot
Work Pnone
. 9
The current exemption for "home6wners" v�as extended to include owner -occupied dwellings
of two units or less and to allow such horn ners to engage an individual for hire who does
not possess a license, provided that the owne as supervisor; (State Building Code Section 108.3.5. 1)
DEFINITION OF HOMEWOWNER:
Person(s) who owns a parcel of land on which he/s e resides or intends to reside, on which
there is, or is intended to be, a one or two family ing, attached or detached structures ac-
cessory to such use and/or farm structures. A person o constructs more than one home in a
two-year period shall not be considered a homeowner.
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attach or
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eowner.
o
The undersigned "homeowner" assumes responsibility for pliancewith the State Building Code and other
Applicable codes, by-laws, rules and regulations,
3t c
The undersigned "homeowner" certifies that helshe understands e Town of No. Andover
ed 1 t�
Building Department minimum inspection procedures and require nts and that he/she will
comply with said procedures and requirements..
HOMEOWNER'S SIGNA
APPROVAL OF BUILDING OFFIC
Zip Code
ISSUED BY THE,,STOCK INSURANCE COMPAN - HEREIN CAhEIJI THE�-T-WPAN - Y
'GRAN'ITE'STATE INSURANCE COMPANY
1310-2
PENNSYLVANIA
MARIO FUENTES
85 CENTRAL AVE
CHELSEA, MA 02150-0000
SEE NAME AND ADDRESS SCHEDULE - WC990610
74402-0000 WC 431-65-85
------------- ------ - - ----------
013-66-0504-00
Member Companies of
American International Group
EXECUTIVE OFFICES: I
70 PINE STREET, NEW YORK, N.Y. 10270
SCULOS & . SANTILLI INS AGCY
WORKERS COMPENSATION AND EMPLOYERS 285 MAIN ST
LIABILITY POLICY INFORMATION PAGE EVERETT, MA 02149-0000
INSUREDIS
I ND IVI DUAL
JOTHER WORKPLACES NOT SHOWN ABOVE: SEE Nj
IITEM 2 1 POLICY PERIOD 12:01 A.M. standard time at the Insured's
mailing address
IPREVIOUS POLICY NUMBER
NEW
ADDRESS SCHEDULE - WC990610
FROM 05/11/04 To 05/11/05
ITEM 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states . listed
here:
MA
W. &111IJ1UVVF5 UdDlilly insurance: Part Two of the Policy applies to the work in each state listed in item 3.A.
The limits of our liability under Part Two are:
Bodily Injury by Accident 100,000 eac� accident
Bodily Injury by Disease $ ;00,000 Policy limit
Bodily Injury by Disease $ 100,000 each . employee
VL11=F oldies insurance: Part Three of the Policy applies to the states, if any, listed here:
SEE ENDORSEMENT - WC200306A
ITEM 4 1 The premium for this Policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans
L�� formation required below is subject to verification and change by audit.
Classifications
� I
SEE EXTENSION OF INFORMATION PAGE - WC7754
TAXESASSESSMENTS/SURCHARGES
Es'i ma'ad Total Rate Per
Code Number Ram u n.r.ti on 1 $,00 OF Re -
10 Annual 11 3 Year I muneration
Estimated
Premium
Annual 3 Year
$14
!XPENSE CONSTANT (EXCEPT WHERE APPLICABLE BY STATE) $132 MA
A.INIMUM PREMIUM $500 MA TOTAL ESTIMATED PREMIUM
f indicated below, interim adjustments of premium shall be made: $500
Semi -Annually Quarterly Monthly DEPOSIT PREMIUM
ENDORSEMENTS (FORM NUMBER) SEE ATTACHED FORM SCHEDUL—E Wc990612
)5/27/04 ASSIGNED RISK 66
Issue Date Issuing Office
9967
Authorized Representative WC 00 00 01
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