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HomeMy WebLinkAboutMiscellaneous - 32 CLARENDON STREET 4/30/2018 (2) 32 CLARENDON STREET 210/069.0-0016-0000.0 . Claim # 2446150 Advantage Claim Services Adjuster Assigned: Glenn Guarente 522 Chickering Road #B North Andover, MA 01845 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws, Ch. 139, Sec. 3B To: Building Commissioner �--er Board of Health or Inspector of Buildings Board of Selectmen Town Hall Town Hall North Andover, MA 01845 North Andover, MA Re: Insured: 32 Clarendon St. c/o Scott LeBlanc Property address: 32 Clarendon St. North Andover, MA 01845 Policy #: 2446150 Loss of: 2011/09/30 File or Claim No. AD 9663 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1, 000.00 or cause Mass._Gen._Laws,_Chapter_143,_Section_6 to be applicable. If any notice under Mass_Gen_Laws,_Ch._139_Sec._3B is appropriate please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. w Glenn Guarente Title: Adjuster On this date, I caused copies of this notice to be sent to the persons named at the addresses indicated above by first class mail. 11-16-11 Signature and date Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B i To: Building Commissioner or Inspector of Buildings 1600 Osgood Street North Andover, MA 01845 RE: Insured: Juliette Darmon Property Address: 32 Clarendon Street i Policy Number: H012297221 Date/Cause of Loss: 8/19/2011, Water Damage to Ceiling File or Claim Number: 25696-W Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Wade Anderson On this date, I caused copies of this Notice to be sent to the persons named above at the addresses indicated above by First Class M:i'agn'afture and Date ANDERSON ADJUSTMENT CO., INC. 50 Nashua Road, Suite 303 PO Box 1098 Londonderry, NH 03053 r Location No. Date �% —.5 TOWN OF NORTH ANDOVER Of i•.. o ,�14•C � A # • Certificate of Occupancy $ Building/Frame/Frame Permit Fee $ s�cMust 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 18616 �/'`--Building Inspectgr� r Date......'�.....�....C�,�... NOR711 3?pe 4, TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING ,SSACMUSEt This certifies that ........ . i a C . has permission to perform .. ,F��xzG cf USC��Q1� �h�� ,ry `................... .... J wiring in the building of..�! p�...... G. G=.. f. .................................... � 3 "^ at..... ..�,� ........................ p ....... ............... ,North Andover,Mass. Fee .© Lic.No�.7 ...... �............. ELECTR[cAL INSPECTOR Check It 5661 Commonwealth of Massachusetts Official Use only # Depa ent of Fire Services Permit No. � � . Occupancy and Fee Checked 'Q BOARD OFF E PREVENTION REGULATIONS [Rev. 11/99] leaveblank APPLIC TION FOR PERMIT TO PERFORM ELECTRICAL WORK All wor to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN IN OR TYPE ALL INFORMATION) Date: : Z —Os- 3 City o Tow /of: Ifo An/,)py e,(( To the Inspector of Wires: By this applicatio the u.dersigned gives no ice of his or her intention to perform tl;g electrical work described below. Location(Street N her) ti-2 Dr,) S7, i Owner or Tenant A t/r? & /C Z 't-) Telephone No. Owner's Address j7leAS9NT A.,Jv�%C Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Und rd g ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: d Q61IZA—\-> e- L:-CT-/L!c o9 L /<v M try Completion of the ollowin table m be waived b the Inspector o Wires. No.of Recessed Fixtures No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA Nev/ In- o.o Emergency Lighting WJJI` No. of Lighting Fixtures Swimming Pool rnd. [3 In- E] Batte Units 44 1^� No.of Receptacle Outlets 36 No.of Oil Burners FIRE ALARMS I No.of Zones No. of Switches /h No.of Gas Burners No.o Detection an W Initiating Devices No.ofTota ,Rmles 1 RC(J'-s No.of Air Cond. Tonsl No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No. ofoo"shers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No.of Dryers. �, Heating Appliances KW Sec ri oyf Devices or Equivalent No.of Water No.of No..of Data Wiring: No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent I OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. 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:) (0—/ ,-Os- Estimated Q—I Q.-Estimated Value of Electrical Work: (When required by municipal policy.) (Expiration Date) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. I certify, under the pains and penalties ofperjury,that the information on this application is true and complete. FIRMNAME: STA-�L1,t NV E L.,6(141 ML ,:3:,-AJ (, LIC.NO.: 'T /4 t Licensee: pY11�� N a LZ i (� � Signature LIC.NO.: 3Y/JV L' (If applicable, enter "exempt"in the license number line`.),�,� Bus.Tel.No.• �g'65'�-5341' Address: I 10 o � a,-, ST M t''+ �+L N HA- ©/S y K Alt.Tel.No..--q 2f - &t s.7f q OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑ owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ J . " Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. � j Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 11/99] leave blank �.� APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: -� , 2_3 '-0 S� City or Town of: 04. AND 0 V t✓ff To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 2 C AR Dtil S% -,1� ' Owner or Tenant A✓ �.� & Telephone No. Owner's Address nleAsJN . A.,Ju­f, Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility.Authorization No. Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: U PG aA`;�, $ L tT,.q i G AL l ry � AMt /y Completion of the ollowin table maybe waived by the Ins ector o Wires. No.of Recessed Fixtures No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA No.of Lighting Fixtures 36 Swimming Pool ove ❑ n- ❑ lVoU.—of Emergency Lighting rnd. rnd. BatteryUnits 4� No.of Receptacle OutletsS No.of Oil Burners FIRE ALARMS ARMS No.of Zones No.of Switches No.of Gas Burners No.-oTUetection an Initiatin Devices No.of es I�C61" _ '�, No.of Air Cond. Total No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: ' Detection/Alertin Devices No.ofshers Space/Area Heating KW Local ❑ unicipal ❑ Other Connection No.of Dryers Heating AppliancesKW Security Systems: No.of Devices or Equivalent No. of Water Heaters KW No.o No.o Data Wiring: 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 by the Inspector of Wires. 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 X'BOND ❑ OTHER ❑ (Specify:) Q i Estimated Value of Electrical Work: (Expiration Date) (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. I certify, under thepains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: cJTA��(„t Nps F,1.&61111 CAL j�ti LIC.NO.: ! A Licensee:.I i��(�'= /NaZZi Signature LIC.NO.: 3 YYSO e (If applicable,enter"exempt"in the license number line.) r Address: I l U 'LP.ws or` ST r M uL N HA- ©,t6y� Bus.Tel.No. '73—6 9r Alt.Tel.No.:y'Jtr - &f r r 7f� 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)El owner ❑owner's a ent. Owner/Agent Signature Telephone No. PERMIT FEE: $ f w TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING See -1I lC $C BUILDING PERMIT NUMBER. DATE ISSUED: 11 A A .4" ic SIGNATURE: A —4 Building Commissioner/In for of Buildings Date z SECTION 1-SITE INFORMATION O 1.1 Property A dress: 1.2 Assessors Map and Parcel Number: T2 ' 19--c(a {� cin �� 0o � & q o � � Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area Fronts ft 1.6 BUILDING SETBACKS 00 Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided s 1.3. Flood Zone Information: 1.8 Sewerage Disposal System: 1.7 Water Supply M.G.L.C.40. 54) Public ❑ Private ❑ zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSE"/AUTHORIZED AGENT '' M 2.1 Owner o1'UR d o1�e ?dame(Print) �. Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: . 0 z M Signature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 LicensednstructionSt�pe isor: ,n Not Applicable ❑ �`'Av�vf l ���t✓� Ute/ Licensed Construction S"pervl or: / 6-pa` / 0 License Number Address q ` 7 f �q D�a� Expiration Date Signature Telephone 3.2 Registered H e Improv en o tractor Not Applicable ❑ Company Name �l y Registration Number r Address 0 Expiration Date Signature Telephone G) North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. The debris will be disposed of in: (Location of Facility) Signature of Permit Applicant 5�--- Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector a NORTH 0 Of 4 over 0 . No. � y2-/�i-Gtr LA E over, Mass., COCHICMEWICK y^ 7�ADRATED `S BOARD OF HEALTH Food/Kitchen Septic System PERMI T D BUILDING INSPECTOR THIS CERTIFIES THAT....................,............... ....... ............ Foundation has permission to erect.................... ................... buildings on ... .................... Rough tobe occupied as ...... ............................................................................ Chimney provided that the person acre g this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisio s of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PES EXPIRES IN 6 MONTHS Fms1 UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR r Rough C"&-,...... Service ING INSPECTOR BUILD Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. $ume<FIRE DEPARTMENT i Street No. SEE REVERSE SIDE Smoke Det. Location C 1A Pvyd10 ST a No. 0 Date ��d� MORTM TOWN OF NORTH ANDOVER x Certificate of Occupancy $ ��s'••°•E��' Building/Frame Permit Fee $ MUS Foundation Permit Fee $ Other Permit Fee $ TOTAL $ r Check # 6 �( a Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT•REPAI RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING aT . rn BUILDING PERMIT NUMBER: DATE ISSUED: r © X SIGNATURE: Buildin Commissio effl for of BuildingsDate Z SECTION 1-SITE INFORMATION O 1.1 Prop y Address: 1.2 Assessors Map and Parcel Number: Map Num Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning Distrid Proposed Use Lat Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided R red Provided v 1.5. Flood Zone Information: 1.8 Sewerage 1 Sys tem: D 1.7 Water Supply M.G.L.C.40. 54) �8 �P� Public ❑ private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ I al SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT ' rn 2.1 Owner of Record Name(Print) Address for Service: Signature Telephone —� 2.2 Owner of Record: > i. Na'nte Print Address for Service: O Z m Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Constru tion Supe tsor: ' Not Applicable ❑ �)aV ( S 6� ) I`e� rnLoa I Licensed Construction Supervisor: Do( O License Number an Address 0 o 05 � ic Signature Telephone Expiration Dat r 3.2 Re6istered Home Improvem nt Contractor Not Applicable ❑ v Compa y Name ) r l U Gag �l�(L r7 Registration Number Address r r Expiration Da e ^ Signature Telephone Y♦ i 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 a llcable New Construction ❑ Existing Building ❑ Repair(s) Alterations(s). ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: Lx/ rl do a14 f M # SECTION 6-ESTIMATED CONSTRUCTION COSTS •Item Estimated Cost(Dollar)to be OFFICIALUSE ONLY Completed by permit applicant 1. Building 90 (a) Building Permit Fee 94"' Multiplier 2 Electrical /- &0 (b) Estimated Total Cost of (� Construction 3 Plumbing d 0 Building Permit fee(a) X (b) 4 Mechanical HVAC / © _/" 5 Fire Protection C� 6 Total 1+2+3+4+5 6c- C90 1 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in all in r elative to work authorized by this building permit application. Signature of er Date l j SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, 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 in 2 NU 3Rz SPAN DIMENSIONS OF SILLS ' DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS n 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 North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. The debris will be disposed of in: F* (Location of Facility) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector lklln—X.. G W The Commonwealth of Massachusetts Department of Industrial Accidents d Office of Investigations Boston, Mass. 02191 Workers'Compensation Insurance Affidavit Name Please Print Name: q U C9 (e Location: 3/)- �b-,L City /V kw i &Y-1VL— Phone # 0 I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Company name: 'A Address C V r6 km(Ln City: / r 1i �� � Phone- insurance honeInsurance Co. - -- _-- Policy# Company name: Address City: Phone#: Insurance Co. Policy# 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 and/or one years'imprisonment_as_well_as.civil..penattlesinkefnrmda_STOP WORKORDER..and..afine_af.($1.00.00)-as*.against.me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pai d penalties of perjury that the information provided above is true and correct. Signature 01 Date J '" Print namec�U( CL (J ter? Phone# Official use only do not write in this area to be completed by city or town official'" City or Town Permit/Licensing Building Dept []Check if immediate response is required ❑ Licensing Board Contact person: ❑ Selectman's Office Phone#: ❑ Health Department ❑ Other 0ORTlt Town of North Andover "_ID °�" S �? a��+ •e AL Building Department 27 Charles Street North Andover, MA. 01845 �,S�•��� S 1CHtts D. Robert Nicetta Building Commissioner (978) 688-9545 (978) 688-9542 Fax HOMEOWNER LICENSE EXEMPTION Please print. DATE JOB LOCATION Number Street Address Map/lot "HOMEOWNER Name Home Phone Work Phone PRESENT MAILING ADDRESS City Town State Zip Code The current exemption for"homedwners"was extended to include owner-occupied dwellings of two units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor: (State Building Code Section 108.3.5.1) DEFINITION OF HOMEWOWNER: Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures ac- cessory to such use and/or farm structures. A person who constructs more than onehome in a two-year period shall not be considered a homeowner. The undersigned"homeowner'assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned"homeowner'certifies that he/she understands the Town of No. Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFICIAL NORTH Town of 2 t a L Over 0 L__ a. dover, Mass., T ° LAKE COCHICHEWICK y �!,9 A°RATED BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT.......... �i C ` � I Foundation r�lN o� N �( n has permission to erect..A.44...... ......... buildings on la d Rough ..... .. ........................................................ Rto be occupied as.....118.Alm....xv. . ....'....03-4N .... 1 .# ............. Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-La s r lati g to the Inspect' n, Alteration and Construction of Buildings in the Town of North Andover. 7 f` D � w PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. , Rough Final PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRU O ST TS ELECTRICAL INSPECTOR Rough .. .. .. .. 410101016001111106.............................. ... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT j Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. ' Date.. . . . . .. ... .'�.J:... . I '10 h of TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION •'ty SSACMUSEt This certifies that . . . . . . . . . . . . . . . : . . . . :`. .�. . . . . . . . . . . has permission for gas installatiori . :':. . 7' . . . . . . . . . . . . . . • �i j in the buildings of . . �'.:-. -� . . . . . . . . . . . . . . . . . . . . . R at . . . ... . . . . . . . . . .. . . . . . . . . . . . . . . . . . . .. North Andover, Mass. Fee.:.-. . Lic. No. :: . . , ..... . . . . . . . . . GAS INSPECTOR V Chlleck#7 J . / J MASSACHUSEI'IS UNIFORM APPUCATON FOR PERMIT TO DO GAS WrING (Type or print) Date //,?/o 2- NORTH ANDOVER,MASSACHUSETTS Building Locations 34 C L14yzr1U0j;J 6T � Permit# /gI.�I2IJVCl2 Amount$ �S^dam' n4 4-1 Owner's Name New❑ Renovation ❑ Replacement Plans SubmittedVj ❑ � a z W W W p OUCA g E.Wx O O 3 WW9W 0 H W C zg z °W OaqW F o O wa � w A a U x > q F O SUB -BA SEM ENT BASEMENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . FLOOR (Pitnt or type) Check one: Certificate Installing Company Name (7!p(/11'J /9, C��/ Si ❑ Corp. Address 36 T PZ L=-=1 ❑ Partner. ylitCTlfiJc/.v �t✓'S. Business Telephone 97 6S—7 />3 ❑'lirm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑/ No❑ If you have checked yes,please indicate the type coverage by checking the appropriate box. Liability insurance policy ' Other type of indemnity ❑ Bond ❑ r Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. t Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code a ter 142 of the General Laws. BY: Signature of Licensed Plumber Or Gas Fitter Title ❑ Plumber City/Town ❑ Gas Fitter License Number ❑ Master APPROVED(OFFICE USE ONLY) n-10,urneyman -� Location No. Date f TOWN OF NORTH ANDOVER * . , Certificate of Occupancy $ s��N�s Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # ��7 Building Inspector r � TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT ELAII RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING �fbrL' BUILDING PERMIT NUMBER DATE ISSUED: «_ rn SIGNAasai TURE: Building Commissioner/Ingxctor of Buildings Date SECTION 1-SITE INFORMATION Z 1.1 Property Address: 1.2Map and Parcel Number: O Map Number Parcel Number 21 olz rd -0(937 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area Fronts ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided ReqWred Provided 1.5. Flood Zone Information: 1.8 Sew 1.7 Water Supply M.G.L.C.40. 34) erase Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ J SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 116.!.0%i i{: Uicti'iCt: rn7 2.1 ner of Recgrd 6 N, Name(Print) Address for Service q 7� S�5 >7c/S' v Signature Telephone 2.2 Owner of Record: s 1 A*-ne Print Address for Service: 0 it z Signature Telephone M SECTION 3-CONSTRUCTION SERVICES Q� 3.1 Licen ed Constructi n S ' or: pa ,V r 9 upery��Z Not Applicable ❑ Ir�,IU / Licensed Construction grvisor: ©' License Number Address Signature Telephone Expiration Date 3.2 Regist red Home Impro31nt Contractor `�7i� Not Applicable ❑ Company Name g—o Registration Number Address 00 G) �� / _ r Expiration Date Si nature � Telephone i { SECTION 4-WORKERS COMPENSATION(MG.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 a0 applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: G,'4 cg v-2 Oaf /l ali owe, r-w4 t ig'x 1 e r1o, 2 c[ �K 1�ea r �,� wvr dCV r a rd�e cl SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant 1. Building �D ©Q (a) Building Permit Fee Multiplier 2 Electrical n (b) Estimated Total Cost of Construction 3 Plumbing °Ley, CPU Building Permit fee(a)x (b) ^, `•rl `�� 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZA ON TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION { U II, hcwA' .ei q o as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are L.nre and accurate,to the best of my knowledge and belief r ] Print Name 3-�'^^ -7 � — Si ature of Owner/Agent Date Wy 1 7 NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2ND3 SPAN DrNIENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHRV NEY 1S BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE aa3e�;siuiwPV Sti8to VW '1i3AO(3N*4N 11nOV3le19Zt► s, [+tHt73Z3'111J d QUtbt] t Zi'Z9 .tau'al 90o;VZ0/01 :seaidx3 w i(yy Jp asHgwnN 21()SV vacins NE?1J 3t12t1SNC30 :e 4'1 $11410110"03111 0"'".40 QWWO8 - _ - Board of Building Regulations and Standards " HOME IMPROVEMENT CONTRACTOR Registration: 120199 Expiration:`11!1!2006 Type: individual DAVID GULEZIAN �s DAVID GULEZIAN 428 PLEASANTmST NORTH ANDOVER,MA 01845 Administrator N. M The Commonwealth of Massachusetts A > Department of Industrial Accidents Ofke of Investigations Boston, Mass. 02111 Workers'Compensation Insurance Afidav# Name Please Print Na : r�� I am a homeowner perfomiing all work myself. 0 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: h �-- ► 11 Ad dress Cft l insurance Co. JL (0 PnIfew -7c/ Company name: , Address Cthr Phone# Insurave Co. Pokv a Failure to secure coverage as required under section 25A or VIOL 152 can lead to the imposition of criminal penaltles of,a Ane up to;1.500.00 andfor one understand that copy of atement may be forwarded to the Office of In'Impris0l"On-n-YAW-101-clIA4=21068 Into hm dA nvvestl �DI'jar��1�.��� °� I 9 ops vsriAcptlon. I do hereby cert ry un70' end penalties or penury that the Intbrmation provided above!s true and carsct Signature Date °r?C Print name Phone# Official use only do not write In this area to be completed by city or town o filar City or Town P ensi []Check d Immediate response/s required ❑ Building Dept Q Licensing Board Contact person: ❑ Selectman's Office Phone m ❑ Health Department ❑ Other North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. The debris will be disposed of i (Location of Facility) Signa ure of ermi Applicant ate NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector NORTH It Town of over Z/ 7Y - t c, 1. -= - o y dover, Mass., o LA COC MI CNE WICK V 7�ADRATED PPa` �cb BOARD OF HEALTH Food/Kitchen Septic System PERMIT T BUILDING INSPECTOR THIS CERTIFIES THAT...................v...................�.........twx.i•ON.. ............................................................... Foundation CIA N S has permission to erect.../.�.SAYI�....... buildings on... 4............................���.............................. Rough to be occupied asgo f OI.AS C= 4 GVI f D ills ` 0 Chimney p )R*.p��•...........I .'w.........�.................. ............ ........................................... .......... provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Ake tion and Construction of Buildings in the Town of North Andover. O ay,� /fit �C J10 V PLUMBING INSPECTOR R VIOLATION of the Zoning or Building Regulations Voids this Permit. G q /3 /, Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE___Jl Smoke Det. rs' Collaborative, Inc. p.a_ Box 7. Wakefield. MA n1BSO 7BI-245-55SB2 - 7B-1-224-3ss3 FAX 7H1-2�5--S0SS FIRE ?A ! ENT OR Til: VILDING C07AMISSIONER. OR BOARD flF � T��� AR N UAD INsprc3CR OF BUILDINGS HARD D �.3�1D� TOWN OF NO A DO TOWN HALL. NO ANDOIxER M,0. i RJE: 1311SDRFD: Ann F. annel1 pRDR�� ':�vRLSS J j HP 1554478 T';>_ i�Ss Water Dara C DSS OF: DrDDiar 1- r�',?5-rli��ii�� va ull� e �a� ct:� :nvoolvi - loss, da.Ia D4 1 "Zt�L � "._ttJ?]-^ _o � e-"c eO SJ ,v�J'�- � {33' l'i5e Jar ^S iS �'J�? ;�i3i's_s�, e?Sc k133 it 3 w:a� -.�' ? un'de- i'lass n. i„?,,5� i,�. , _? a =1i733�r 3nsi , av 3 L. _ nce writer er aind I n lova -ion, pc)31_�' abe', a D� 3Dss and cla3D or Le i3 �+2 Sin w =a - ersuiis pane� C=_05=4 copies ca S.a = class mai 7 3 - =3L"to 'Lila ►=rS� '- ` - � 2�•tts�a?-s or 3 7i5233'a:-.S to r �tQ7� ai�� il{e �C%D3er 23, 1 $D, 'Ml s- House ± 3 �' or www n 'x':13 cn a 1 S5 ;10-i ,y the Fire .Dai�- or Arson.Squad D7 iia city or more is sus-z?i ne' m a building. - R C Gonnnram Sid j,-vL+ RECEIVED DEC 2 7 2004 Merrimack: Mutual fire-Ins Co. iomP��y. BUILDING DEPT. 12116/04 Date