HomeMy WebLinkAboutMiscellaneous - 34 CAMPION ROAD 4/30/2018I
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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that A'........1S P.c ...v. ....'
..j7----
has
........5:.S..r.... .f.........
permission to perform . y............l
i%/ �G �G X141 17
wiring in the
%building of.................%f...........................................................
L �''"�,b r7 I�
at ...... Y..... .................... .............../.......®, North Andover, as
Fee....�5.......... Lic. No.....c�s... ......../si.%...:...........:.':.f......
/ELECTRICAL INS CTOR
Check #
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t
/� �1,/ o/ —_----- Official Use Only —
t✓ommanwers lf(a�dcu�ccdnl nl
o(Je�arfrrlonf oue ��ervice9 Permit No.
Occupancy and Fee Checked
BOARD OF FIRE PREVE"!TION REGULATIONS [Rev, 1/07j _ (leave blank)_ --_
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code NI TC), 527
GMT?. 12..00
(PLEASE PRINT IN INK OR TYPEALL INFORPM TION) IDate: l_f/ aCi or Townof: _ f 1 t: � 2 - �� - —
' - ���t� Tot .e Inspector of Wi. es.
By this application the undersigned gives notice of his or her intention to perforin the electrical work described below.
Location (Street & Number) t_-� J_J 0/1, M njAl -
Owner or Tenant
C
Owner's Address
Is this permit in conjunction with a building permit?
Purpose of Building -
Yes [] No W
Telephone N
(Check Appropriate Box)
Utility Authorization No.
Existing Service Amps/ Jolts Overhead ❑ Und rd
g �1 No. of Meters -_—_
New Service Amps / Volts Overhead ❑ Undgrd U No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Comoletion of the following table may be waived by the InsDector of Wires.
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
No. of Total
Transformers —_ KV A _
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
_ ,Above In- —
Swimming Poo,
_ grind._ 1.
--�rnd.C
o. of mergency L,>g .> ing --- --
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
_
FIRE ALARMS No. of Zones _
No. of Switches
No. Gas Burners
No. of Detection ai d
of
I,.itiatinK Devices
—
No. of Ranges
___ _ _
No. of Air GonTatald, Tons
--
_ _
No. of Alerting Devices
—
No. of Waste Disposers
_
HeatPuNu►nbe,� I:otos-_' KNV ..
•r .. ...
_ _ i _ _
No. of Self -Contained
Detection/A3erting Devices
No. of Dishwashers _
Space/Area Heating KW
Loc connection ❑ Other
No. of Dryers
Heating Appliances KW_S
curity S
v
No..of Water
Heaters KNYBallasts
No. of No. of
Signs
es or Equivalent
Data
No. of Devices or Equivalent
No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring:
__---- ------ -- --__—_--No. of Devices— or Equivalent
— .... ..__ N -i
—
OTHER: 3100 °1
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of El ctrical Work: � —_ (When required by municipal policy.)
Work to Start:inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE C E GE: 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 [JJ BOND f_1 OTHER ❑ (Specify:)
I certify, under the. pains and penalties of perjury, that the 'n ormation, on this application is true and complete.
FIRM NAME: _ Se r_� Se t LIC. NO.: ��51
Licensee: (Y� r'} ",JiW' 1 Signator _ ti LTC. NO.. C ��
(ijapplicable, enter "exem t"in the 1;ce.nse number � e s T (o ?rib
Address: 1 G� t,�" or �� r. 1�p �U, 14 03o Bus. el. No..
Alt, Tel. No.:
*Per M.G.L. c. 147, s. 57-51, securiry work requires Department of Public Safety "S" License: Lic. No. Oo 53 —
OWNER'S INSURANCE WAIVER: I ani aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. 1 aurthe (check: one) G owner U own 's aeent.
Owner/Agent
Signature --__ Telephone No. PENT FEE: —_—
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Location Ir
�
No. zig v Date ,' 9 u
TOWN OF NORTH ANDOVER
9
s ' Certificate of Occupancy $
• i ;
JCMUS <� Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
TOTAL
Check #
1754
$ C
Building Inspector
` TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER: DATE ISSUED:
e
SIGNATURE: If 14vt
Building Commissioner for of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
!�J
Map Number Parcel Numbef
1.3 Zoning Information:
1.4 Property Dimensions:
Zoning Diaiic—t Proposed Use
Lot Areas Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Required Provide Required Provided
Required Provided
1.7 Water Supply M.GL.C.40. 54) 1.5. Flood Zone Information:
1.8 Sewerage Disposal System:
Public ❑ Private 0 Zone Outside Flood Zone 0
Municipal ❑ On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
for
Nam (Print) Address Service
Signature Telephone
2.2 Owner of Record:
9
Name Print Address for Service:
V
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Co truction Supervisor:
Not Applicable ❑
e
L A
ieensed Construction Supervisor:
License Number
r
Address
l /(�
CJ U
Expiration Date
ature r Telephone
3.2 Registered Home Improvement Contractor
Not Applicable ❑
Company Name
Registration Number
Address
Expiration Date
48Signature Telephone
Ma
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SECTION 4 - WORKERS COMPENSATION (NLG.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 ❑ 1 Existing Building ❑ I Repair(s) ❑ Alterations(s) ❑ 1 Addition ❑
Accessory Bldg. ❑ I Demolition ❑ I Other ❑ Specify
Brief Description of Proposed Work -
1 SECTION 6 - F.STTMATIRD r0NSTU1TrT1nN rnCTC t
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) X (b)
4 Mechanical (HVAC)v
5 Fire Protection
6 Total 1+2+3+4+5
Check Number
aL%-llUiv is UWtvtK AUlrlUK1LA11UN 1'U BE C:UMFLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, ' , as Owner/Authorized Agent of subject property
Hereby authorize to act on
My beha ; in al)tmatter. relati ork authorized by this building permit application. O
Si e of r Date
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
of Owner/.
Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 1 2 ND3
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
a& Worn, OMMald of rfw,�atts
m jxment of Indrr.�Aaidenu
of Tnvatoatiow
600'4 ah St?W
(Boston, ate 02111
Wo kM, Cetttpenasaon Insurance Affidavit
FjTrn • i.go 4174FIA
Locaron:
City; Telephone #:
t
O I am a homeowner performing all arork myself.
arr sole proprietor and have RO one working ffi sty Ca acitY
D I am as employer provitiing workers' compensation for my employees working m this job
Company Name: "
Address:
City : �
Tei hone #:
Iuuncs cons a� Policy #: �� 7 �1 6 A 43
nsag
p y
G 1 am (efrcle one) sole proprietor, general contractor, or homeowner and have hi.rta •be contracters l:{t4 below who have the foliowing
workers' compensation policies: r "
Company Name:
Addtc�;
Insursace Company:
Company Name:
Address:
Telephone #:
Policy #' -
City. Teiephone #:
Insurance Company;
Policy #-
Attach additional sheet if necessary
Faiiu m to secure coverage as regsired under Secuor. 25A of MGL 15B can lead to the =position of criminal penalties of a fine up to S1,500.00
and/or one years' imprisonment as well as civil penalties in the form of it STOP WORD ORDER and a fine of S100-00 a day again- me. I
understand that a copy of this statement may be forwarded to tba Office of Imeedgatiions of the DIA for coverage verification.
I do hereby aerrfb- sunder the pains and pen.Sittes of perjuryy that the information above is true and correct
Of Icial Use ONLY - Do not wrlte In this are
I
Swiding ,)apartment
'try orTv,, riPetmttJl.icense #'. _ -- C L;rernsinp itcarC
o Selectmen s ofte
C :Health Gesartrnent
C Check If ImmediHte response is requiroa C Otr'ar
�l b Castricone Roofing & Siding
.� REPAIRS FREE ESTIMATES
Telephone 978 682-4266
MARIO CASTRICONE
31 Court Street, North Andover, Mass. 01845
I/we, the owner (s) of the premises mentioned below, hereby contract with and authorize you as contractor, to furnish all necessary
materials, labor and workmanship, to install, construct and place the improvements according to the following specifications, terms and
conditions, o mises below
�� described:
Owner s Name...... AAOW/.fl.............
.. .. ... .. ..
? .:'L ..
Job Address j.�...1_ i .................................................City. ,t�........ State........... .............................
SPECIFICATIONS
...... r... ......... ,.......... ..._......................................................................I...............
...................................................................................... ..`...?,
..................................................................:................................................................:.........................................................................................
. ..
Materials and labor to cost.L1�....................... Payable .... ........ .�........... on and balance in.........
monthly installments of $ .........................................each, payable on ........................................day of each and every month thereafter until paid
in full (..............% charge per year is to be added to above cost of labor and materials and is included in monthly payments.)
.Contractor will do all of said work in a good workmanlike manner.
'Upon completion of above work, all undersigned agree to execute and deliver to contractor, their joint note in accordance with his (their) above obligation anc
completion as requested by the contractor. Upon refusal to do so, contractor may at its option declare the entire contract price or so much as then remains unp-,
immediately due and payable. It is agreed that if permitted by law contractor shall be paid by the owner(s), all reasonable costs, attorney fees and expenses,
addition to the amount due and unpaid, that shall be incurred in enforcing the terms and conditions of this contract and/or any lien in connection therewith.
It is further agreed that this contract may be assigned by contractor; and also that the obligations hereof shall bind and apply to their heirs, successors or estat
of the parties.
The undersigned warrant(s) that he is (they are) the owner(s) of the above mentioned premises and that legal title thereto stands of record in his (their) name(
PROVISO: This contract shall be void and of no effort if credit approved of owner(s) is refused.
There are no representations, guaranties or warranties, except such as may be herein incorporated, if any, nor any agreements collateral hereto, nor is ti
contract dependent upon or subject to any conditions not herein stated. Any subsequent agreement in reference hereto shall be binding only if in writing and sign
by all parties.
Cover attic storage cleaning not included.
Receipt of a copy of this contract is hereby acknowledged, and it is further acknowledged by the undersigned that the foregoing provisions have been read a
the contents thereof understood and that no representation or agreement not herein contained shall be binding upon the parties and that all of the agreements a
understandings of said parties are contained herein.
Owner or Owners are not responsible for Property Damage or Liability while job is in operation.
IN WITNESS WHEREOF, the parties have hereunto signed their names this ............... day1..
Accepted: a���'• .
Si................................
....::�.............
wner
WNER HAS 3 DAYS IN WHICH TO CANCEL CONTRACT)
Per. t,Lc ...... tib.�l........................
Representative
Signed......................................................................................
Owner
Signed......................................................................................
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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ..........
.........................................................
1 1 14�
has permission to perform...................... . ................ ;7!7 .......................................
wiring in the building of ................. ............... ........................
, .1 1 7"2 . ......... .
................................................
at ......... North Andover, Mass.
Fee....... / . . .... Lic'. ..................................................................
ELECTRICAL INSPECTOR
Check#
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
IRE WA MULMPAL7H UP AL4)i"- (;HU6P1J Ill' uttice use only
UVA DEPARTAIrWOFPUBLICS4FM Permit No. �Z
BOARD OFMEPREVEM70NRECUL4TIONSS27CMR 12:00 Occupancy&Fees Checked
PPLICATIONFOR PERMIT TO PERFORM ELECTRICAL WORK
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dat / L u
Town of North Andover
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number)
Owner or Tenant
Owner's Address
CA,m P10 )
G t-&"VN/q
Is this permit in conjunction with a building permit: Yes [2' No (Check Appropriate Box)
To the Inspector of Wires:
Purpose of Building /moi✓ N1 4-c-- Utility Authorization No.
Existing Service Amps / Volts Overhead M Underground r7 No. of Meters
New Service Amps / Volts Overhead Underground No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work
No. of Lighting Outlets
No. of Hot Tubs
No. of Transformers
Total
ZZO
KVA
No. of Lighting Fixtures
Swimming Pool Above
Below
Generators
KVA
10
and
ound
No. of Receptacle Outlets
of Oil Burners
No. of Emergency Lighting Battery
Units
-7—DNo.
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS
No. of Zones
No. of Ranges
No. of Air Cond. Total
/
Tons
No. of Detection and
No. of Disposals
No. of Heat Total Total
Pumps
Tons
KW
Initiating Devices
No. of Sounding Devices
No. of Dishwashers
Space Area Heating KW
No. of Self Contained
Detection/Sounding Devices
LocalMunicipal
Other
No. of Dryers
Heating Devices KW
Connections
No. of Water Heaters KW
No. of No. of
Signs
Bailasis
No. Hydro Massage Tubs
No. of Motors
Total HP
I ---
OTHER
IrmartxcuAr�tge Ramat btheteguitmirtsdhsadtsmsGatealLaws YEL—,
NO
Iha�eaamagLiabt7dyhstxanoePblxyutigCotVeUe a • ageo �strt♦ialec�uvala�t YES
lhavest.km2advandpoofofsm=1othe0Tw-YES O If}puha%e&odwdYESpimesdc&thetWcfwmaWbydmkirtgthe
BOND OTHER ftwe)
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E5quab n Dw
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Estim"VahtedU t %A Wads $
Rough ��Av Fatal
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Lice wl,b 4 Z 7 x C, S�
fssTeLNa bo 3 3sz-Z��N
,w0v�i i lM ��^' "i{ d 3k�J AIL Tel.NU
OWNER'SWAIVER;ta<nawatethattheL=sedoesttheinstra=wv=Wonissubeiia> We*nda>tasm4medbyMassada>ctsCtnffdLaws
and drtn yWmkseonthspeunit twaivesthista i.
(Please check one) Owner a Agent
Telephone No. .PERMIT FEE $ '/�5
Date. /" . // � c
No 4.
TOWN OF NORTH ANDOVER
. O
° p PERMIT FOR PLUMBING
This certifies that ...�•••••••••••••••
has permission to perform ....��.�..� �.�.`.a'•`• '. • •
plumbing in the buildings of . "c. `" ........
at ...3..
.......... 1; North Andover, Mass.
Fee. Lic. No.... `:..'........... .:....... ....c-- . -.7.-... .
PLUMBING INSPECTOR
Check # % �L
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
jP
11
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building
New F1
Renovation
Type of Occupancy
Replacement
FIXTURES
Plans Submitted Yes
Date
Permit # 7 7y
Amount
No 11
(Print or type), Check one:
Installing Company Name A U-1 I L' Corp. _
t
Address ? y� Partner. .
Business Telephone _� 4r'-,//9 J 9 Fi�Co.
Certificate
Name of.Licensed Plumber.
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy �� Other type of indemnity Bond ❑
Insurance Waiver. I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner F� Agent Q
I hereby certify that all of the details and informatio a submitted or entered) in above applica ' are true and accurate to the
best of my knowledge and that all plumbing work dins . Mations der Perm su fo this application will be in
compliance with all pertinent provisions of the M sachu7etts Sta m Chap of the General Laws.
Title
City/Town
APPROVED (OFFICE USE ONLY
Type of Plumbing License
ice seu er Master Journeyman ❑
J 5 J Date ..................... .
„pRTH TOWN OF NORTH ANDOVER
,e,1�00L
p �
PERMIT FOR GAS INSTALLATION
F F
s •
i y i
�,SSACHUSEt
s
This certifies that � .. ...................':.......... .
has permission for gas installation ..............
in the buildings of :.............:.........z .................. .
at .. . ............................... . North Andover, Mass.
Fee.. ..:.. Lic. No.......:�.. ........................
GAS INSPECTOR
r
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING$�
_ (Print pr Type)
_�irL�` _glass. Date X2000 Pcrmit
_ /�j
Building Location�y fin, '� 0j- Owner's Name / l CbnAan
�? X3/I
`�, •% — J Type of Occupancy_
New k Renovation ❑ Replacement ❑ Plans Submitt : Yes❑ No ❑
Installing Company Name TOWNSEND OIL COMPANY
Address 75 WEST MAIN STREET
-- GEORGETOWN MA 01833
Susiness Telephone 978-352-8711
Check one: Certificate
Corporation
❑ Partnership
❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter REN JACKSON
.*fS�,URANCE COVERAGE:
I nc'Y a current liability insurance pc,icy or its substantial equivalent which meets the re:uire,i encs of MGA Ch. 142.
Yes U No ❑
If you have checked s• please indica'e the tyke coverage by checking tine a.pprcpra`,e t•_,.
A lizbil;jr insurance policy LX Gt^er tyrc of irtie,-n;ty Bond
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by
Chapter 142 of the Mass. Genera! Laws, a. -,d tha' my signature on this permit application wz:ves this requireiment.
Check one:
0Yrner❑ A_ent ❑ .
&gnature of Owner or w.'ner'S
I hereby ce &ry that a;l cf the details and information I have submitted (cr entere•�) in above application are true and accurate to the best cf my
k^,cw'edge and that e piumbing work a:,d insta'la'icr,s per`o :ed under Lhe permit iss ed for this app(ica,ion *, H be in compliance with a`i
pe„irert proyisicns of Ltie hdlss.ad-�use"s State Gas Code and Chapter 142 of the General Laws.
FFI—C-E-
T -� of License:
Plumber Signature of Licensed umber or G Fitter
Gasritter 978
aster License Number
Journeyman
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SUB—BSMT.
BASE 4!c NT
1ST FLOOR
I
2ND FLOOR
3RD FLOOR
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4TH FLOOR
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6TH FLOOR
7TH FLOOR
STH FLOOR
Installing Company Name TOWNSEND OIL COMPANY
Address 75 WEST MAIN STREET
-- GEORGETOWN MA 01833
Susiness Telephone 978-352-8711
Check one: Certificate
Corporation
❑ Partnership
❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter REN JACKSON
.*fS�,URANCE COVERAGE:
I nc'Y a current liability insurance pc,icy or its substantial equivalent which meets the re:uire,i encs of MGA Ch. 142.
Yes U No ❑
If you have checked s• please indica'e the tyke coverage by checking tine a.pprcpra`,e t•_,.
A lizbil;jr insurance policy LX Gt^er tyrc of irtie,-n;ty Bond
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by
Chapter 142 of the Mass. Genera! Laws, a. -,d tha' my signature on this permit application wz:ves this requireiment.
Check one:
0Yrner❑ A_ent ❑ .
&gnature of Owner or w.'ner'S
I hereby ce &ry that a;l cf the details and information I have submitted (cr entere•�) in above application are true and accurate to the best cf my
k^,cw'edge and that e piumbing work a:,d insta'la'icr,s per`o :ed under Lhe permit iss ed for this app(ica,ion *, H be in compliance with a`i
pe„irert proyisicns of Ltie hdlss.ad-�use"s State Gas Code and Chapter 142 of the General Laws.
FFI—C-E-
T -� of License:
Plumber Signature of Licensed umber or G Fitter
Gasritter 978
aster License Number
Journeyman
SOS ONL
Location¢
No. S5 Date
NORTH Of
tiTOWN OF NORTH ANDOVER •`'D '•.�0
i? • OL
F p Certificate of Occupancy $
Building/Frame Permit Fee $ �5
Foundation Permit Fee $
� s�cHus t
Other Permit Fee $
Sewer;Corrnection Fee $
Water Connection Fee $
TOTAL
[JUN
IPP4 Building Inspector
6129 Div. Public Works
Location
No.
04
Date
NORTH TOWN OF NORTH ANDOVER
O
p Certificate of Occupancy $
_ Building/Frame Permit Fee $
foundation Permit Fee $
2 Other Permit Fee $
Sewer Connection Fee $
N Water Connection Fee $
TOTAL $
Q v�
Building Inspector
Div. Public Works
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FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
"PLICANT: ,Z�cd,(�eJ L Phone 6 fx0 6-2
LOCATION: Assessor's Map Number Parcel
Subdivision / Lot(s)
uzstreet �/dl�/G `r �c+ St. Number c3
************************Official Use Only************************
COMMENDATIONS OF TOWN AGENTS:
' 1>5V �� Date Approved -6 1 [q13
Conservation Administrator Date Rejected 6 J
Comments
Date Approved
Town Planner Date Rejected
e '
Comments
Date Approved
Food Inspector -Health Date Rejected
Date Approved
Septic Inspector -Health Date Rejected
Comments
Public Works - sewer/water connections
- driveway permit
Fire Department
Received by Building Inspector Date
Location 3V L , f l% )I (JAJ Pd
No. 3(0-s- Date
d
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
TOTAL
Check # )�/��
14 7
S
,6-a
Building Inspector
1.1 Property Address:
3 y QR6 Ccs t,x, 10
1.2 Assessors Map and Parcel
Number
Number:
Parcel Number
NMap
1.3 Zoning Information:
Zoning Diaiic—t Proposed Use
1.4 Property Dimensions:
Lot Areas
Frontage ft
1.6 BUILDING SETBACKS ft
Name (Print)
Front Yard
Side Yard
Rear Yard
Required Provide
Required Provided
Regaired
Provided
2.2 Owner of Record:
1.7 Water Supply M.G.L.C.40. 54)
Public ❑ Private ❑ Zone
1.5. Flood Zone Information:
Outside Flood Zone 0
1.8
Municipal
Sewerage Disposal System:
❑ On Site Disposal System ❑
an'4 > >tvnl z- - rKvrLKI T vwlvrKarilY/AU lriVKlL.lSll A(GEN'1'
2.1 Owner of Record
18 let MC Lennmyl
3 `/ pct
gra
Name (Print)
Address for Service:
^
—330
Signature Telephone
2.2 Owner of Record:
Name Print
Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable
❑
-Y-&s
Licensed Construction Supervisor:
475: a 7
/ 4ve
License Number
(� I #T4ll � 4 �4
�ea-3S
Addre
1
1117
V
1 J O
2
Expiration Date
S'r ature Telephone
//
3.2 Registered Home Improvement Contractor
Not Applicable
❑
S4"e_
16,305-V
Company Name
Registration Number
Al /,Q
Address
%
�
Expiration Date
Signature Telephone
T
rn
M
e
Z
0
f -1
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 ....... K No ....... ❑
SECTION 5 Descri tion of Proposed Work(check all applicable)
New Construction ❑
Existing Building ❑
Repair(s) ❑
Alterations(s)
Addition ❑
Accessory Bldg. ❑
Demolition ❑
Other ❑ Specify
Brief Description off/ Proposed Work:
Ke,OtQLte n licks 4 e glao,r 4 ulin' e'cl glaze. ,,-e;i
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
OFFICIAL USE ONLY
1. Building
0
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
100
Building Permit fee (a) X tbl
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5
Cp
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, , as Owner/Authorized Agent of subject property
Hereby authorize to act on
My be f, in all matte relative to work authorized by this building permit application.
Si f e of Owner Date
S CTION 7b OW ` ER/AUTHORIZED AGENT DECLARATION
as Owner/Authorized Agent of subject
I r/ebyNdeclare.
H that a statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
71 akq
Print ame 1
Jd l/8'�0
S-Vnature of Owner/ ent Date t
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR T ABERS iST2 ND3 RD
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
w
✓rie �omnouaea��i o� i7%aaaac�,u
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 047567
Birthdate: 11/07/1963
Expires: 11/07/2001 Tr. no: 9075
Restricted To: 1 G
JAMES H LYONS
261 HYATT AVE
BRADFORD, MA 01835
J1.
HOME IMPROVEMENT CONTRACTOR
Registration: 103054
Expiration: 7/6/02
Type: Private Corporatio
Lyons Home Inc
James Lyons
ADMINISTRATOR 261 Hyatt Ave.
i Bradford HA 01835
Administrator
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.
01 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: i.V�� s/aYncs 1y c
e_
City' l� /`a i vJ c� r�Lr d!& 3 � Phone # 9 81 37 ,)od /,I
Insurance Co. CAI /i Policv * 6S5 A —a
Company name.
Address
City: Phone #
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 penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day 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 herby certify under the pains and penalties of perjury that the information provided above is true and correct.
Date _ /0 //g/o s
Print name Phone # �17� 37aaaGa
Official use only do not write in this area to be completed by city or town official E] Building Dept
❑Check if immediate response is required Building Dept ❑ Licensing Board
❑ Selectman's Office
Contact person:_ Phone #: ❑ Health Department
❑ Other
FORM WORKMAN'S COMPENSATION
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-, Date . 72,23:-.9.S
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that ,.,..... , .. .
has permission to perform A:�� .7 huX.
plumbing in the buildings of .... X ..............
at.. 3'�- . �.r4-z-�-�.� /C?ru ..�. i�........ , North Andover, Mass.
Fee . .
I..a.
PLUMBING INSPECTOR
Check # 12-9A I�,��ZL
"} �t ►.� Y3� ►.a 1�
5672
A
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building
New r-1 Renovation
/ D W /C VWners N
Of
Date'TU.
M it/,y tq PU Permit #
Amount
Replacement aT
FIXTURES
Plans Submitted Yes 11 No
(Print'or type)
Installing Company Name
/
r� /'i1
-� t "�
�n/Vy
Check one: Certificate
El Corp.
Address 9-� G 6
i
11 Partner.
'�'/
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Business Telephone
s(
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❑
Firm/Co.
Name of Licensed Plumber: . Y 109L/T1 .4-2,
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy 1� Other type of indemnity ❑ Bond ❑
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner Agent
I hereby certify that all ofthe details and information I have submitte ,(or entered) in above application are 4
best of my knowledge and that all plumbing work and installation ed and ermit Issued forthi
compliance with all pertinent provisions of the Massachusetts to lumbing Code and C t r 42 rai
BY OR
1gn icens um er
Type of Plumbing License
Title �
APR"i
City/Town i ns um er Master ® Journeyman 19PPROVED (OFFICE USE ONLY
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FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: , E�/ J Phone LJ3
LOCATION: Assessor's Map Number Parcel
Subdivision /� DSU Lot (s) 0"?"
Street St. Number
************************Official Use Only************************
RECO NDATION OF TOWN AGENTS:
Date Approved
Conservation Administrator Date Rejected
Comments
Date Approved
Town Planner Date Rejected
Comments
Food Inspector -Health
Septic Inspector -Health
Comments
Public Works - sewer/water connections
- driveway permit
Fire Department
Received by Building Inspector
Date Approved
Date Rejected
Date Approved
Date Rejected
Date
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3 2 2 1 Date..7:.-,? . ....
v,O pT a ti TOWN OF NORTH ANDOVER o
PERMIT FOR GAS INSTALLATION
This certifies that . „TA (-.<. :;
has permission for gas installation. :.f
l
in the buildings of �e1 .6"/-- .................... ;S
at . ? .`!..��A ?`!?! ���... % `� �� ....... North Andover, Mas0s.
Fee. 3 .'.. Lic. No... < t. ?. �.. :.. �1.,.:-:L_: �. .........
,/GASINSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
Y
fid, �-
NORTH ANDOVER. Mass. Date 7/12 99 Permit # L �.
Building Location Owner's Name ALAN R _ M LENNAN
NORTH ANDOVER, MA Type of Occupancy SINGLE
New [N Renovation ❑ Replacement ❑ Plans Submitted: Yes[) No ❑
Installing Company Name TOWNSEND OIL COMPANY Check one: Certificate
Address 75 WEST MAIN STREET C$ Corporation
GEORGETOWN, MA 01833 ❑ Partnership
Business Telephone 978_352_8J1 1 ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter�'N JACKSON
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes i No ❑
If you have checked Vis, please Indicate the type coverage by checking the appropriate box.
A liability insurance policy ij Other type of indemnity ❑ Bond ❑
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.
Check one:
Owner❑ Agent ❑ -
Signature of Owner or Owner's Agent
I hereby certify that a!I 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 the permit issued for this ap lication will be in compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
By T of License:
Plumber Signature of Licen umber or Gas ter
Title Gasfitter
Master License Number 978
C ity/Town Plumber
APNIOY'ED (O ICE US ONLY
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Installing Company Name TOWNSEND OIL COMPANY Check one: Certificate
Address 75 WEST MAIN STREET C$ Corporation
GEORGETOWN, MA 01833 ❑ Partnership
Business Telephone 978_352_8J1 1 ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter�'N JACKSON
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes i No ❑
If you have checked Vis, please Indicate the type coverage by checking the appropriate box.
A liability insurance policy ij Other type of indemnity ❑ Bond ❑
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.
Check one:
Owner❑ Agent ❑ -
Signature of Owner or Owner's Agent
I hereby certify that a!I 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 the permit issued for this ap lication will be in compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
By T of License:
Plumber Signature of Licen umber or Gas ter
Title Gasfitter
Master License Number 978
C ity/Town Plumber
APNIOY'ED (O ICE US ONLY
i
Date. . ......
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that�
has permission for gas installation "i.
...........
in the buildings of . & �.t. .
at /1. ........ North Andover, Mass.
..........................
GASINSPECTOR
Check#
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E;t (ding Loc..a,ion ' C.ell,
Tyr- of O�c�ctin, y
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emar, O Pians Su�7i;,e-d: YesL It's
J
I'n'={ling
Con, pany Name TOWNSEND PROPANE SERVICES
Address 75 WEST MAIN STREET
GEORGETOWN, MA 01833
SU''siness Telephone 987 3528711
Name of Licensed Plumber or,Gas Fater L�L�fyA/�er
Check one: Certicate
GX Corporation
[[ Pa: tners,ilp
Firmlco.
11`:SURANCE. COVERAGE:.
I �.,a e a Cul
rre.t Ik?:!!!ty in sl:rance pc;:cY or its s 'bs`�nt:i'r'.•
a! ey :"r3:?i �} Ci ee'j t': re�J'.r -2rne ;' ,, ��`_ ,,. I �?
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