Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Miscellaneous - 345 BERRY STREET 4/30/2018 (2)
N_ O Location i2�"f"� No. I'?� Date', '� Check 41-15b 25905 TOWN OF NORTH ANDOVER 1 Certificate of Occupancy $ Building/Frame Permit Fee $154 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Building Inspector TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: S Date Iss IMPORTANT: LOCATION 3V Date Received icant must complete all items on this /\t, An d avel-r " 4 0 l 8c s - PROPERTY OWNER t) 0.vl l�-O k of t'¢, t& ( T Print 100 Year Old Structure MAP NO: �PARCEL:I_ ZONING DISTRICT: Historic District Machine Shop Village yes no yes no ves no TYPE OF IMPROVEMENT PROPOSED USE ResicLe6tial Non- Residential ❑ New Building� l?One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Akeration No. of units: ❑ Commercial Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: PQ- — irn o'f I S So. n' roof - OWNER: Name: L" Please. Type or Print Clearly) I9 Address: r'y` E w rt'y kT- CONTRACTOR Name: bj o qk� Gv*A-� f ('0054. Phone: S'? -GB?- Address: ?5-6 f' Supervisor's Construction License: CS lookG6_� Exp. Date: !� / Home Improvement License: 1 3S . Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASE ON $125.00 PER S.F. Total Project Cost: $ �{� D� FEE: $ S Check No.: Receipt No.: ;-a.ca s� NOTE: Persons contracting with unregistered contractors do not have access to the Ruarantyfund Signature of Agent/Owner Signature of contracto Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ElSta ped Plans ❑ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comm Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Tow Engineer: Signature: Located 384 Os000d Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signatureldate COMMENTS The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeEibly r Name (Business/Organization/Individual): r ((A It `� �S•�l`j �cj� cc cc) Yts f 3,tc� Address: R �'d 9 City/State/Zip: ff, f'l0" M iq � /fit/ S Phone #: 4 � 9 `6 99 -d-Y Are you an employer? Check the appropriate box: 1. L.r✓I 1 am a employer with .- 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. I ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ 1 am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] employees. [No workers' comp, insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. [:1 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.[9Other 9 4r rz-,�bdf I *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: rc,t ce Y ° / Policy # or Self -ins. Lie. #: (!J C S" 3 / 5- 38 ?1$7© ( X Expiration Date: ct L.?, 13 Job Site Address: ?VS Q,rrtiL S� City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certounder the pains an�penaltie perjury that the information provided above is true and correct. Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #• Cr 14 71, Cy 1A IV r('�NSTRut�MN This form satisfies all basic requirements of the state's Home Improvement Contractor Law (MGL chapter 142A), but does not include standard language to protect homeowners. ISeek legal advice if necessary. Any person planning home improvements should first obtain a copy of "A Massachusetts Consumer Guide toy Home Improvement" before agreeing to any work on your residence. You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757 or on our website. . Homeowner Nformation Contractor Information I ; Company Name a f1Ut�._4 �,CI CLL < +� �' lG 1' � ��S e C��,Sf►�u�� -Street Address (do not use a Post Office Box address) Contractor/Salesperson/ Owner Name 3 yS- cc City/Townv State ' Zip Code Business Address (must include a str address) V&4— M 4!,; d / S 5-0 Daytime Phone Evening Phone City/Town State Zip Code q ?9- ; Mailing Address (It different from above) Business Phone 973.6S f �„� Federal Employer ID or S.S. Number r Lmv [squires that most home Home Improvement Contractor Reg. Number Expiration date ors improvement cve Va validrcgistrntionnumber/3SS The Contractor agrees to do the following work for the Homeowner: (Describe in detail t e work to complette�d1,nspe/cifying the e, /brand, and grade of materials t.Qj be used, bus a d'tional sheets if ne,,cetstsa 5'F'�1F1 S` i1 V ct3ga,(' .v-u� F _WA ({�� (�in IGT Sk lin CLL( ecwe_.:` � - a t ri M� �, w�h� v pf d c�cCtii�ct s►�� iJIL4k 30 tb f Q -Paee r Lwin-tpA. - {� ��bl c��` , Sr -(w,1 ACS Required Permits - The followingjbuilding permits are required Proposed Start and Completion Schedule - The following schedule will and will be secured by the contractor; as the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise (Owners who secure their oevn permits will be excluded from the Guaranty fund provisions of o2 1 Date when contractor will begin contracted work MGL chapter 142A.) 15-11d, when contracted work will be substantially completed. i Total Contract Price and Payment; Schedule The Contractor agrees to perform the work furnish the material and labor specified above for the total sum of. Payments will be made according to ;the following schedule: $ S -00 ,0i i i t upon signing contract (not to exceed 1/3 of the total contract price or the cost of special order items, whichever is greater) $ by_� /_; or upon completion of $ by (_ or upon completion of 72 $ 3 _QW. LIJ upon completion of the contract. (Law forbids demanding full payment until contract is completed to both P party's satisfaction) The following material/equipment must be special $ to be paid for ordered before the contracted ,4o!rk begins in order to meet the completion schedule..,(**) $ to be paid for NOTES: (*) Including all finance charges (**) Law requires that any deposit or down -payment required by the contractor before work begins may not exceed the greater of1(a) one-third of the total contract price or (b) the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. .I �_ r�u u res alt terms of the warren must be attached to the cont[ ct Subcontractors -The contractor agrees to be solely responsible for completion of the workdescribed regardless of the actions of any third par'hi/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subco materials and labor under this aeerntractors for nent Contract Acceptance - Upon signing, this document becomes a binding contract under law. Unless otherwise noted within this document, the contract shall not imply that any lien !or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract! g i • Don't be pressured into signing the contract. Take time to read and fully understand it. Ask questions if something is unclear. • Make sure the contractor has a valid Home improvement Contractor Registration. The law requires most home improvement contractors and subcontractors to be g to terediwith the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at 10 Park Plaza, Room 5170, Boston, MA 02116 or by calling 617-973-8787 or 888-283-3757. • Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can confirm coverage, or ask to see a copy of a "proof of insurance" document. • I{now your rights and responsibilities. Read the Important Information on the reverse side of this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business, provided you no the contractor in writing at his/her main; office or branch office by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this agreement. See the attached notice of cancellation form for an explanation of this right DO NOT SIGN THIS CONTRACT IF THERE ARE AW BLANK SPACES!!! Two identical copies of the co Intl must be completed and signed. One copy should go to the homeowner. The other copy should be kept by the contractor. omeown-err 'eSignature Date Oe' -Dan (,' ;�o1,r�a u 11- Contractor's Signature _ 1 r/ id Date I Office�t"�o� mer airs �i es egu a o 'Y HOME IMPROVEMENT CQNTRACTOR Registration: -138569 -Type:. VTGUTExpiration: .`/�}j2013 DBA TER S v �„ I SCOTT WRIGHT ,-- is 350 BERRY ST.= N0. ANDOVER, MAb1$45 :.�';° Undersecretay, Massachusetts - Department of Public Safet% Board of Building Regulations and Standards . Construction Supervisor License License: CS 102663 SCOTT WRIGHT ; 350 BERRY ST NORTH ANDOVER, MA 01845 Expiration: 8/12/2013. CoPmnixskmer• Tr#: 3384 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 NOTES and DATA — (For department use ® Notified for pickup - Date Doc.Building Permit Revised 2010 Building Department The fohowing is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits o Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract ❑ Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o 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) ❑ Building Permit Application ❑ Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract a Mass check Energy Compliance Report a 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: Doc.Building permit Revised 2012 r WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY AR INFORMATION PAGE Issued by LM INSURANCE CORPORATION Policy Number WC5-31S-387187-012 NEW BUSINESS NEW Account Number 1-387187 1. Insured and Mailing Address SCOTT WRIGHT DBA WRIGHT GUTTERS 350 BERRY ST NORTH ANDOVER, MA 01845 27243 Liberty Mutual Group 175 Berkeley Street Boston, MA 02117 Issuing Office 181 Issue Date 10-03-12 Sub Account 0000 FEIN 015582666 RISK ID 164106 Status 01 — INDIVIDUAL Other workplaces not shown above: SEE ITEM 4. PREMIUM - EXTENSION OF INFORMATION PAGE 2. Policy Period: The policy period is from 09-30-2012 to 09-30-2013 12:01 A.M. standard time at the Insured's mailing address. 3. Coverage A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 100, 000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 100,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: SEE END WC 20 03 06A D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE 4. Premium: The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Code Premium Basis Total Rate per $100 Estimated Annual Classifications Number Estimated Annual Remuneration of Remuneration Premium See Extension of Information Minimum Premium $ 500 (MA) Premium will be billed ANNUAL Producer 0004-013810 T A SULLIVAN INSURANCE AGENCY INC 344 SOUTH UNION STREET LAWRENCE MA 01843 Sales Representative 3000 Sales Office Name WESTON Total Estimated Annual Premium $ 1,975 ©1987 National Council on Compensation Insurance,lnc. All Rights Reserved Insured Copy WC 00 00 01 A Ed. 07/ 01/ 2011 s Extension of Information Page WC 00 00 01 A Item 4. State of: MASSACHUSETTS Classification of Operations Premium Basis Rate Entries in this item, except as specifically provided elsewhere in this Code Estimated Total An- Per $100 Of Estimated Annual policy; do not modify any of the other provisions of this policy No. nual Remuneration Remuneration Premium . 0001-01 SCOTT WRIGHT DBA WRIGHT GUTTERS FEIN # 01-5582666 SIC CODE 1799 NAIC CODE 238390 350 BERRY ST NORTH ANDOVER MA 01845-0000 SHEETMETAL WORKDRISHOPVERS AND 15538 I$ 27,333 I 5.72 I$ 1,563.00 OUTSIDE NOC TOTAL CLASS PREMIUM $ 1,563.00 MERIT RATING PLAN 1.00 9886 $ 0.00 STANDARD TOTAL $ 1,563.00 EXPENSE CONSTANT 0900 $ 338.00 TERRORISM RISK INS ACT 2002 .03 9740 $ 8.00 MACHWC (SURCHARGE) 1.042 0936 $ 66.00 FINAL TOTAL $ 1,975.00 POLICY TOTAL ESTIMATED COST $ 1,975.00 Experience Modification: RISK ID: 164106 Policy No. WC5-31S-387187-012 Page No. 1 GPO 2923 Insured Copy WC 00 00 01 A NOTICE TO EMPLOYEES NOTICE TO EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 1 Congress Street, Suite 100, Boston, MA 02114-2017 617-727-4900 - http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152, Sections 21,22 & 30, this will give you notice that I (we) have provided for payment to our injured employees under the above-mentioned chapter by insuring with: LM INSURANCE CORPORATION NAME OF INSURANCE COMPANY PO Box 9102 Weston, MA 02493-9102 1-800-762-5026 ADDRESS OF INSURANCE COMPANY WC5-31S-387187-012 09-30-2012 09-30-2013 POLICY NUMBER EFFECTIVE DATES T A SULLIVAN INSURANCE AGENCY INC (978)683-4700 NAME OF INSURANCE AGENT PHONE # 344 SOUTH UNION STREET LAWRENCE MA ADDRESS OF INSURANCE AGENT SCOTT WRIGHT DBA WRIGHT 350 BERRY ST EMPLOYER ADDRESS EMPLOYER'S WORKERS' COMPENSATION OFFICER (IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries'arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER Insured Copy I WC5-31S-387187-012 FORM NUMBER Miscellaneous Forms Schedule- FORM chedule FORM NAME WORKERS COMPENSATION FORMS AND ENDORSEMENTS GPO4652 01-96 MA BROKER COVER LETTER GPO4756 R4 01-09 PRIVACY PRACTICE DISCLOSURE NOTICE MACCR7 03-12 MA CONTRACT CLASS PREM ADJ PRG LTR GPO4621 01-96 POLICYHOLDER INFO PACKET COVER PAGE GPO4692 03-97 POLICY ENCLOSED LETTER GPO4695 07-01 MA WC GUIDE LETTER GPO 4713 R4 - MA 05-12 CONTACT AT A GLANCE CNI 90 02 07-11 ANNUAL MEETING & LOSS PREVENTION NOTICE WLOGO 07-11 LIBERTY LOGO COVER PAGE GPO4936 01-07 NOTICE TO EMPLOYEES WC 00 00 01 A 07-11 INFORMATION PAGE - WC 00 00 01 A GPO2923 01-96 EXTENSION OF INFO PAGE WC 99 50 01 07-11 POLICY JACKET WC 00 00 00 B Insured Copy WRIGSC2 OP ID: AC A 06 CERTIFICATE OF LIABILITY INSURANCE 701117/2013 TE 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(ies) 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 Phone: 978-683-4700 T. A. Sullivan Ins. Agcy, Inc. 344 S. Union St. Fax:(AIC, Lawrence„ MA 01843 Amy Cupeles CONTACT -PHONE FAX A/c No Ext): a/c No): E-MAIL ADDRESS: GENERAL LIABILITY INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Worcester Insurance Company INSURED Scott Wright 350 Berry St N.Andover, MA 01845 INSURER B: INSURERC: INSURER D: INSURER E: SPP0000004226L INSURER F: 12/01/2013 COVERAGES CERTIFICATE NUMBER: REVISION NIIMRFR- 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 DDL UBR POLICY NUMBER POLICY EFF MM/DD POLICY EXP MM/DDNYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE F—I OCCUR SPP0000004226L 12/01/2012 12/01/2013 DAMAGE TO RENTED PREMISES Ea occurrence $ 300,00 MED EXP (Any one person) $ 50,00 PERSONAL & ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,00 POLICY PRO LOC JECT $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO ALL OWNEDSCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE $ Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY Y / N TORY LIMIT ER EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVEE.L. OFFICER/MEMBER EXCLUDED? r N / A E.L. DISEASE - EA EMPLOYEE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ A Commercial Applica SPP0000004226L 12/01/2012 12/01/2013 A DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Installation of gutters CERTIFICATE HOLDER CANCELLATION TOWNOFN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF NORTH ANDOVER THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. NORTH ANDOVER, MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD V, rA O _ W L6 O Q m> C U N T��- V) V) o d z Z 0 m C m L 7 Of T v U LL o W H Z z m > J d to 7 1= LL cc W N z a u W J W OA 7 d' U N f6 LL O V a z _ Q to C' LL WC C a w W oc Li m O Z VI N N .Q Epo L ,,L N C O � o~ L Q. CL � = w 1 tm H O C •� Q L L � •a F— p cn O 2 m N W C-0 � O O LULL '0 d Cc N C t O v 0 W 0 � c p V Q O -a (v Nw= C N -0 p Ez O m co a. W ` r W CL CO V Cf) uj J C C O� • � O Q a) �a c cn 0 Q L � O cm O � C cc O M 0 J i m •a _ CD C > °� aD Q (A 0 — c 0 o sC�a •a � - m .Q Epo L ,,L N C O � o~ L Q. CL � = w 1 tm H O C •� Q L L � •a F— p cn O 2 m N W C-0 � O O LULL '0 d Cc N C t O v 0 W 0 � c p V Q O -a (v Nw= C N -0 p Ez O m co a. W ` r W CL CO V Cf) uj J Date .� .4 �-. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...... .. . lv 5.... c 11.E .. . has permission to perform GPpf.&XCICY� /:.... L..... . wiring in the building of ..� u ��� l .............. . at .... �3f '" !�(..... ST......... , N h Andover, Mass. Fee* . Lic. No. . 3.3 .M. ...... / . ELECTRICAL INSPECTOR 1 / Check # '1069 Commonwealth of Massachusetts Official Use 0 ly Permit No.. UT, � Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank 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 W INK OR TYPE ALL I7VFORMATIOA9 Date:�J� 12, City or Town of: NORTH ANDOVER 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) Owner or Tenant 71�p,(� ivG/a /G c Al�L% Telephone No f. 7�"�Zy %,�F Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No Y (Check Appropriate Box) Purpose of Building G e Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: ASG S'�G i� l//�r Z , 3 1Zl l'�ti©LIA.,SilitiI? i Completion of the following table may be waived 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 Swimming Pool Above ❑In- Elo. rnd. rnd. oEmergency Lighting Batte 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 Dis osers p Heat Pump Totals: Number Tons No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑Other Connection No. of Dryers Heating Appliances KW SecNoto Devic : or Equivalent No. of Water Heaters KW No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP TelecommunicationsNo. of DevicesorEquivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: / S'� Ci. �1J (When required by municipal policy.) Work to Start-. 2 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, tinder thepains andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: 67, LIC. NO.: e:� 3! 3 Licensee: �,T,y�� y ��1 �P Signatures/ l LIC. NO.:z[/C� (Ifapplica le, enter "exempi" in the license number line.) Bus. Tel. No.;!!!ra 7 6 Ze>sQ Address: & &nx Z3 Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ 0 The Commonwealth of Massachusetts 07 Department of IndustrialAccidints Office of Investigations UV 600 Washington Street Boston, MA. 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ,22 j/,�:�]aV Address: Po d _ 3 Z City/State/Zip:6�y�i,,ASd N ,l/ fr 61'Z d Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub -contractors 7• ❑ Remodeling 2. V11 am a sole proprietor or partner- listed on the attached sheet. t ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. g, ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10. E] Electrical repairs or additions required.] officers have exercised their 3111 am a homeowner doing all work right of exemption per MGL 11 .0 Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] t employees. [No workers' 13. ❑ Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certto under the pains and penalties of perjury t0at the information provided above is true and correct. Phone 4: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person: Phone Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be retained to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or' -permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: Tho Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA. 02111 TeX, # 617-727-4900 ext 406 or 1-877-MASSAF Revised 5-26-05 Fax # 617-727-7749 www.mass,govfdia Commonwsatu o` y%%assac%aeslEs Official Use Only c� Permit No. 732 �lJtParfsrnsliE o�,}irt Jsrvicsd �_•_,__ BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Clucked Rev. 11/99] ticavr• 61nn4\ APPLICATION FOR PERMIT TO PERFORM .ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Clectrical Code (MCC), 527 CNIR 12.00 (PLEASE PRINT IN INK OR TY E ALL It f O 1•M TION) Dnte: `�/%� o�G. eZD00 City or Town or: To the Inspector of fires: BY this application *the undersigilea gives notfice, of his or her intention to perform the electrical, work described below. Location (Street R' Number) 3 �157 i Owner or Tenant oQ r/l �" Telephone No, G051 773;G' Owner's Address Is this permit in conjunetiori with.rt building permit? Yes Q No 0 (Check Appropriate Box) Purilose of Building, Utility Authorization No.40GSD Existing Service Iael Amps -/,V/ d,y Volts Overhead Undgrd ❑ No. of tsicters . New Service Anips / Volts Overhead ❑ Undgrd ❑ No. of Meters. Number of Feeders and Ampacity 3� 1 ocation rind Nature of Arracn aaaruoniJat detail 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:) (Ex ration Date) Estimated Value of Electrical Work:* (When required by municipal policy.) Work to Start: ' r„r•,7p I cerdfj; tinder !re aiir alirl FIRM NANIE: Licensee: (If applicable ek Address: OWNER'S 1N; required by law. Owner/Agent Signature _ I/- Inspections to be requested in accordance with MEC Rule 10, and upon completion. rllies of ped'17, that the itrjorntation on this application is trite and complete: LIC. NO.: /J�G/710 Signature �t�" g — �ecCt LIC. NO.:z1vs'r F&C- 1 Bus. Tel. No. :Y7f 37V"i/� Alt. Tel. No.: JILANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally By my signature below, i hereby waive this requirement. 1 am the (check onc) ❑ owner ❑ owncr's agent. Telephone No. PERt11IT FLL•: , C> .....,..•mow" y I.#0 orrv,vue wrote May oe aal ed b • the htJ cctor o%IYIrrS. No. of Recessed Fixtures No. of cent: Susp. (Paddle) Fans ! 0.01 Tota Transformers • KVA No. of Lighting Outlets No. of Hot Tubs Generators XV A No. of lighting Fixtures Swimming Pool ove ❑ n- ❑ o. o mergency g r nig rad. grnd. Battery Units No hof Receptacle Outlets No. of Oil Burners FIRE ALAILi•IS No. of Zones No. of Switches No. of Gas Burners t o. InUe-tenti Devices t No. or Ranges No. of Air Cond. Turps - Ifo. of Alerting Devices No. of Waste Disposers eat unip Totals: i um er ons i o. of e - onta ne Detection/Alerting Devices No. of Dishivashers Space/Area Heating KAY Local❑ urric pa Connection ❑Other No. of Dryers Heating Appliances KWec No: o Water No. f Devices or Equivalent. Heaters KW o. o r o. o Signs Ballasts Data Wiring: . Devices No. of or E ulvalent No. Hydromassage Bathtubs No. of iltotors Total HP a econtmun cations rrtig: No. of Devices or E uivalent OTHER: Arracn aaaruoniJat detail 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:) (Ex ration Date) Estimated Value of Electrical Work:* (When required by municipal policy.) Work to Start: ' r„r•,7p I cerdfj; tinder !re aiir alirl FIRM NANIE: Licensee: (If applicable ek Address: OWNER'S 1N; required by law. Owner/Agent Signature _ I/- Inspections to be requested in accordance with MEC Rule 10, and upon completion. rllies of ped'17, that the itrjorntation on this application is trite and complete: LIC. NO.: /J�G/710 Signature �t�" g — �ecCt LIC. NO.:z1vs'r F&C- 1 Bus. Tel. No. :Y7f 37V"i/� Alt. Tel. No.: JILANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally By my signature below, i hereby waive this requirement. 1 am the (check onc) ❑ owner ❑ owncr's agent. Telephone No. PERt11IT FLL•: , C> ACORD-, CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YY) 11/15/00 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Phaneuf Ins. Agency,) Inc. P.O. Box 1296 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Haverhill, Ma. 01831 POLICY EFFECTIVE DATE MM D/YY POLICY EXPT DATE MM/DDIRAION N INSURERS AFFORDING COVERAGE INSURED INSURER A: National Grange Mutual Pinette Electric INSURER B: Safety Ins. Co. 48 Willie St. INSURERc:Liberty Mutual Haverhill, Ma. 01832 INSURER D: INSURER E: MPP28213 COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MM D/YY POLICY EXPT DATE MM/DDIRAION N LIMITS AUTHORIZED REPRES T IVE < =, 'f AL'Al GENERAL LIABILITY EACH OCCURRENCE $500 000. A X COMMERCIAL GENERAL LIABILITY MPP28213 09-01-00 09-01-01 FIRE DAMAGE (Any one fire) $500,000. CLAIMS MADE F—I OCCUR MED EXP (Any one person) $ 10,000. PERSONAL & ADV INJURY $ 5 0 0 0 0 0. GENERAL AGGREGATE $ 1 m GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 1 m POLICY PRO LOC JECT AUTOMOBILE LIABILITY ANY AUTO I COMBINED SINGLE LIMIT (Ea accident) $ $ 250, 000. B X ALL OWNED AUTOS SCHEDULED AUTOS 545942 10/01/00 BODILY INJURY 10/01/01 (Perperson) $ 500,000. HIRED AUTOS NON -OWNED AUTOS BODILY INJURY (Per accident) '250, 000. PROPERTY DAMAGE (Per accident) (,GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO $ AUTO ONLY: AGG EXCESS LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE I AGGREGATE $ $ i $ DEDUCTIBLE $ RETENTION $ C WORKERS COMPENSATION AND EMPLOYERS'LIABILITY WC1-31S-246443-030 09-11-00, 09-11-01 X WOC STATU- RY LIMITS EERR E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ OTHER I DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Electrical Contractor CERTIFICATE HOLDER I I ADDITIONAL INSURED: INSURER LETTER: CANCELLATION Town Of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION North Andover, Ma. 01845 DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON T E INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRES T IVE < =, 'f AL'Al ACORD 25-S (7/97) / " © ACORD CORPORATION 1988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. V ACORD 25-S (7/97) ?COO ( ' FORM U -LOT RELEASE FORM % "W ` 03 ri 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 or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT �LdAl"[a[f PHONE �g' io$%-6333 LOCATION: Assessor's Map Number /Or— PARCEL SUBDIVISION --P/4 _—_ -- _ LOT (S) _ STREET_ST. NUMBER_3S *************"******OFFICIAL USE ONLY********************* REOGMMENDATIONS OF TOWN AGENTS: SERVATION ADMINIATRATOR D gAV_RRGVE DATE REJECTEDZ_ 7 Ib®—__—___ COMMENTS_MwS# F�'le —p,+ - - ,g1 won !oo _----- _---- TOWN PLANNER COMMENTS FOOD IMSPECTOR-HEALTH` SEPTIC INSPECTOR -HEALTH COMMENTSLL _P t,+ -:71'1 VY) A-4 A-, DATE APPROVED DATE REJECTED_ DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED d"r PUBLIC WORKS - SEWERMATER CONNECTION DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR _---_ -----DATE --- Revised 9197 jm The Commonwealth of Massachusetts 1.2 Assessors Map and Parcel Number: / O Sh State Board of Building Regulations and TOWN OF NORTH ANDOVER Standards BUILDING DEPARTMENT Massachusetts State Building code Lot Area (sq) Frontage(ft) 780 CMR fres APPLICATION TO CONSTRUCT REPAIR, RENOVATE, CHANGE THE USE OF OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date 1.1 Property ddress: _.- 5 free 1.2 Assessors Map and Parcel Number: / O Sh �drfl, pVP� Map Number Parcel Number 1.3 Zoning Infomration: 1.4 Property Dimensions: Si ture Lot Area (sq) Frontage(ft) Zonin Di,, iar I Proposed Use fres 1.6 Front Yard Side Yard Rear Yard Required Provided Required I Provides I Required I Provided 107 Water Supply 9MG.L.C.40.41.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public Private -0 Zone n Outside Flood Zone Municipal a On Site Disposal System 2.1 Owner of Record t Jean i' L 4an."JI B&ry f NamIL^ ' ')�' Address: 6 <J Si ture Telephone 3.2 Registered Home Improvement Contractor. Authorized Agent: Company Name Name (Print Address Expiration Date Signature Telephone cc!`9 nv a rnNCTDrt1' 11ATiN QrDVrrC FnD DDnirrTm 7 FSC THAN i4 nM rITRIC 1 FF.T nF FNr'r. Un SP 3.1 Licensed Construction Supervisor. < Not Applicable ' Licensed Construction Supervisor: License Number Address Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor. Not Applicabl Company Name egistration Number Address Expiration Date Signature Telephone Revised 1997 JMC SECTION 10b - OWNER/AUTHORIZED AGENT DECLARATION I, DAWI E L- J-. rDUD AULT , as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Name of SECTION 11 - ESTIMATED CONSTRUCTION COSTS I Item Estimated Cost (Dollars) to be completed b permit applicant 1. Building 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5. Fire Protection 6. Total =(I +2+3+4+5 7-7-v Date Official Use Only (a) Building Permit Fee Multiplier D (b) Estimated Total Cost of 160 Construction from (6) Building Permit Fee (a)x(b) i Check Number SECTION 6 - DESCRIPTION OF PROPOSED WORK check all applicable) New Construction [3 1 Existing Building Repairs P Alterations 0 Addition 13 Accessory Bldg. [3 1 Demolition [3 Other Specify figovr ig t)Ao v r Brief Description of Proposed: 9,(2jul7n D ' M Mercantile 11 Q R Residential E3 SECTION 7 - USE GROUP AND CONSTRUCTION TYPE I �,/ h USE GROUP Check as applicable) A Assembly A-1 A-2 A-3 A-4 A-5 B Business 13 E Educational Q F Factory Q F-1 F-2 H High Hazard 13 Q I Institutional Q I-1 I-2 I-3 M Mercantile 11 Q R Residential E3 R-1 R-2 R-3 S Storage Q S-1 S-2 U Utility Q Specify: M Mixed Use E3 Specify: S Special Q Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS. ADDITIONS AND/OR CHANGE IN USE Existing Use Group: Proposed Use Group: Existing Hazard Index (780 CMR 34) SECTION 8 - Building Height and Area BUILDING AREA Number of Floors or stories include basement levels Floor Area per Floor (so Total Area (so Total Height (ft) CONSTRUCTION TYPE IA Q IB 13 2A Q 2B 0 2C Q 3A Q 3B 13 4 Q 5A 0 5B Q Proposed Hazard Index (780 CMR 34) Existing (if applicable) Proposed SECTION 9 -STRUCTURAL PEER REVIEW (780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes Q No Q SECTION 10a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, JI /)q I , As Owner of subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Owner revised bldg form/state JMC Date i Location M Date ' ..- t MORIN, TOWN OF NORTH ANDOVER �r ! ► TOT11 C ,, $ Building Inspector Div. Public Works Certificate of Occupancy $ 00 Building/Frame Permit Fee $ , �SSACMUSEt Foundation Permit Fee $ UYO" f r�nit 1 ee $ Sewer Connection Fee $ 1 Uiii r.�Connection Fee $ �r ! ► TOT11 C ,, $ Building Inspector Div. Public Works AO.AO. Date M TOWN OF NORTH ANDOVER 11111111111, Building Inspector / -3 CY 6 Div. Public Works } Certificate of Occupancy $ Building/Frame Permit Fee $ s�CHust Foundation Permit Fee $ >>,'' (Other Permit Fee $ Sewer Connection Fee $ ver Connection Fee $ - a3, TOTAL $ 11111111111, Building Inspector / -3 CY 6 Div. Public Works � N W a 0 IOD a 0 ro m wa) N m A' ro ri ul Q 0 N 0_ rl w a) m d 44 a 0 , A rj ' CZr w Ea z U) p 0 z N Z W >0 a �0 � J � � � m W O a 0 0 z w s~ m d 0 m Irc IL N R' i Z In 0 W d O z 0 aJ 0 co z �3 Lr)I0 H IL J JJ 4J 4) r -i Z 0 0 ) V4 J N � •rl U CLI Q1 co w O z Z a w a m E N.o 0 FAl 4J a, In -8 H r -I w m J W rc O F z w I W U) a m O O a to C W z 3 0 p )I� 'z Ln d' IW f Q z N F u W F I u C m N W z � Y 4JU x r -I t• •rl GQ 00 x N I a m Z rc 0 o � rc o l7 z 7 O LL LL O F I O W I s W m W C7 a Z 0 It LL co r-1 x 0 O z 0 0 LL LL 0 W N m z < J 0 w J J LL C 0 w o_ W z J E N x u ZLL q 0 0 Z Q � � J w Q m i N N N 7 w W w O F f rc 0 LL Z O u 0 _Z 0 J m J J Z a LL i 0 u Q N J W CL IL a LL O K Q 0 m E a 0 LL Z W IL 0 m L n 01, t g I 0 z f W W L u L to W i t� W • 0 a O a Lr r1 U M Qo W O �f 4c J . W .+ w �3C Z ro z) OIgo 0 U J W I. � d w m a WZ w W 0 co Z z z o wm J i F J j z Z U1 0 0 0 1 w z W> N W 0 0 0 rc M LU Z z d F A `W 0 Nm W f 0 0 m ; < O f p 1 W W f m W W ! N m w cam' 1 �yb W ? ? m W 0 m 0 0 0W LU < m z w m J J F 0 W 0_ W F LL LL V W I J ] (7 Q 0 N t u m LL < W F CS m W W ` - W l7 U' W F < f w C i� UI d d W < d D m IL d (� G! TOP; OF $ARRIEAc 711.0 r C N y C <O 3 V m 0 M Nunn .F BAmZiER TO�_ SYSTEM ANa � i r � �� 'UML CrRA�C "\ , - D URE / ti - > 3 T m / N 0 0 R S E v zv y w Np tim OZ NOn fi E E D►� dCL m n2or- 7t m Y < N O 10 z 0 Z 0 a Nb�T y 0 Z _ zI I Z fiI 111 _ zmOG�cADxNTt Oy�NyvAODAm� II Iw D ~„ o m A m z O 3 0 m > fN Z m= v A O C G1 p D T N~O O Z 00 cm 0 I ( r 7 £DCBE• 6 111 14 � TOP; OF $ARRIEAc 711.0 r v m C.BOT�M OF BAlligl EJV: /Ot.B7 (NOrr- A—L`! DITUH Mals oAMll .TE BARRIER T O SE �Aoo�INV ON, /hoc FACE or STRUCTURAL 8^,KRlCR� 9(0 ' Nunn .F BAmZiER TO�_ SYSTEM ANa � i r � �� 'UML CrRA�C "\ , - A A ti URE / ti - > 3 T m / N 0 , zo R S E v zv 0° tim OZ i O fi E E D►� a m n2or- 7t m < ^ D t° z (AN<D D ~ m N N �lCa1 flpm v 00 O O v Z Z zN N O A3�Oz �0 00 m < MK-AML slN z; J D m w v m m n A 00 n N D; v C N Z r n D Nunn � C O nxn > A y n:yC _ I^ W "\ T C A A ti A ti. ti - > 3 T m z vm 0 n F Z zv 0° tim OZ 0 N; a m 7t m < ^ D t° z Z y 0 Z I Z fiI 111 I�I�N_ III I II` II Iw n o 0 LLl_�_ 1111 T p N A Z I/�n W N ` IOfN T � C O nxn > A y Z _ I^ W O TT_T_ m?? 's°xm ti AvDO>>? Z z vm 0 n F Z zv 0 { ^ D t° z LJ_11� A00 N Z I fiI 111 I�I�N_ III I II` II Iw I��I N PM 1N= uj O. CS Z� •a W4 0~ zC 0 ICID u V a W 0 V .� C, W_ LH W LO > Z W W U. Z ar �A Z � o 0 — V) C z m� �o o z � z u � N � C oc o m a V u o m C12 > U Z W m Oi E c W 0)' 0 C ice'• G C C � C ¢ C a: U ii ii V) U- ccU. m0) PM 1N= uj O. CS Z� •a W4 p zC ICID V a V .� C, LO > ar �A — V) C m� �o o � z � � N � C V W C12 > .zogoadsul buTpTTng Aq paATaoag Zb��2%h gTuizad APMaAT.Ip suoTgoauuoo lagaM/jamas pagoacag agea pano.zadV agEa gueutgaadaa eaTa - sx.zoM oTTgnd sguaun OZ) guab� ugTEaH s4uammo0 pagoaCag agpa auuETd uMo NQ b. o panoaadV agpa ,P7 •� '� "% •.��ul, p j sguaulmo0 pagoaCag agEa .zogpzgsTutuzp� uoTgenzasuo C / pano.zadV agea : SJ,Na9K Mm30 Sid IallfO aura aaqutnH -gS �aaz�s �zzag gaa�gS (s)goZ uotsTATpgns 99 TaoxEd 0 80T aaquinH dpN s , aossessV :KOISK'J(yI 000£ -CLE auogd gsrul AqTpaH bUTPTU :IKVZ)MddK *****************uoTgoas sTgg gno sTTT3 gueoTTddV**************** IsguBmea- nbaa ao suoTgpTnbaa 'MET agegs 20 TpooT aTgeoTTddu Atm ggTA aoueTTduoo uLoa3 aeumopueT ao/pup gueoTTdde aqg aAaTTa3 you scop sTgy •pauTeggo uaaq aAeu uoTgoTpsTanC buTApq sgua�pd9a pup spaeog uzo�3 sgTuLzad/sTenoidde Azpssaoau TTP gegg AJTzaA og pasn ST UzoJ sTgs : SNOIJZII2%ZSKI KHO.!l E[SVWISx soz - n KH03 pl ? p) `(13N JIS i a Sn of uDol JaIJD pauJn4aJ s4UIJd F1 6L anp spiq Jo3 n luawwo:) PUD MaIAaJ JOJ E] s4uiJd pa4:)aJJo:)uJnpd uo14nglJlslp Jol saldo:)liwgnS U lonoJddD Jo} saido:),itugnsa8 Gt suoipaJJo:) Jol pauJnlad 7 pa4ou sD panoJddy n pa111wgns sD panoJddy n palsanbaJ sy 1-1 asn JnoA Jo3 ❑ IDnOJddD Jo3 :Molaq pa�l�ay� so (]311lWSNV81 3dV 3S 1 X] JapJO a6uD4D El suo14D:)ili:)adS E] saldwDS ❑ suOld A s4uud ❑ :swan 6ulMollo} ayl DIA Jano3 aIDJDdas Japun Ei pa4:)D44y Pry 3a L uOlIN3iiv ON EOf - J -L 3;v(1 ri Jw/ 40 N0I1dI8:)S34 839wnN 31V4 S31dG� X] JapJO a6uD4D El suo14D:)ili:)adS E] saldwDS ❑ suOld A s4uud ❑ :swan 6ulMollo} ayl DIA Jano3 aIDJDdas Japun Ei pa4:)D44y p;�mzTu17-q, �(Q) xr-,q�� Jaaal }o AdOD ❑ s6uIMDJQ El no.k `JNIaN3S 388 3M :N3W311N39 L LSt,-JvLc [Bog] 01 See LO VA 'II!uJaneH PeOd MOON 2t72 •out Aueduaoa Buippn8 1auue43 123NNVHM Pry 3a L uOlIN3iiv ON EOf - J -L 3;v(1 p;�mzTu17-q, �(Q) xr-,q�� Jaaal }o AdOD ❑ s6uIMDJQ El no.k `JNIaN3S 388 3M :N3W311N39 L LSt,-JvLc [Bog] 01 See LO VA 'II!uJaneH PeOd MOON 2t72 •out Aueduaoa Buippn8 1auue43 123NNVHM 0 z Q L �. O W Q L6 W u N m ON N P4 W O H U O D M N M E 2 z d m U U y A� W U d' Q U Lfl Q O F V1 H W W �" c/1 H y y H � a � PCl y � Ln a M o A Av w o V1 wa � y roo �W o N n mi %4MI 0 w LLI CLO �r 74. C y � � � • Z 0 h :. c Z :V u U Z o �. z r0 C - . � CL. :p 0 0 y �n H C — C '3 a a U > o C3 C o a c o CK2 Q o0 �o `o •o ' _ .. o a e N ate+ c `W. y o y LAW G •� y V Z Lw • .. a ., a — Z CFC y •a s e p 1— Gz7 = F, • LU L .� c ,� o %p .Qj W • Z 'A •� = '� p .. Q F s J `� c R 1-1 Ln V to C IM7 Q c O Z `V Ot • cc - `\�. v _ , � W 96 oeW'd O • a N W. V \v CL 43Vf� Z�J Z W� ti `.z _ d CID m L CJix L W cm> L co� ul Y0)E o ¢u ii ¢¢ cn ii cr U. m N mi %4MI 0 w LLI CLO �r 74. C y � � � • Z 0 h :. c Z :V u U Z o �. z r0 C - . � CL. :p 0 0 y �n H C — C '3 a a U > o C3 C o a c o CK2 Q o0 �o `o •o ' _ .. o a e N ate+ c `W. y o y LAW G •� y V Z Lw • .. a ., a — Z CFC y •a s e p 1— Gz7 = F, • LU L .� c ,� o %p .Qj W • Z 'A •� = '� p .. Q F s J `� c R 1-1 Ln V to C IM7 Q c O Z Location No. �3 G Date NOR, TOWN OF NORTH ANDOVER 9 ` Certificate Occupancy of $ s�04 BuildinglFrame Permit Fee $ �-- Foundation Permit Fee $ Other Permit Fee $ TOTAL $ ? 4 /�y Check # 12i / / i7JVQr? — Building Inspect r Z `S � r u z r � Z = u z o C z C i a c c c c U U -C z 0 z a C C G ^ 1 z; c � N , z- OC t ``J a �S � 0 C C -< U U U G C c c a z z z z C O o c C = T U U U - U J L r1•• G L 'J C Z Z Z F Q C G C c a C z o d _ o 43 vi �' In viLo 5 = N z C n Ln in �r - Z c Z C- F Z M 00 W V VI .c J r i s �1 = •\ J C U c ^� `S IN Ir z r � Z = z o C z C i a c c c c U U -C z 0 z a C C c ^ 1 z; c OC t a C C C c.. U U U C c c a z z z z C O o c U U U U J L Z % O C C c a ^� `S IN Ir z r � Z = c :v C z C i a c c c c U U i zl z a C ^ 1 z; c ^� `S IN Ir � r � c :v C z C i a c c c c U U = FORM U - LOT RELEASE FORN:4 -- 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 or requirements. ****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT �/ Anid Aud'Yctad1,-A -PHONE q90'4"41� 6 LOCATION: Assessor's Map Number tri PARCEL Jf/9 SUBDIVISION AIA LOT (S) STREET ST. NUMBER * ********* ******************OFFICIAL USE ONLY***************—**** �z-Jbrc-c2 WAXV �P� ACI RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMIN TRATOR DATE APPROVED DATE REJECTED COMMENTS Cts �^ l�-C�✓�� j TOWN Ld DATE APPROVED Z DATE REJECTED CO NTS 4 FosZ60 INSPECTOR -HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR -HEALTH DATE APPROVED DATE REJECTED COMMENTS m to b e � PUBLIC WORKS - SEWERIWATER CONNECTIONS . DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm ! 1 T, • �� Town of North Andover". �? `• F ti A Building Department 27 Charles Street �o ; North Andover, MA. 01845 0 D. Robert Nicetta Building Commissioner (978) 688-9545 ,.,:(978)688-9542 Fax Please print DATE %-- 9 - C7 0 JOB LOCATION P/5 4ti r Number "HOMEOWNER Lk, -Ile e�'�mU Name PRESENT MAILING ADDRESS 3Y HOMEOWNER UCENSE EXEMPTION S 4 Street Address C -to V®f'PGi U Home Phone 79-- U6-7-296 Map / lot Work Phone City Town State Zip Code The current exemption for "homeowners" 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 one home 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 APPROVAL OF BUILDING OFFICIAL -23 40. 49 '' j i 1 \ Nei ' '► CL W 3. 4 Ali uj 3,,,r Q + + 0 u r 3Ir Ir �' N. tl► ti a S r d0 Q \ \ f �, 1 1 \ N\ \\ Z E1 iilY ° "' U .p 1 ol \%0 ° p 4c i- w 117 Ck lob OL 11 N 0 aJ Z \ . .x1 \' To\$\ o< 9 �_ \, W� Ida : ♦ �' 'C� fC uj \ , S CC(C D i:•s V : r � r \ cr c40 Q oC 0 ` QOJCO ILp �� o tj Q�N O / f 00040 Z C p ka CD # \ m 1` p, � '8p. \ � t � N IL.0� 9 a \'v 4 0 V , % 0 -40 4� w \` 1 \ i ' A v JtC � + I r Z} o �0 O N% W4 6 o p 0 W — �• I° • 61 Q ' 3 - • IJ Ij n a� _p r r F oCL � Q �r In4 O Ix [Y o W a0-2 'Z CC� WW W IL 400 : 1Q D? oz z� 7 LL X09-0 M3nj w to �� CL o Z :z 0 all -. N(tir dl 2 N ` I 10111 --ANI L:33-INI o C Ir vJ Q tl \ � 2 iJ 72 _p r r lui Q oCL � Q �r 0 Ix [Y wtr fgw a0-2 'Z WW W IL 400 : 1Q D? oz z� 7 LL X09-0 M3nj w to �� CL o O— f-" :z 0 all -. N(tir dl 2 UtLy ` I 10111 --ANI L:33-INI Q 2 C Ir vJ N \ � O . N Z �W Q to \ O 40 �. 1 Q —0 :2 W ff L,LJ FOIL_ a to z3 �, W k co iL,Q 0 - 9 0 O O uj r'J i 1 O u - J N = O U s O ¢ 1 1 t _ _ O o p 3dld 'I'� 1�hb3H `?11X3 b — L8'6oJ =,hNr 13i1f'10 � ` Q I L�"BOJ r N7b.L 3 �r0 vs►o.L.Log \ \� 2 •, I *AN! 131N/ � L2'Q11 = nSvl 1311no Lb-ol1"AN I .L3-7NI Z i X r �N 4 [Y W �- ifj0 J F t c0 WW W IL 400 : 1Q p 31- z� o X09-0 M3nj w to �� CL o O— f-" :z HH F cC -. N(tir dl cc oa m 10111 --ANI L:33-INI \ l �O_2 al N \ � O 3dld 'I'� 1�hb3H `?11X3 b — L8'6oJ =,hNr 13i1f'10 � ` Q I L�"BOJ r N7b.L 3 �r0 vs►o.L.Log \ \� 2 •, I *AN! 131N/ � L2'Q11 = nSvl 1311no Lb-ol1"AN I .L3-7NI Z i X r �N 4 • ;La .O *)L.01 1"k ;kN r Aj : 1Q p 31- 3drd ->nd �• W X09-0 M3nj w to ----lam< Ld (4b. H,$) :z -. N(tir dl cc La3S M3N 3dld 'I'� 1�hb3H `?11X3 b — L8'6oJ =,hNr 13i1f'10 � ` Q I L�"BOJ r N7b.L 3 �r0 vs►o.L.Log \ \� 2 •, I *AN! 131N/ � L2'Q11 = nSvl 1311no Lb-ol1"AN I .L3-7NI Z i X N W � f w O -a U. 7 ��c� a" a w. :(f) . �s • ;La in .. *)L.01 1"k ;kN r i3 -11no : 1Q p 31- W � ----lam< :z cc 10111 --ANI L:33-INI \ l �O_2 al N x�u �W Q to \ O Q —0 :2 W L,LJ FOIL_ z3 �, to k 0 O O 0 - 9 0 O O uj r'J i 1 id A 3�� Iku six j LL O zit =O 4 r� O W l -iWW W Q w Z 1 '- JA uj O 40 CoA An W Z. LU w Y in. w .w z0 qt Us 4 N W � f w O -a U. 7 ��c� a" a w. :(f) . �s C/) m m m cn0 m v C � d 'v O CD 0 Z v) C. O O CL =• y aCc -0 � O � o p CD CDCL O .cr SrCD O CSD �. C CD y dv y O Cc CD I 0 b n 0 cn A C C O d 2 N O cr V! a <m y O Horan Z ?� H ?a -+a m mmH „# y N >•m m = > > m CA o : m 0, O,�.c O O O yO . M C Er AL y �va m a� to C CD � CD o mcpm ?�/ : • �y2t 4a CD y p d ' CA Cm H CD:� m A Cn " Q H m o A/ 30DCD CD b O\ CD o z 9F h •C O�ACD C Ocn � g 'A � m •'� H CD m o :� G A'a0 *too 4 �CD: N, D °' '} O ^�C rB o O �. O O�Q y��,�yyyi �' �• O OCQ Ctl O �• O to C)4 w• �- O OCC 0• ^ x O d d -XI Im 0 c 5CHEOULE: OF TIE DISTANCES aF =��3 ' _ 341 O K " 6 ��. 71, = 4-o.8' Q H = Z8, 0' P H = 42,1" OS- 3D.3 pi= �- SCHEDULE L' J 1 1Cl. JEPT;C. O K " 6 ��. 71, PK, ? D g0X (0U r L ET) ` 110.3'I r x.10 L VACH (L� — i10-2-3 =rxL< L—EACH PsPE6M)= 11i0.211, L OF INVERTS SEPTIC TANKINLET")= 1 1Cl. JEPT;C. TANK(!—'�±! TIL ET)= !10.74 D- g )( CINLE T-) - 110--+ D g0X (0U r L ET) ` 110.3'I r x.10 L VACH (L� — i10-2-3 =rxL< L—EACH PsPE6M)= 11i0.211, 11 )SAL -SYSTEM NK LOT 4A YJ 40 LOT A R.A 66,369S.F. 1.52 ACRES UPLAND=38,540 S. F. LOT 6A cn-Ncf . zi BARRIE r4^LL Sox NI I I F F 3+ G p osr ol 0 H C. PH = 42, 1' Oz= 3D.3' P � e - 3' 40 CO ?,J4t RE T I— f b9 -} FCUNVRTtQN C Ao 0 Stpric TANK too k L 6 C) L cn-Ncf . zi BARRIE r4^LL Sox NI I I SCHEDULE SEPT -IC TANh ,5F_-PTtC T_Atj� D- Sox Cl NJ L L)- 13OX ((-)L17 t__ N1 ED L F_ A C �__l U_r4D LF. -ACV) I F F 3+ G p osr 0 H PH = 42, 1' Oz= 3D.3' P � e - 3' SCHEDULE SEPT -IC TANh ,5F_-PTtC T_Atj� D- Sox Cl NJ L L)- 13OX ((-)L17 t__ N1 ED L F_ A C �__l U_r4D LF. -ACV) I