HomeMy WebLinkAboutMiscellaneous - 352 FOSTER STREET 4/30/2018TOWN OF NORTH ANDOVER
Office of the Building Department
of N° oT1 qti Community Development and Services
120 Main Street
'D North Andover, MA 01845
978-688-9545
Paul Hutchins, Local Building Inspector May 18, 2017
To: John Walsh
352 Foster Street
North Andover, MA 01845
From: Paul Hutchins, Local Building Inspector
Dear Mr. Walsh,
Per your request I reviewed the building file for your property on 352 Foster Street and there
are no open permits present in the file.
Thank you,
C�
Paul Hutchins
Local Building Inspector
Location &5 Z t (z _ 1r
No. Date d
NORTN
TOWN OF NORTH ANDOVER
3?0. ,�.O0W--
-J6.
AhL
A
Certificate of Occupancy
$ _
�
Building/Frame Permit Fee
$Z
,SSACHusE�
Foundation Permit Fee
$
Other Permit Fee
$
Sewer Connection Fee
$
w
Water Connection Fee
$
Xkj (-uL C
TOTAL
$
Building
Inspector
tszo/95
16:00 212.50 PAID
Div. Public Works
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FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all neces C-3
approvals/permits from Boards and Departments having Jori 9tia
have been obtained. This does not relieve the applicant
landowner from compliance with any applicable local or st law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: 1�14 � �S' Phone
LOCATION: Assessor's Map Number Parcel
Subdivision
Street
55 fElf- Sf .
Lots)
St. Number 35Z
************************Official Use Only************************
RECOMMENDATI NS OF TO AGENTS:
Date Approved
Conservation Administrator LLII �+ Date Rejected t
Comments 'i�l S�w.zeJ P,v��;i�e� Li 4-,,� ,wj
Town Planner
Comments
Food Inspector -Health
Septic Inspector -Health
Comments
Public Works - sewer/water connections
- driveway permit
---Fire Department
Received by Building Inspector
OGT 16
Date Approved
Date Rejected
Date Approved
Date Rejected
Date Approved d Z
Date Rejected
Date
:�w.� w:s.G. ..-.�..:::::idar�wG�iQ '�' ci-r.+'.."' .......•.._ _ . ,�'a_L m � � • ��
--
--
HONE IMPROVEMENT CONTRACTOR_,:
Registratioe 100126
Type - PRIVATE CORPORATION
ErPiTation 06/18/96
Douglas P. Yasika/Des-Coa Sys
Douglas P. Yasika
GGr r .o n &41;olby Rd/ PO #698
A0MN1STR,TCei Danville NH 03819
./fie L�airnec;�•r:o%r(r• ,i � (�r,,.;.rclr.;,,: •'*
Restricted To: 00
DEPARTMENT OF PU9LIC SAFETY
CONSTRUCTION SUPERVISOR LICENSE 00 - None
Number: Expires: 3irt5date: 1A - Masonry only
CS 051622 02/27/1998 02'2?/195.3 16 - 1 S 2 Family Holes
Restricted To: 00 L
DOUGLAS P YASIIA
X I
12 COLBY RO PO81 698
OAK VILLE, NH 03819
10/03/1995 14:09
KENNETH R. MAHONY
Director
5087942088
LAW OFFICES
,lOY.Cf
Town of North Andover >i01ki" &Kos EIR
COMMUNITY DEVELOPMENT AND SmVICES ` � ��
146 Main Street
North Andover, Massachusetts 01845
(508) 688-9533
John P. Walsh Trustee of the KJJ Realty Trust DECISION
352 Foster Street Petition# 041 -95
North Andover, MA 01845
PAGE 03
C0�
The Board of Appeals held a regular meeting on Tuesday evening, August 8, 1995 upon
the application of John P. Walsh, Trustee of the KJJ Realty Trust requesting variances
under Section 7, paragraph 7.1, 7.2 & 7.3 and table 2 of the Zoning Bylaw so as to permit
relief of 43,539 square feet of lot dimensional area from the requirements of 87,120 square
feet, relief of 25 feet from the street frontage requirement of 175 feet, relief of 16 feet for
the addition, from the side setback requirement of 30 feet and relief of 20 feet for the
unattached garage from the side setback requirement of 30 feet. The applicant is also
requestirig a Special Permit under Section 9, paragraph 9.2(1) so as to construct an
addition onto a legal non -conforming structure located at 352 Foster Street, Zoning
District R-1.
The following members were present and voting: William Sullivan; Scott Karpinski,
Joseph Faris, John Pallone and Ellen McIntyre.
The heating was advertised in the North Andover Citizen on 7. 19.95 and 7.26.95 and all
abutters were notified by regular mail.
Upon a motion by Scott Karpinski and seconded by Joseph Faris, the Board voted
unanimously to Grant the Variances as requested. Upon a motion by Scott Karpinski and
seconded by Joseph Faris the Board voted unanimously to Grant the Special Permit as
requested. Voting in favor: William Sullivan, John Pallone, Joseph Faris, Scott Karpinski
and Ellen McIntyre.
The Board finds that the petitioner has satisfied the provisions of Section 10, Paragraph
10.4 of the Zoning Bylaw and that the granting of these variances will not adversely affect
the neighborhood or derogate from the intent and purpose of the Zoning Bylaw.
The Board finds that the applicant has satisfied the provisions of Section 9, paragraph 9.1
of the Zoning Bylaw and that such change, extension or alteration shall not be
substantially more detrimental than the existing non -conforming structure to the
neighborhood.
130APD OP APPEALS 688.9541 0= 1140 688-9745 CONSERVATION 688-9130 HEALTH 689-9140 PLANNiNO 688-9335
Julie Panim D. Robert Nicada w4dwar ktoward Sag&* am Kathkw Brt&q CoWroll
10/03/1995 14:09 5087942088
Dated this 16th day of August, 1995.
I
1
i
i
LAW OFFICES PAGE 04
BO RD OF PEALS,
Wi tam ullivan n Pallone
Joseph Faris Ellen McIntyre
Scott Karpinski
9
s
10403/1995 14:09 5087942088
.-%
Any appeal shall be filed
within (20) days after the
date of filing of this
Notice in the Office
of the Town{ Clerk.
LAW OFFICES
TOWN OF NORTH ANDOVER
WSSACHUSE`i TS
BOARD OF APPEALS
NOTICE OF 06CIS1ON
PAGE 02
?s j�a:��
REGI -'` "
¢gYCE ER.WliAW
TO R HDOYER
AuG
A, Vue COPY
'Down Clerk
1;tila is to certify that twenty ;� ; .:.� Date Au gur9 t 16,
'1995
hcva atepred from dela of deduloniljc:
lvitraA0"otan wt. l Lf�� Petition No. 041-95
JcyaeXSnkdsMW Date of Hearing -8-8-95
4,
Um Clerk
y
Petition of John P. Walsh, Trustee of the KJJ Realty Trust
Premises affected 352 Foster Street
Referring to the above petition for a variation from the requirements
of SecCion 7 ara. 7.1,-7.2 & 7 e
permit relief of 43,539 square feet of lot dimensional area froth the
requirements of 87,120 square feet, relief of 25 feet from the street
frontage requirement of 175 feet, relief of 16 feet for the addition,
from the aide setback requirement of 30 feet and relief of 20 feet for
the'unattached garage from the side setback requirement of 30 feet. The
applicant is also requesting a Special permit under Section 9, para. 9.2(1)
so as to construct an addition onto a legal non -conforming structure.
After a public hearing given on the above date, the Board of Appeals
voted to Grant_ the Specialormit & Variance and hereby
authorize the Building Inspector to issue a permit to:
John P. Walsh, Trustee of the KJJ Realty Trust
for the construction of the above work,
c iS�kKK
The Board finds that the petitioner has satisfied the provisions of section 10,
para. 10.4 of the Zoning Bylaw and that the granting of these variances will not
adversely affect the neighborhood or derogate from the intent and purpose of the
Zoning Bylaw. a n,
The Board finds that the applicant has
satisfied the provisions of Section 9,
para. 9.1 of the Zoning Bylaw and th$t
such change, extension or alteration
shall not be substantially more
detrimental than the existing non-
conforming structure to the
neighborhood.
Board.9f AP ls,
.
William S- ll van, llalrman
John Pallone Joseph Faris
Scott Karpinski Ellen McIntyre
lYJ! 11�J 177J 14: U DUO f 74GUOO LHW urr 1tJCJ
i
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I,
Registry of Deeds
Northern District of Essex County
Lawrence, MA 01840
I '
09/UM
DOHEHIC 5CALIS,E C;T
0 64 Rec:time 1104 Type HOr ?.(x.00
Inst 204313
I
Total 10.'10
d 65 Favment Check 10.00
THANK YOU! Thomas J. Burke
Rp9ister of Daed:s
i
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I
10/03/1995 14:09 5087942088
LAW OFFICES
DOMENIC J. SCALISE, ESQUIRE
89 Main Street
North Andover, Massachusetts 01845
Telephone: (508) 6824153'
Fax: (508) 794-2088
PAGE 01
i
i
i DATE: October 3, 1995
i
i
I
,Faesimiie Number: (508) 794-2088
Telefax to the Following Number: (603) 382-3945
i
Company Name:
Attention: DOUG Y.
From: DOMENIC J. SCALISE
Regarding: WALSH
i
Message: FOLLOWING PLEASE FIND A 'COPY OF THE NOTICE OF
DECISION WHICH WAS RECORDED AT THE REGISTRY OF
DEEDS AND COPY OF RECORDING SLIP. IF YOU SHOULD
NEED ANYTHING ELSE, PLEASE ADVISE. THANK YOU.
a
Total Number of Pages (Including This Cover Page): 5
IF ALL PAGES ARE NOT RECEIVED, PLEASE CALL BACK AS SOON AS POSSIBLE
AT THE ABOVE NUMBER.
This telecopy is attorney-client privileged and contains confidential information intended only for
the person(s) named above. Any other distribution, copying or disclosure is strictly prohibited.
If you have received this telecopy in error, please notify us immediately by telephone, and return
the original transmission to us by mail without malting a copy.
I
r�
I
10/03/1995 14:09 5087942088
LAW OFFICES
DOMENIC J. SCALISE, ESQUIRE
89 Main Street
North Andover, Massachusetts 01845
Telephone: (508) 6824153'
Fax: (508) 794-2088
PAGE 01
i
i
i DATE: October 3, 1995
i
i
I
,Faesimiie Number: (508) 794-2088
Telefax to the Following Number: (603) 382-3945
i
Company Name:
Attention: DOUG Y.
From: DOMENIC J. SCALISE
Regarding: WALSH
i
Message: FOLLOWING PLEASE FIND A 'COPY OF THE NOTICE OF
DECISION WHICH WAS RECORDED AT THE REGISTRY OF
DEEDS AND COPY OF RECORDING SLIP. IF YOU SHOULD
NEED ANYTHING ELSE, PLEASE ADVISE. THANK YOU.
a
Total Number of Pages (Including This Cover Page): 5
IF ALL PAGES ARE NOT RECEIVED, PLEASE CALL BACK AS SOON AS POSSIBLE
AT THE ABOVE NUMBER.
This telecopy is attorney-client privileged and contains confidential information intended only for
the person(s) named above. Any other distribution, copying or disclosure is strictly prohibited.
If you have received this telecopy in error, please notify us immediately by telephone, and return
the original transmission to us by mail without malting a copy.
I
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❑ LETTER
DES -CON' SYSTEMS, LTD. ❑ INVOICE
❑ STATEMENT
❑ JOB #
April 16, 1996
Mr. Kenneth Surette, Local Inspector (Hand delivered 4/17/96)
Town of North Andover
Building Department
120 Main Street
North Andover, MA 01845
Re: Walsh Residence
352 Foster Street
Subject: Building permit for addition and carriage house
Dear Mr. Surette:
Per our discussion in your office when you signed off on the rough frame
construction on 3/20/96, please be advised that this letter is to confirm that
conversation wherein I advised you my assistance as a licensed General
Contractor to Mr. Walsh's house projects was no longer requested.
To further recap, Mr. Walsh had asked me to obtain his Certificate of
Occupancy for the projects, advising me he gone as far as he wanted to with his
projects at that time. You, in turn, advised me that you would not issue the C.O.
until the buildings were totally complete. I conveyed this to Mr. Walsh.
From the get -go and in the interim, we have assisted Mr. Walsh whenever
asked, with sub -contractor referrals and building material suppliers.
Most recently, we were asked by Mr. Walsh to install the insulation in the
buildings which we did with our own crew, and completed this weekend. Per our
understanding of the town's building codes, we called for and scheduled a building
department inspection for this insulation work, which we understand will be
inspected tomorrow.
Since Mr. Walsh has made it clear to me that he's finishing his projects on
his own, please hold this letter on file to confirm that my services and assistance
as a licensed General Contractor on these projects are no longer requested, and
that my license is not valid for anyone else to use while working for.Mr. Walsh at
his residence, unless prior approval is obtained from me in writing.
Sincerely,
Douglas P. Yasika
Chairman & CEO
CC: Brad Yasika, President
John Walsh, Home Owner 7 1995
12 COLBY ROAD • DANVILLE, NH 03819 9 (603) 382-6773 • FAX: (603) 382-3945
- cd :`rom �: 2 cf
......_.:;%jrg ofs�L
V
Any appeal shall be filed
within (20) days after the
date of filing of this notice
t ,ORT}f 1
O �, Sao
O R
S'"ACHU5tit
NORTH ANDOVER
OFFICE OF
THE ZONING BOARD OF APPEALS
27 CHARLES STREET
NORTH ANDOVER, NIASSACi-RJSEITS 01845
NOTICE OF DECISION
Property at: 352 Foster Street
NAME: John P. Walsh, Trustee of KJJ Realty Trust
ADDRESS: 352 Foster Street
North Andover, MA 01845
RECEIVED
JOYCE BRADSHAW
TOWN CLERK
NORTH ANDOVER
1999 SEP 22 P 1: 01
FA.X (973) 6883-9542
ATTES1%.
eClerk
C4
DATE: 9/15/99
PETITION: 031-99
HEARING: 9/14/99
The Board of Appeals held a regular meeting on Tuesday. evening, September 14, 1999, upon the application of
John P. Walsh, Trustee of KJJ Realty Trust, 352 Foster Street, North Andover, requesting a Special Permit under
Section 9, paragraph 9.1 & 9.3 of Table 2, as to permit construction of a breezeway between an existing non-
conforming house and unattached garage.
The following members were present: William J. Sullivan, Walter F. Soule, Robert Ford, Scott Karpinski.
I
Upon a motion made by Scott Karpinski, and 2nd by Robert Ford, the Board voted to GRANT a Special Permit
under Section 9, paragraph 9.1 & 9.2 as to permit the construction of a breezeway between an existing non-
conforming house and unattached garage. Voting in favor. William J. Sullivan, Walter F. Soule, Robert Ford, Scott
Karpinski. Reference Plan of Land by Appleton Land Surveying, Inc. 234 Essex Street, Lawrence, MA., James
Curran, Professional Land Surveyor, #33495, dated: 8/4/99, and reference elevation drawings by: William Balkus,
Architect„ #4452, dated: 718/99. Voting in favor. William J. Sullivan, Walter F. Soule, Robert Ford, Scott Karpinski.
Please Note: A variance was previously granted on 8/16/95, petition #041-95, see attached.%U I t90 PM�:Lv
Note: The granting of the Variance and/or Special Permit as requested by the applicant does not necessarily ensure
the granting of a Building Permit as the applicant must abide by all applicable local, state and federal and building
codes and regulations, prior to the issuance of a building permit as requested by the Building Commission.
SPECIAL PERMIT
The Board finds that the applicant has satisfied the provision of Section 9, paragraph 9.2 of the Zoning Bylaw and that
such change, extension or alteratio shall not be more detrimental than the existing non -conforming structure to the
neighborhood. S
By order of th Zon'ng Board of Appeals
ml/1999decision/44 William J. S Ilivan, Chairman
BU:Utll UP :11'Pl:.\LS (ixx')i {I 8(! LDINGS oSx-9545 CONST{R V:\TION' G89-9530 1IE.\L'rl1 (SSS -9:40 PL:\NNINU (iS\-vi3
Any appeal shall be filed
within (20) days after the
dace of filing of this
Nocice in the Office
of the Town Clerk.
Ackut
TOWN OF NORTH ANDOVER
MASSACHUSETTS
BOARD CT APPEALS
NOTICE OF DECISION
.j010E
+TO1dN �.LC;;K
NORTH ANDOYER.
AUG 16 3 1 7 PI? '95
Date August 16, 1995
Petition No. 041-95
Date of Hearing 8-8-95
Petition of John P. Walsh, Trustee of the KJJ Realty Trust
Premises affected 352 Foster Street
Referring to the above petition for a variation from the requirements
of Section 7, para 7 1, 7.2 & 7.3 and Table 2 of the Zoning Bvlaw so as to
permit relief of 43,539 square feet of lot dimensional area from the
requirements -of 87,120 square feet, relief of 25 feet from the street
frontage requirement o'f 175 feet, relief of 16 feet for the addition,
from the side setback requirement of 30 feet and relief of 20 feet for
the UlLattached garage from the side setback requirement of 30 feet. The
applicant is also requesting a Special Permit under Section 9, para. 9.2(1)
so as to construct an addition onto a legal non -conforming structure.
After a public hearing given on the above date, the Board of Appeals
voted to Grant the Special Permit & Variance and hereby
authorize the Building Inspector to issue a permit to:
John P. Walsh, Trustee of the KJJ Realty Trust
for the construction of the above work,
cf
The Board finds that the petitioner has satisfied Ehe provisions of section 10,
para. 10.4 of the Zoning Bylaw and that the granting of these variances will not
adversely affect the neighborhood`•or derogate from the intent and .purpose of the
ZoningBylaw > n
The Board 'finds {that- the applicant has+ r
satisfied"the--p�rov�si`eec-R&I 9,
;.;para. 9, l of'\the��Zcn .ng B ria' c t int .. <
�. ,:�.. Board of`z9Appls.,
such ::change„ ; xten o>z :off a"atY: �4 i.'i /.;t7/ AA A -
� Jr
Any appeal shall be filed
within (20) days after the
dace of filing of this
Nocice in the Office
of the Town Clerk.
Ackut
TOWN OF NORTH ANDOVER
MASSACHUSETTS
BOARD CT APPEALS
NOTICE OF DECISION
.j010E
+TO1dN �.LC;;K
NORTH ANDOYER.
AUG 16 3 1 7 PI? '95
Date August 16, 1995
Petition No. 041-95
Date of Hearing 8-8-95
Petition of John P. Walsh, Trustee of the KJJ Realty Trust
Premises affected 352 Foster Street
Referring to the above petition for a variation from the requirements
of Section 7, para 7 1, 7.2 & 7.3 and Table 2 of the Zoning Bvlaw so as to
permit relief of 43,539 square feet of lot dimensional area from the
requirements -of 87,120 square feet, relief of 25 feet from the street
frontage requirement o'f 175 feet, relief of 16 feet for the addition,
from the side setback requirement of 30 feet and relief of 20 feet for
the UlLattached garage from the side setback requirement of 30 feet. The
applicant is also requesting a Special Permit under Section 9, para. 9.2(1)
so as to construct an addition onto a legal non -conforming structure.
After a public hearing given on the above date, the Board of Appeals
voted to Grant the Special Permit & Variance and hereby
authorize the Building Inspector to issue a permit to:
John P. Walsh, Trustee of the KJJ Realty Trust
for the construction of the above work,
cf
The Board finds that the petitioner has satisfied Ehe provisions of section 10,
para. 10.4 of the Zoning Bylaw and that the granting of these variances will not
adversely affect the neighborhood`•or derogate from the intent and .purpose of the
ZoningBylaw > n
The Board 'finds {that- the applicant has+ r
satisfied"the--p�rov�si`eec-R&I 9,
;.;para. 9, l of'\the��Zcn .ng B ria' c t int .. <
�. ,:�.. Board of`z9Appls.,
such ::change„ ; xten o>z :off a"atY: �4 i.'i /.;t7/ AA A -
I
ESS.FX NORTH REGIST Y 0 EEDS
LAWRENCE, MASS,
ATRUE COPY: ATTEST
REGISTER OF DEED
Registry of Deeds
Northern District of Essex County
Lawrence, MA 01640
10/21/99
D SCALISE KB
N 53 Rec: Type FLAN
Inst 3801.2.
Copies
It 54 RCe1lc�: Type NOTC
Inst ..38013
Copies
Total
B 55 Payment Check
THANK YOU! Thomas J. Burke
Register of Deeds
16.00
3.00
10.00
1.50
30.50
30.50
Location "
No. ' Date f
HORTN TOWN OF NORTH ANDOVER
p Certificate of Occupancy $
JF
_ Building/Frame Permit Fee $
AU T.' Foundation Permit Fee $
Other Permit Fee $
Sewer Connection Fee $
Water Connection Fee $
TOTAL $ %
Building Inspector
Div. Public Works
7
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J The Commonwealth of Massachusetts
---�i WCZ
Department of Industria! Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Afdavit
Name :U-4
�4HAI j i✓() 1<,}%f/�E/_
/i/ .fl fcs�7� Rease Print
J
Name' D Al 41V
Location: ✓� lyJrT�� �J
City %V4�i� /7_VI�01/6 %1% /�y5 Phcne I�(,c.clR�� 7���35�'-5'3�a �X/•la?
2K1 am a homeowner cericrmin4 all work myself
F7I am a sole prcpnetcr and have no one working In any cacac,ty
I am an empIcyer prcvidinc wcrkers' CCmCenzatlen icr my eri iClOvees working on this job.
Ccr cenv name:
Addres
Phcne ---
Insurance Co. Polic•i
Ccmcanv name:
Add
N
Phcne m,
Insurance Co.Polio
Failure to secure cnverace as recuirea under Szrtien 2EA or MGL 152 can lead to the imposition cr criminal penaities cr a fine up to 51,500.00
and/or one years' imprisonment as we!! as civii penadies in `,he Form or a STCF'NCRK CR.CE= and a rine c (51 00.001 a day against me. !
understand that a ccqe�, this s,aement may be ferwarced to the Circe of Inv@s:icailcns ct the 'CIA fcr ccverzge verification.
I cc herecy car:,. -v �ncerjhq�arns and penaities er ce. jury that the inicrmadcn prcvrded above is ti%:e anc ccrrec:.
Signature
Print name
Cffical use eniv
do not write in this area to Ce ccmpieted
by c;iy cr town cmc;a;
Permit/'Lcensinc
Cay or Tcwn
CU Dept
Licens;nc Ecard
Seiec}man's Office
h'eaith Cepartment
Other
[C`eck .r immediate resccnse is required
Ccntac: person none T
Jul -20-99 10:50A The Elizabeth Grady Co -s 1781391477
JOHN P. WALSH_
352 Fo ster Sty et, N". Andover
TO:
MIKE MCGUIRE
FROM:
JOHN & KATHLEEN WALSH
DATE:
JULY 20, 1999
SLJBJECT:
INFORMATION REQUESTED FOR 352 FOSTER STREET
Mike,
Following is the Notice of Decision you requested from the Town ol'North
Andover. We would appreciate any consideration you can grant us in expediting our
situation_ If you have any questions or need additional information, please contact me
directly at (781) 391-9380 ext. 12.
Thank you in advance for your cooperation with this matter
JPW/jad
Post -it' brand fax transmittal memo IM Ia cf pages '
'b M l Ke (`rlc is v i' frO�" •�o�n W u 1 �l
414, k �q k g3S
"1WlJU-T i
North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
Number is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c11,S150A.
The debris will be disposed of in:
0, ST, /1% iy/%Gf/YI�N�
(Locaticy(jo Facility)
Signature of Permit Applicant
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
JOHN P. WALSH
352FosterStrwt, N.Andover
July 12, 1999
MiAael McGuire
Local Building -Inspector
Town of North Andover
27 Charles Street
North Andover, MA 01845
Dear Mr. McGuire,
Enclosed please find: 1) a completed application for breezeway addition,
2) architectural drawings and 3) plot plan. If you have any questions, please contact me
at 781391-9380. Thank you.
Sinc y,
J P. Walsh
352 Foster Street
Enclosure
JPW/jad
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8 Release Signature
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Tenns And Conditions
Definitions On this Arbill, 'we,"our,' and "Lis"rufur to
Federal Express Corporation, its employees, and agents. "You"
and "your` refer to the sender, its UITIPIOYUS, and agents.
Agreement To Terms By giving cis your package A Fa
(JUINOr, You agree to all the terms on this Airbill and in our
current Service Guide, which is available on request. You also
agree to those terms on behalf of any third party with an
interest in the package. If there is a conflict between the
Service Guide and this Airbill, the Service Guide will control.
No one is authorized to change the terms Or Out Agreement,
Responsibility For Packaging And Completing
Airbill You are responsible for adequately packaging your
goods and pioperlyfilling outthis Airbill. If you ornitthe number
of packages and/or weight per package, our hilling will he
based on our best estimate of the munboi of packages we
received and/or an estimated "default" weight per package
as determined by us.
Responsibility For Payment Even if you give us
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responsible for all delivery costs, as well as any costwo incur
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Limitations On Our Liability
0 And Liabilities Not Assumed
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an interest in the package
if you or the recipient violates any of the terms of our
Agreement
for loss or damage to shipments of prohibited hums
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control, including but not limited to acts of God, perils of
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• For other shipments, the highest declared value allowed is
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VBIUL," in which case the highest declared value allowed
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Items of "extraordinary value" include shipments containing
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tiable instruments, and other items iisted in our Service Guide.
• You may send more than one package on this Airbill and fill
in the total declared value for all packages, not to exceed
the $100, $500, or $50,000 per package limit described above,
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the maxinicurn allowable declared valveisf orthp total dociared
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Filing A Claim YOU IMUST MAKE ALL CLAIMS IN
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set out in the current Service Guide.
You may Call 0 - Ut Customer Service department at
1.800-Go-FedU_: (800-463-3339) to report a claim; however,
you must still file a timely written claim.
Within 90 days after you notify us of your claim, you must
send us all the information VOL; have about it. We aren't
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11 the recipient accepts your package without noting any
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Delivery to Residential Locations Shipments to
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Right To Inspect We may, at our option, open and
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the shipment is prohibited by law; or if the shipment would
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FORM U -LOT RELEASE FORM
INSTRUCTIONS: This form -is used to verify that all necessary approvals/permits from
Bsaraiiti 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******************'k'�**�
APPLICANT.. IIAI #&16'k11ZEi/✓ �sH PHONE �-a�k� %S�'
LOCATION Assessor's Map Number 7 PARCEL `
SUBDIVISION LOT (S)
z 7
STREET' S%��iQ �l ST. NUMBER"
* **
.******************OFFICIAL USE
+�1�ecze cu
RECOMMENDATIONS OF TOWN AGENTS:
ha ntizra.a
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CONSERVATION ADMINISTRATOR DATE APPROVED I of
DATE REJECTED
• COMMENTS
x
TOWN PLANNER
COMMENTS
FOOD INSPECTOR -HEALTH
CTOR-HEALTH
COMMENTS
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
PUBLIC WORKS - SEWERIWATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE
C5 y ►',C.1 £X o M -7 13 `� A VYI M M `C ---�—
Revised 9197 jm
Date.1z-/.v•••••
TOWN OF NORTH ANDOVER
O �
P
' PERMIT
FOR. GAS INSTALLATION
y
SSACMUSEtS77
This certifies that ..1��`�.` .!.�
..................... .
has permission for gas installation
S Y. -� ............
in the buildings of . ti- fel s- ...............................
at ..........
. , North Andover, Mass.
Fee. Lic. No. 3oay ....
( . .............
6AS INSPECTOR
Check # / y
6657
U
If'
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
a
No- aiej' , mass.
City, Town
Building,3`S-A ro� ✓ P --d
AT: Location,35-A ,rL
Date_ IQ bb k&�
Permit #
Owner's
Name
Type of Occupancy :90 i dZA CC
Renovation ❑ Replacement ❑
Plans Submitted Yes ❑ No ❑
(Print or Type) ii ''
Installing Company Name �1od Pn Q f ( Inc,
Address q1 _ _ 1—(,111 r i ('_, d :34-rP.P -
Business Telephone `1 +(1— nL I
Check One: Certificate
Corp.
❑ Partnership
❑ Firm/Company
me of Licensed Plumber orGaassiitter
,,
I hereby certify that all of the details and information I have submitted (or entered) iri above application are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under Permit issued for this application will be in compliance with all pertinent
provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
I have informed the owner or his agent that 1 do not have liability insurance including completed operations coverage.
Signature of Owner/ Agent
I have a current liability insurance policy to include completed operations coverage. ❑
By _
Title
City/Town
APPROVED (OFFICE USE ONLY)
FORM 1243 A.M. SULKIN CO. 1989
TYPE LICENSE:
❑
Plumber
Si nature of Licensed
51-,6asfitter
Plumber or Gasfitter
❑
Master
�
1300
❑
Journeyman
License Number
■■■■■■■■■■■■■■■■■■■■
NOR
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Room
■■
Wellmlys •
■■■■■■■■■■■■■■■■■■•■■`■.■■■
• ..
■■■■■■■■■■■■■
ENNE
■
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..
■■■■■■■■■■■■■■■■■��■■■■■■■■■
• •-
■■■■■■■E■■■■■■■EN■
■■■S■N■■n
M.O.■■■■■■■■N■■■N■■■EE■W■■M■■■■■'
(Print or Type) ii ''
Installing Company Name �1od Pn Q f ( Inc,
Address q1 _ _ 1—(,111 r i ('_, d :34-rP.P -
Business Telephone `1 +(1— nL I
Check One: Certificate
Corp.
❑ Partnership
❑ Firm/Company
me of Licensed Plumber orGaassiitter
,,
I hereby certify that all of the details and information I have submitted (or entered) iri above application are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under Permit issued for this application will be in compliance with all pertinent
provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
I have informed the owner or his agent that 1 do not have liability insurance including completed operations coverage.
Signature of Owner/ Agent
I have a current liability insurance policy to include completed operations coverage. ❑
By _
Title
City/Town
APPROVED (OFFICE USE ONLY)
FORM 1243 A.M. SULKIN CO. 1989
TYPE LICENSE:
❑
Plumber
Si nature of Licensed
51-,6asfitter
Plumber or Gasfitter
❑
Master
�
1300
❑
Journeyman
License Number
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The Commonwealth ofllassachusetts
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 Legibly
`( Name (Business/Organization/Individual): � 4- D CA/ 1,V c.
�_ Address: C? [ Ly lwv � / c L_b
City/State/Zip:�� /11,P91Phone #: ZL.T3 j- -a� E
Are you an employer? Check the appropriate box:
1. I am a employer with q5
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I 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. ❑ I 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.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
S. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
I .❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
*Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information'
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
iContractors 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: Ujh' ltgS°�e°-e%Rgz — 4 -rt_
Policy # or Self -ins. Lic. #: " 000 s q 4d Expiration Date: OVO
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $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 certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: F,-vwu�, Date:
Phone M C? 7f-- 531'
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 #:
1
mfor ation and Instructions
lassacbusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
trrsuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
xpress or implied, oral or written."
m employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
,f the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
eceiver 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
twelling 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."
dGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
-enewal 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
mter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
-equirements 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 returned 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 bum 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.
I'he Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
.vised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia
Datez `..�.—.'7 .......
0,
TOWN OF NORTH ANDOVER
10
PERMIT FOR WIRING
This certifies that ....... ....................................... ............
has permission to perform
........... 4 .....................................
44
wiring in the building ................. .........................
1-1
at-....., : ...... North Andover, Mass.
c. ................... .....
Fee:.................. Li i ... ? -i - F
ELECTRICAL ��i
Check 41
7773
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. P7i / 3
Occupancy and Fee Checked
[Rev. 1/07] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 5 7 CM 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: // C U
City or Town of: NORTH ANDOVER To the Inspector ofWires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) 3 -1�- a IQ�e2lZ'-12 5)-
-
Owner or Tenant -7 5 k N L&4 _ <
Telephone No.
Owner's Address \ 1� I i
Is this permit in conjunction with a building permit? Yes L; ---"No ❑ (Check Appropriate Box)
Purpose of Building Q t,A/-e L� �/� Utility Authorization No.
Existing Service Amps
New Service Amps
Volts Overhead ❑ Undgrd ❑ No. of Meters
Volts
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Overhead ❑ Undgrd ❑ No. of Meters
�V t iZt,.0
c
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 Tota
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑ In ❑
rnd. rnd.
o. ot Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
g
No. of Waste Disposers
Heat Pump
Number
ons
KW
o. o elf- oRained
Totals:
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water. Kms,
No. o No. of
Data Wiring:
Heaters
Signs Ballasts
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
elecommunications firing:
No. of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
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 i force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE OND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties of per'u , that the information on this application ' true and complete.
FIRM NAME: ��� i�/Lv �l SLIC. NO.: S-1 1'
Licensee: Signature LIC. NO.:
(/f applicable, enter ' ex tnpt" in the license number line.)/' f' , / Bus. Tel. No. S -
Address: ��//!// �2r/ �]/f� CJ t1%>°r two < st G f �� y 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. 1 am the (check one) ❑ owner ❑ owner's agent.
Owner/Agent PERMIT FEE: $-3'
Signature Telephone No.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street :
Boston, MA 02111
s� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Letzibly
Name (Business/Organization/Individual):
Address: V— 17�'7 /l J,// e V� �0/ I/e
City/State/Zip: 6!Ava�__"4 1 S Phone #: % �/ s �d--7 � T
Are you an employer? Check the appropriate box:
. ❑ I am a employer with 4. ❑ I am a general contractor and I
.employees (full and/or part-time).*
I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
❑ 1 am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
have hired the sub -contractors
listed on the attached sheet.
These sub -contractors have
workers' comp. insurance.
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, §1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10f Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
*Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information.
t 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:
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address: I 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 certif u er th pains an realties of perjury that the information provided above ' true -red correct.
Siunature: Date: �� 5 L__ -
?,?F) 1<_� ?, -
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 #:
Date .:... � ....... .
TOWN OF NORTH ANDOVER
P
PERMIT FOR GAS INSTALLATION
This certifies that .. /1-4 rh ,z-' ....-:........ .
has permission for gas installation
in the buildings of.. `.?.. .......................... .
at .................... , North Andover, Mass.
Fee.—''..... Lic. No........... :��c �,��........
GAS INSPECTOp
Check # ,/e/- G /
700
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
r"tr ►�D��It Mass.
City, Town
Building {{
AT: Location 3 5 r r Si_
Date 1 Z f 3010q
Permit #
Owner's
Name
Type of Occupancy: ICS)1,1&/%
New 0 Renovation ❑ Replacement ❑
Plans Submitted Yes ❑ No Q
* (Print or Type)
Installing Company Name
Address
Business Telephone
esaLV�Amo
Check One: Certificate
sir, z Corp.
ElPartnership
Ha ®` q co o ❑ Firm/ Company
Name of Licensed Plumber or Gasfitter
AIv(,'),'- l<
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that all plumbing pork and installations performed under Permit issued for this application will be in compliance with all pertinent
provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
I have informed the owner or his agent that I do not have liability insurance including completed operations coverage.
Signature of Owner/Agent
I have a current liability insurance policy to include completed operations coverage. ❑
By
Title
City/ Town
APPROVED (OFFICE USE ONLY)
FORM 1243 A.M. SULKIN CO. 1989
TYPE LICENSE:
❑ Plumber Signature of Licensed
Plumber or Gasfitter
Gasfitter
[� Master Xd�/ p
❑ Journeyman License Number
tea:
AM
..
■■■■■■■■■■■■■■■�mom
■IM■■■M■■■
..�■■■■■■■■�■■■■■■■■■�■■�■■■■■■
* (Print or Type)
Installing Company Name
Address
Business Telephone
esaLV�Amo
Check One: Certificate
sir, z Corp.
ElPartnership
Ha ®` q co o ❑ Firm/ Company
Name of Licensed Plumber or Gasfitter
AIv(,'),'- l<
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that all plumbing pork and installations performed under Permit issued for this application will be in compliance with all pertinent
provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
I have informed the owner or his agent that I do not have liability insurance including completed operations coverage.
Signature of Owner/Agent
I have a current liability insurance policy to include completed operations coverage. ❑
By
Title
City/ Town
APPROVED (OFFICE USE ONLY)
FORM 1243 A.M. SULKIN CO. 1989
TYPE LICENSE:
❑ Plumber Signature of Licensed
Plumber or Gasfitter
Gasfitter
[� Master Xd�/ p
❑ Journeyman License Number
tea:
m
z
0
In
m
m
11Z
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 Lep-ibly
Name (Business/organization/mdividual):
4. D,9 / 0 i L IAIC-
Address: 91 LYlw t r' -1L L6 �sSTREF_-r
City/State/Zip:�46o- / /yl>9 a/ Phone #:
Are you an employer? Check the- appropriate box:
1.;4 I am a employer with q5
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet $
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. ❑ I 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.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Budding addition
10.0 Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
*Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information'
t Homeowners who submit this affidavit indicating they are 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: j�Ho,t
�SA�IR�-Ta�e�
S' eJppu tie, s Cc�.�,
��,� sir•_ �'�o
Policy # or Self -ins. Lie. M "
00031441-
44
Expiration Date: Or o a AD00 q�_
J9b Site Address:
City/State/Zip:
A':iach 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 certify under the pains and penalties of perjury that the information provided above is true and correct
F
Phone M 179-- 58 ci -9 EYf
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 #:
.\4
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 -contractors) 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 returned 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 fbryou 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 bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would lice to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial. Accidents
Office of Investigations
600 Washington Street
Boston, MA 92111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-05 www.mass.gov/dia
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9
HOME IMPROVEMENT CONTRACTOR;— -
+ Registration 100126 -
Type - PRIVATE CORPORATION
Expiration 06/18/96-
Douglas P. Yasika/Des-Con Sys
Douglas P. Yasika
1;.;olby Rd/ PO #698
anville NH 03819
''✓fie L�curu�c�ru:�alCr :! � (�z,,,,.ich.:-rt7
T
DEPARTMENT OF PUBLIC SAFETY
CONSTRUCTION SUPERVISOR LICENSE
Nuiber: Expires: lirt9date:
CS 051622 02/21/1998 92%2?/1950
Restricted To: M
DOUGLAS P YASIKA
12 COLBY 10 P081 698
DAN YILLE, NR 03819
Restricted To: 00
00 - None
1A - Masonry only
10 - 1 6 2 Faaily Hoes
LU
Z J
' Q W
FORM U - LOT REIM SE FORM ►_-�
�o
00
INSTRUCTIONS: This form is used to verify that all neces z �
approvals/permits from Boards and Departments having juri is
have been obtained. This does not relieve the applicant
landowner from compliance with any applicable local or st law,
regulations or requirements.
****************Applicant fills out this section*****************
u V� a(s�, Sd 83 -6611
APPLICANT: Phone
LOCATION: Assessor's Map Number Parcel ^'
Subdivision Lot(s)
Street • St. Number 35Z
************************Official Use Only************************
RECOMMENDATI NS OF TO AGENTS:
Conservation Administrator
Comments
Uj_
#tA s,_b • iQj
771 15.
Town Planner
Comments
Food Inspector -Health
Septic Inspector -Health
Comments
el.,�iw
Date Approved /0/0
Date Rejected
" flr4 ar Lk�,� _�W,)ftej C, ID t
Public Works - sewer/water connections
- driveway permit
---tire Department
Date Approved
Date Rejected
Date Approved
Date Rejected
Date Approved Z ,:f_y
Date Rejected
Received by Building Inspector Date
OCT 16
1 V, V J, 1 .. i I
coo
KENNE M R MAHONY
Dlretror
Town of North Andover
COMMUNITY DEVELOPMENT AND SERVICES` 8 "
146 Main Street
North Andover, Maaaaehusetts 01845
(508) 688-9533
John P. Walsh Trustee of the KJJ Realty Trust DECISION
352 Foster Street Petition# 041 -95
North Andover, MA 01845
The Board of Appeals held a regular meeting on Tuesday evening, August 8, 1995 upon
the application of John P. Walsh, Trustee of the KJJ Realty Trust requesting variances
under Section 7, paragraph 7.1, 7.2 & 7.3 and table 2 of the Zoning Bylaw so as to permit
relief of 43,539 square feet of lot dimensional area from the requirements of 87,120 square
feet, relief of 25 feet from the street frontage requirement of 175 feet, relief of 16 feet for
the addition, from the side setback requirement of 30 feet and relief of 20 feet for the
unattached garage from the side setback requirement of 30 feet. The applicant is also
requesting a Special Permit under Section 9, paragraph 9.2(1) so as to construct an
addition onto a legal non -conforming structure located at 352 Foster Street, Zoning
District R-1.
The following members were present and voting: William Sullivan, Scott Karpinski,
Joseph Faris, John Pallone and Ellen McIntyre.
The hearing was advertised in the North Andover Citizen on 7.19.95 and 7.26.95 and all
abutters were notified by regular mail.
Upon a motion by Scott Karpinski and seconded by Joseph Faris, the Board voted
unanimously to Grant the Variances as requested. Upon a motion by Scott Karpinski and
seconded by Joseph Faris the Board voted unanimously to Grant the Special Permit as
requested. Voting in favor: William Sullivan, John Pallone, Joseph Faris, Scott Karpinski
and Ellen McIntyre.
The Board finds that the petitioner has satisfied the provisions of Section 10, Paragraph
10.4 of the Zoning Bylaw and that the granting of these variances will not adversely affect
the neighborhood or derogate from the intent and purpose of the Zoning Bylaw.
The Board finds that the applicant has satisfied the provisions of Section 9, paragraph 9.1
of the Zoning Bylaw and that such change, extension or alteration shall not be
substantially more detrimental than the existing non -conforming structure to the
neighborhood.
BOARD OP APPEALS 699-9$41
BLr ING 699-9345
CONSnVATtON M-9530
HEALTH 689-9540
PLAPMMO fits-9s3s
Julie Paro,o
D. Robert NkdUs
M ei Ho+.ud
ganam start
8r6e9 cAl`ea
10/03/1995 14:09 5087942088
Dated this 16th day of August, 1995.
LAW OFFICES
PAGE 04
I
BO OF PEALS,
Wi lam ullivan Pallone
Joseph Faris Ellen McIntyre
Scott Karpinski
H
r
10/03/1995 14:09
rJ �
5087942088 LAW OFFICES RAGE 02
s., toss •
Any appeal shall be filed tt�i�
within (20) days after the
data of filing of this ,L•OWN OF NORTH ANDOVER
Notice in the Office ULA9SAC1iLiS=S
of the Town Clerk.
BOARD OF APPEALS
NOTICE OF DECISION
"1:11C into canny ftt twoniy
hcvs alapaed tm m data of decidon i4sJ
VALX ut MIN! d2 W.
Data
Joyce A. Br.eshaw
t,. T._M Clok
'a
RECD: i•'� t.
4gyCE 6 UDSOW
;0 xNDOM
AUG I6 3 147 ?� 5
.A' iESt'
ATMs COPY
Town Clerk
Date August 16, 1995
Petition No. 041-95
Date of Hearing 8-8-95
Petition of John P. Walsh, Trustee of the KJJ Realty Trust
Premises affected 352
Referring to the above petition for a variation from the requirements
of Section 7 ars. 7.11.7.2 & 7.3 and Tab e
2 of the zoning Bylaw no an t
permit relief of 43,539 square feet of lot dimensional area from the
requirements of 87,120 square feet, relief of 25 feet from the street
frontage requirement of 175 feet, relief of 16 feet for the addition,
from the side setback requirement of 30 feet and relief of 20 feat for
the unattached garage from the side setback requirement of 30 feet. The
applicant is also requesting a Special Permit under Section 9, para. 9.2(1)
so as to construct an addition onto a legal non -conforming structure.
After a public hearing given on the above date, the Board of Appeals
voted to Grant the Special Permit & variance and hereby
authorize the Building Inspector to issue a permit to:
John P. Walsh, Trustee of the KJJ Realty Trust
for the construction of the above work, XAV0UX. "VrL��1XL' XX x
The Board finds that the petitioner has
satisfied the provisions of section 10,
para. 10.4 of the Zoning Bylaw and that
the granting of these variances will not
adversely affect the neighborhood or derogate from the intent and purpose of the
Zoning Bylaw.
The Board finds that the applicant has
satisfied the provisions of Section 9,
para. 9.1 of the Zoning Bylaw and that
Board of Ap is,
such change, extension or alteration
shall not be substantially more
William Still van, airman
detrimental than the existing non-
conforming structure to the
John Pallone Joseph Faris
neighborhood.
Scott Karpinski Ellen McIntyre
Re,?istry of Deeds
Northern District of Essex County
Lawrence, MA 01840
09/12/95
MIENIC SCALISE CT
0 64 Rec:time 1104 Type N01' if).()O
Iris 1 29438
Total 10.E
N 65 Payment Check 10100
THAM( YOU! Thomas J. Burke
Register of Deeds
i
10/03/1995 14:09 5087942088
i
.. _ - .i - _ _ - - - • - - - - - - - - - - - - - - - - - - - - - - - - - - - -
i
j
1
LAW OFFICES j PAGE 01
i
DOMENIC J. SCALISE, ESQUIRE
89 Main Street
i
North Andover, Massachusetts 01845
Telephone: (508) 6824153'
Fax: (508) 794-2088
DATE: October 3, 1995
i
-Facsimile Number: (508) 794-2088
Telefax to the Following Number: (603) 382-3945
Compahy Name:
Attention: DOUG Y.
From: DOMENIC J. SCALISE
Regarding: WALSH
Message: FOLLOWING PLEASE FIND A COPY OF THE NOTICE OF
DECISION WHICH WAS RECORDED AT THE REGISTRY OF
DEEDS AND COPY OF RECORDING SLIP. 1F YOU SHOULD
NEED ANYTHING ELSE, PLEASE ADVISE. THANK YOU.
Total Number of Pages (Including This Cover Page): 5
IF ALL PAGES ARE NOT RECEIVED, PLEASE CALL BACK AS SOON AS POSSIBLE
AT THE ABOVE NUMBER.
This telecopy is attorney-client privileged and contains confidential information intended only for
the person(s) pained above. Any other distribution, copying or disclosure is strictly prohibited.
If you have received this telecopy in error, please notify us immediately by telephone, and return
the original transmission to us by mail without tnaldng a copy.
Location � Z-- S STT
No. 6-/8 - C Date 12112 ke.
A
TOWN OF NORTH ANDOVER
Certificate of Occupancy $ _
N
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fe t� $ ZS �
ti
Sewer Connection Fe $
56
Water Connection Fee $
TOTAL
..r
9437
$ Zs�
Lgl
CCBui16ector
Div. Public Works
'S
M
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KAREN H.P. SEI. ,ON +d ... =Town of 47
Dirrrror NORTH ANDOVER
BUILDING �•�Kw_
CONSERVATION DriMIO c of
PLA .NNI
PL:\��IXG PLANNING & COlD1UNITY DEVELOPMEI T
CHIMNEY APPLICATION AND PERMIT
DATE 1
LOCATION
OWNER'S NAME O \A
120 Main `Street. 01M
(508) 682-6483 -
PERMIT 0S 1$ . (-'
BUILDER'S NME S.- fs-T MS
MASON'S NAME GNIE?%k,>\,- -� �L
MASONS ADDRESS z- \Cx she S� �CNCSzo� . N 4i
:�.ASON' S TELEPHONE (v 03- 5� 435'
MATERIAL OF CHIMNE- c -m \) 'I. 6 0 \ c \C
INTERIOR CHIMNEY EXTERIOR CHI:4NEY 9 a L Glc:,
NUIBER A1D SIZE OF FLUES
THICiviESS OF HEARTH V -A 0--S
W -J -1 _ chimney or f_reol=ae conf.._-.. to requirements of the code and
have rules and recu'_aticns been receivea:
GATE lZ �I 9S'
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SIG:�riiUR._. OF M�£.j _
i 3800
EST. CONSTRUCTION COS T i CO2: i R. C: PRICE
PERi•1T_T GRJkITED n FEE Z�
ROBERT NICZTTA, Bi.;ILD..:G
INSPECTED
REi�.ARKS_
cr -� avrCK REQUIRED
THIS PERMIT MIUS T BE DISPLAYED ON THE PREIAISES
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t�TRICTIONS
# 021-42-3426
OPR ONLYFJ FEE:
HEIGHT:
99,P/27/1950
THIS
DOCU
OTHERS THUMB PRINT CARRIE. OMENT MUST BE
N HE
RIGHT THE HOLDER WHEERNENGN OF
I ED IN ",S OCCUPATION. TION
MORE IMPROVEMENT CONTRACTOR
Registration 100426
Type - PRIVATE CORPORATION
Expiration -06/18/96
Douglas P. Yasiki/Des-Con sys
-Douglas P. Yas i ka
-;f lby Rd/ PO 1698
ADMINISTRATOR -5--y-Olinville NH 03819
DEPAMMENT OF Puma_
SWM
1010 COMMONWEALTH AVE
BOSTON, MASS, 02215
LICENSE
CONSTR. SUPERVISOR
EFFECTIVE DATE
LIC -NO.-
04/01/1992 057622
D13LI13LAS p YnSIKA
12 COLBY RD pOBX 698
DANVILLE
NH 0.-., ,
-19
r 1 NOT VALID UNTIL SIGNED By LICENSEE AND OFFICIALLY
STAMPED , OR . SIGNATURE OF THE
COMMISSIONER
SIGNr IT OF LICENSEE
A 'PRifb)"" x
MORE IMPROVEMENT CONTRACTOR
Registration 100426
Type - PRIVATE CORPORATION
Expiration -06/18/96
Douglas P. Yasiki/Des-Con sys
-Douglas P. Yas i ka
-;f lby Rd/ PO 1698
ADMINISTRATOR -5--y-Olinville NH 03819