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HomeMy WebLinkAboutMiscellaneous - 315 TURNPIKE STREET 4/30/2018 (6)e t 1 a t * k � Z X�SAYMMAM, miss x woo. To. F 1,101 0r x loom Af 1 MWAS ul 1 � 1' son xyM V" so N I , 1 Y, cK. t Y _ r 1 ;.r F &. 1 Date . 6Y.rrtiraf�as TOWN OF NORTH ANDOVER PERMIT FOR WIRING r72;: 7, This certifies that ..../. !..`t2� ?<!�r...0 Oma- ............. . has permission to perform ... (� 4' tt C wiring in the building of . 1?�Eh��-!���!�. �o«•!.rte ......... at ...3. 4..,A -A.{ .....S r ... , North Andover, Mass. Fee. �2S°- ° Lic. No..( � y 76/) ...... � ..... P ELECTRICAL INSPECTOR Check # � i02} i P ( ommonwea(.t'h, of Maejac4wetb Official Use Only part`men� o/ 7ire Serviced Permit No. Ad 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 (M71471 7 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALI, INFORMATION) Date: g -).— City City or Town of: A/cmf -A Aeydd vt,2 To the Inspettorof Wires: By this application the undersigned gives notice of his or her intenntion to perform the electrical work described below. Location (Street & Number) 315 ITRyPi K ---S* *P.,41, /O�JAVtr, C.0 )1tifl-c., Telephone No `%7? 16 639 Owner or Tenant �'1YR✓L�►^1pGk � . Owner's Address SAy+-- Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Pro osed Electrical Work: id �c 6 tR611n d� 1..J I P>^ Tijo Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters Completion of the folloii4nz table may be ii;ah,ed by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires AboveIn- Swimming Pool ❑ ❑ o. o Emergency Lighting rnd. rnd. Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches 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 Number Tons I KW I No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring No. of Devices or E uivalent OTHER: Attach additional detail if desired, or as required big the Inspector of 117ires. Estimated Value of Elec Tical Work: (When required by municipal policy.) Work to Start: �� 1-z-- 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 undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete.�,.15 FiRM NAME: Licensee: Signature ( LIC. NO4 J9 -q (If applicable, este -eiempt" in 7e license num e line.)XJ Bus. Tel. No.: Address: .,' 4 Q Alt. Tel. No.: /t� i?%I *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lie. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee doe required by law. By my signature pb,,Qjov. I hereby waive this regbiremen Owner/Agent 112 -10 AP Signatgre Telephone 9Af 0--47 � S� g 76 93-7 c- / firl not have the liability insurance coverage normally i am the (check one) ❑ owner ❑ owner's agent. PERMIT FEE: $ Location 3 f J 114AP, Ee— No. lY Date [ Check # / / C t S 25610 TOWN OF NORTH ANDOVER �l Certificate of Occupancy $ / Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Building Inspector BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 1,4 Date Received ^Too Date Issued:T�_ �11_ I CHO IMPORTANT: Applicant must compjete all items on this page r. LOCATION_3 AIPQ� T-1- P CA -T H AA-) D 4) 0 6k, Print PROPERTY OWNER _C _kX jL_1 L4V�:� c 0 LL Print MAP NO: PARCEL: —ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition TWO or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic well l Floodplain Wetlands fttershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: Identification Please Type or Print Clearly) OWNER: Name: t169C_ 0(_t_ i?—�- roe Phone: 9 11 Address: 3 CONTRACTOR Name:AXk_FH AM6M�' 140(UfOilwone: 337- P� 0/ �2 4'I S q ?6-tH&O, 57— JX)JG_y4yOT-H 1.4-11+ 0;,t_l Ole Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Date: ARCHITECT/ENGINEER Phone: Address: Reg. No FEE SCHEDULE: BULDING PERMIT: MOO PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125,00 PER S.F. Total Project Cost: $ FEE: $_ 161� - Check No.: 116 q � Receipt No.: 9SEW(D NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fiend Signature of Agent/0wneA4L_x_!5x Signature of contractor Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NUTh5 and DATA — (For department use ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ tBuilding Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 NORTA03 OP ID: KMS ACORO' CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) F08/02/12 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 800-585-1905 CONTACT NAME: Sampson Insurance Agency, Inc. 97 Libbey Parkway,Suite 110 781-682-9740 PHONE FAX A/C No Ext : AIC No): E-MAIL ADDRESS: P.O. Box 890039 Weymouth, MA 02189-0001 EACH OCCURRENCE $ INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Continental Casualty PERSONAL&ADV INJURY $ INSURED North American Amusement Inc. Robert J. Perkins JR. INSURER B: PRODUCTS - COMP/OP AGG $ 641 Summer Street INSURER C INSURER D Weymouth, MA 02188 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE POLICY NUMBER OLICY EFF IDD/ MMD POLICY EXP MM DDIIYYYY LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE F—I OCCUR I I AUTHORIZED REPRESENTATIVE U/� �%, I�da04% EACH OCCURRENCE $ DAMAGETO RENTED PREMISES Ea occurrence $ MED EXP (Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GENT AGGREGATE LIMIT APPLIES PER: [--]JECT F7 LOC POLICY PRO- PRODUCTS - COMP/OP AGG $ $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NOWOWNED �. HIRED AUTOS AUTOS P1 I COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident $ 1, UMBRELLA LIAB EXCESS LIAB OCCUR HCLAIMS-MADE I EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION$ $ - A WORKERS COMPENSATIONWC AND EMPLOYERS' LIA BILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICERIMEMBER EXCLUDED? ❑ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A 6S59UB0489N89612 05/12/12 05/12/13 STATU- OTH- X TORY LIMITS ER E.L. EACH ACCIDENT $ _ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT $ 500,000 I I DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Coverage subject to policy terms and conditions. J CFRTIFICOTF Hni nFR CANCELLATION MERRI01 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Merrimack College 315 Turnpike St N. Andover, MA 01845 AUTHORIZED REPRESENTATIVE U/� �%, I�da04% ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD J Department of Public Safety License to Operate Amusement Devices Robert "Bob" Perkins License #: MA -002 -12 (781)337-1901 North American Amusements Expiration Date: 5/1/2013 Certified Maintenance Mechanic 641 Summer Street Robert Perkins. Jr. Weymouth MA 02188 U.S. I.D. # Device U.S. I.D. # Device C.S. I.D. H Device 09908 Fun Jeeps Ride 09910 Whisper Flectronic Go 10438 70' Rapid Slide 1002668 Wild One Roller Coaster Obstacle Course 10675 52' Chair Swing 1002749 Fire DocMoonwalk 10823 Karts 09911 Kiddie Race Car 09912 Magical Playhouse (NM) 09914 Aztec Ride 09915 Gyro (NM) 10112 Kiddie Feris Wheel 10113 Sky Fighter Jets 10362 Tubs of Fun 10434 Spider Tubs of Fun 10435 Pirate Ship 10436 Flsina BuglBumble Bee 10437 8 -Spirit Mern Go Round 10438 70' Rapid Slide 1002668 Wild One Roller Coaster Obstacle Course 10675 52' Chair Swing 1002749 Fire DocMoonwalk 10823 Kiddie Viking Ship 13386 Kiddie Batter\ Bumper Can 13387 Uncle Al's Plane Kiddie Ride 1001415 Inflatable Wacky Shack 1001807 Moonwalk 1001943 Moonwalk 100194.5 Moonwalk 1001946 Inflatable FAtreme Obstacle Course (NM) 1001949 Inflatable Chaos Obstacle Course (N� Commissioner o ublic Safety Issued Dale Paee I of I ALLIED SPECIALTY INSURANCE, INC. - 10451 GULF BOULEVARD, TREASURE ISLAND, FL. 33706 Toll Free 1-800-237-3355 National 1-800-282-6776 Florida Certificate Number: 78 CERTIFICATE OF INSURANCE This certificate neither affirmatively nor negatively amends, extends or alters the covera e afforded b the policy(ies) described hereon and is issued as a matter of information and -confers no right upon the holder. The polic (ies) identified below by a olio number is in force on the date of certificate issuance. Insurance is affordedyon1Vy with respect to those covera es for which a specific limit of liability has been entered and is subject to all terms of -the policy having reference thereto. Nothing herein contained shall modify any provision of said policy. In the event of cancellation of the polic the company issuing said policy will make all reasonable effort to send Notice of cancellation to the certificate holder at the address shown herein, but the Com any assumes no responsibilities for any mistake or failure to give such notice. Any insurance made a part of the policy includes as a person insured with respect to an occurrence taking place at a Carnivals site, (1) the Fair or exhibition association, sponsorintq organization or committee (2) the owner or lessee there of (3) a municipality granting the Named Insured permission to operate a(n) Carnivals, but only as respects bodily injuryor pro ertyy damage caused by or contributed to by the negligence of the Named Insured Pwhsle acting in the course and scope of their employment. NAME & ADDRESS OF INSURED: ADDITIONAL INSURED: North American Amusement, Inc 641 Summer Street Town of Andover, MA Weymouth MA 02188 Merrimack College 315 Turnpike Street NAME & ADDRESS OF CERTIFICATE HOLDER: North Andover, MA 01845 Merrimack College 315 Turnpike Street North Andover, MA 01845 DATES: August 30, 2012 PRIMARY COVERAGE EXCESS COVERAGE Company: T.H.E. Insurance T.H.E. Insurance Company Company Policy Number: CPP0100933-02 ELP0010215-02 ILITY LIMITS$5,000,000 BI1PyD AGG: $1,000,000 $0 OCC: $1,000,000 $1,000,000 $0 Excess of Excess of $1 000,000 �0 Food Products: $1,000,000 553uu0, uuu .5 Policy period: From: 05/01/12 05/01/12 00/00/00 To: 05/01/13 0*/01/13 00/00/00 - COMBINED SINGLE LIMIT Coverage shown herein applies only to those items scheduled on or endorsed to the policy. JulZ 2 2012 DATE OF CERTIFICATE ISSUMME- -0 fi0( Equipment Contract for 2.012 This contract is made on August 2, 2012, between North American Amusement Inc. and committee stated for the following event: Committee Name: Merrimack College Contact Person: Allie Stinson Date of Event: August 30, 2012 Contact Address: Merrimack College Running Time: 8:00 am to 11:00pm 315 Turnpike Street Location: in front of Sakowich Campus Center Merrimack, MA 01845 Total Rental Fee: Special $4,700.0 Contact Phone: 978-837-5438 Deposit: Please Sign & Return Contact Fax: 978-837-5004 Balance due on Arrival: $4,700.00 Contact Cell: The checked equipment is rented for the above date(s) & time(s): INFLATABLES RIDES ao� RIDES O Moonwalk X Tubs of Fun a O Aztec Ride O Wacky Shack O Sky Fighter Jets O Spirit Merry Go Round O Bungee Run O Pirate Ship X 70' Rapid Slide O Boxing Ring O Kiddie Ferris Wheel O Sports Tug of War O Kiddie Race Cars O 55' Extreme Obstacle Course O Bumble Bee Ride O Chaos Obstacle Course O Fun Jeep Ride O Mechanical Bull O Gyro-Orbitron X Wild One Roller Coaster O Viking Ship Obstacle Course q Power FID # 04-2947586 • Generator O 52'Chair Swing O Magical Fun House O Whisper Go -Karts O Uncle Al's Plane Ride O Battery Operated Bumper Cars Food X Cotton Candy O Fried Dough GAMES O R&Y&B Games & Booths O NEW. Dunk Tank O Speedpitch O Football Toss or Soccer Kick O Inflatable Basketball O Hi -Striker O Football Game Tfailer O Basketball Game Trailer O R&W Games & Tents O Jacob's Ladder Climb O NEW. Zero Gravity Chamber Game North American Amusement Inc. has the right to change equipment, of equal value, due to mechanical problems. In the event of cancellation due to rain, please notify the office at (781) 337-1901 before 7:00am the morning of the event and the deposit will be refunded in full. No refunds for any other reason. Please Send Directions! I have read front & back and understand the information. Please sign & return within 10 days of receiving. Signature Title • Tax Exempt # Please Read Back & Sign Both Sides al x W x LL O m c t Y -D O LL E +-� N.2 � O- VI o a z Z D m = C 3 LL Lqq 7 w N C U LL 0 U d z Z GLU d SOA 3 w LL 0 W C z J V LU LCO 7 w u .i N LL 0 O a lA Z 0LL -C 7 CC M LL ►- LU G Q LLI LU ` cuC m z y v {% �+ N Y O (n 0 O_ � O •CL L } Q.� 4)ate., ® - �o Vt E Q. i L N L O.0 h c Cc P o V L cc to J N ,� L c a) N m 0 =_ m c VJ — m.0 c0 r E%- o a) o z a� 0 x,0.0 m 3 c o� L Q. Q. d 0 o = c a L 2� _ rL p Ca O C� m N W = '0 +�-+ O O ui w -I*- I*- LL •� 4-1 N C V V W E t� � = i Li 01 0-0 4)CL y., N H -00 % C O0 H t +0 .+ o.oL) U) w a W F- LU W a - O U cn LLIJ 0 LU 7 COz m `Iv E O Z O D � W Q 'E m m 0 70 v 0 O CL a� Q 4. LU H W W C9 W N Location 31�s- �-'t•�.r'` -3 a No. <'y 9 Date 140R,h TOWN OF NORTH ANDOVER ` Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # `Building Inspector A. �TO I f 1\ OF NORTH AND V 7 Eft BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REP RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY D%`ELLING BUILDING PERMIT NUMBER: n, DATE ISSUED: ,7 SIGNATURE: Building Cotnmissionerfl for of Buildings Date CTi f'TtnAl t c1r1ry T%XVr%n1L5 • q"^V r 1.1 Propaty :\ddress: /6'U�hN- �� �ul��h eve - h)RIIAmg et —315-7—(A hI iYl/ B �JA�/ 1.2 Asses ---ss Map a:ad Rare Map Number ! V:a,nber: Parcel Number �z 1.3 Zoning Information: Zoning Distrid Pr osed Use 1.4 Property Dimensions: Lot Area Fronts e ft 1.6 BU I DING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Re red Provided 1.7 Water Supply XG.L.CA0. 54) 1.5. Flood Zone Information: Public ❑ Privato 11Zone Outside Floud 7"o ❑ CL`/'TiAY�r 1 nn ATTaT.rl♦ n 1.8 Municipal Sewerage Disposal System: ❑ On Site Disposal System 0 - ___.._y_.__ „�_lL.l�nil..a''/AV i11V1��ln•�L'hVrllla 4111oncOistrict: Yes No 2.1 Owner of Record ov game (Print) Address for Service : v d y G+ lgnature Telephone .R2.2 Owner of Record: — s Name Print — A Adress for Service: zstgnature Tcle SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor:-- -- -- Address -- -- Signuture ------ ---- - ------1';;Cephone 3.2 R.,istered Tome Improvement-Ontiaactor ?.,1dt ass 'Ic hone Not Applicable License Nptmber C:YTfratlon Date Not :5 pplicable ❑ d i:ctrution Number Expiration Date crVTrnnr a - wnRKF.RS COMPENSATION (M.G.L. C 152 6 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 all u Ucable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Tdditio n ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: Ae,rte ve arr o 12- >/ /o% �zaxxv''e L9Xia' SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) Y (b) 4 Mechanical (HVAC) 5 Fire Protection 6 Total (1+2+3+4+5 va - Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR/APPLIES FOR BUILDING PERMIT I, ✓ y Li �O u ! C as Owner uthorized Agent o . ubject property Hereby authorize to act on LMyalt, ina matters re ztive t work a rized by this building pennit applicationre o wirer Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION k I as Owner/Authorized Agent of subject property Herebv declare that the statements and inforniation on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Signature of Owner/Agent Date r NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF 110OR TINIBERS 3 SPAN DRAENSIONS OF SILLS DINIENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X IVATERIAI, OF CI-I1N1NFY IS BUILDING ON ,SOLID OR FILLED IS BUILDING CONNECTED TO NATU10L, GAS LIME 3 N m m m m y m y v m v y CD C � � CV � O St y CD O RC2 d � C O CZ y a� � o m CD o v CD o �F CLQ CD CD o CD C O CA Q, v y �■ O co CD I S. C2 CA O CD CD Z O CD C CO A.. cn cn n O cn C 0 C?-cO N .. y ` CT N o m �a� m CD e �. ZrI N P= w m CL .. a 0 zr!R CD mfA 0: C ~' O O N TO.: =r Oo O m CL14) 1 m3 Ot N ?. cr CL d c C m : y H � O OO m d fA SfA S � O O cn N CD moo: dd: CLIO Cm) C130 0 IA I c c o �o o �c oma: y Mam Mn CA -1 _ O z 0 N r 0=3 0 9 0 )Mh ZI lO TM v I o'° w E IT QT r z �^00 9d r z ?r n w 'Ti C/) ~n O. x d ro rob M n p x I TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REP RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMTf NUMBER: n DATE ISSUED ` SIGNATURE:2� r-- Buildin Commissioner/12§"r of Buildings Date C77!`T7A1►T 1 [iTi! i�mi1\f�r. n.r.... aavl\ •-.aaacit\1'V1l1�lAl1V1\ 1.1 alierty Address: ►- 1 Ove P),411A w �►' 1.2 Assessors � ' MaPNumbe; Man and Parcel Number: Parcel Number /Yl�rrirl7att� CDIIE9� 3 ?"urn ST: �z 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area Frontage ft 1.6 BUILDING SETBACKS l Front Yard Side Yard Rear Yard Required Provide Required Provided R red Provided 1.7 Water Supply M.G.L.C.4o. 34) 1.3. Flood Zone Into metion: Public ❑ Private 0 zone Outside Flo-; Zone 0 1.8 Sewerage Disposal System: Municipal 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERS AUTHORIZED�►GENT --. - Historic District: Yes _ No _ 2.1 Ownerof ecord CylriS�ir�y1 %�%�''( /rCh�7l./ �/� _��'%/yh .U� i✓��/�1� /V/`J� game (Print) Address for Service: v 3 0/9 7 rgnature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Tele hone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Not Applicable 0 License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone Mo M X SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result ' in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: Q /Z Z12D6o�, CL'!`TinN [ _ UCTT➢d A Tri n irnNCTDITCTInN Vnv.TC �X/d Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY I. Building (a) Building Permit Fee Multi Tier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) Y (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 ev . Check Number SECTION 7a OWNER AUTHORIZATION 1U l5E i;UMFLE1EV WMf4 OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I ✓A'/�a u ! as Owner uthorized Agent o ubject property Hereby authorize to act on My behalf in a matters re five t work a rized by this building permit application. r Tature o weer Date Ccr,,rTr%N 171, nUUN17D/A1rrTIInDI71Vn A!_FNT nFrI.ARATInN 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/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB RD SIZE OF FLOOR TII EERS 1 2` 3 SPAN DIMENSIONS OF SILLS DM ENSIONS OF POSTS DM ENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 10/17/2005 15:16 FAX 9788375225 PI tI Ift, Merrimack College OIA o§ RW �n �4. 9 s a�■ 0 �R I 19 001 LI r r Z 0 W 0 Ul v W o s y N� (D N 3' o �_sN � % (D Z�o w CD `G Z Z o o o m �. rt �r m 191) 90 0 cr �. D :D N m CD Q (D a N 3 c 2) 13 < �m cr CL CD o - Itd CL (D m 51 ITI Z C)5 �_� Cc D 5 m D '°Zo 5 Z � 5 � 5 5 G1Awl. 7' v� T N �0 �z m ooN cc< _ nm r* Ni -n m r Z a N 70 In �m MO Z '= v *NW 0�vW O� 0 m z goo 0 mm v '_, . n min K M _ � mo M -I n o --i o 5 v N z= Zr 7 CD 55 V CD " 5 �N O ? tv G 5 O Qnl m N 0. N N• cD ,.r 0 ? 5 �`°N .� 5,� 5 m CL 5 3�d�•"'w•yrt 5 ��= S N x m03m "a a o• (D o 0 = 5 m o CD cD = m Q m 5 m C y M 3 5 N0M °-2)(D 5LaACL �yCDS a P* 1 5 mr* 5zD'� o(D 5m 0o SD �� 5Z 5D �3m 50 �� D0V* M.Q C� Q 5M "mo) c� 5� z i n�'�o 5cnfoo N CD Sz5 a,'a 5 r r Z 0 W 0 Ul v W o s y N� (D N 3' o �_sN � % (D Z�o w CD `G Z Z o o o m �. rt �r m 191) 90 0 cr �. D :D N m CD Q (D a N 3 c 2) 13 < �m cr CL CD o - Itd CL (D m 51 ITI Z C)5 �_� Cc D 5 m D '°Zo 5 Z � 5 � 5 5 G1Awl. 7' v� T N �0 �z m ooN cc< _ nm r* Ni -n m r Z a N 70 In �m MO Z '= v *NW 0�vW O� 0 m z goo 0 mm v '_, . n min K M _ � mo M The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print Name: Location: City Phone am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity m an employer providing workers' compensation for my employees working on this job. PB4 �a Company name: che.614.4.1 0411 1 ✓elzf e'hari- ,_rervice, Z e- - MAKY -6,17'0 Address /,R ell/ Ion Qrrye City: fro//is 403oVf Phone#: 10 03-8XJ-s32e Insurance Co. S f_ lea u / S 7,r'a ve/t'rs _745. Policy # PJua -ZSS-)L 5 V 2 - z Company name: Address City: Phone #: Insurance Co. Policv # 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 $1,500.00 andlor one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. 1 understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby cerfdy under the pains and penalties of perjury that the information provided above is true and correct. 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