HomeMy WebLinkAboutMiscellaneous - 36 PATTON LANE 4/30/2018N
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NEW ENGLAND CLAIMS SERVICE, INC.
Incorporated 1985
Reply Tor
P.O. Box 345
Mansfield, MA 02048
TEL. (508} 337-8058
FAX (978} 927-3002
Li
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` 131 Dodge Street, Suite 6
ASSOCIO
h J Beverly, MA 01915
' R+O(h[,F)AN
MI�`��" TEL. f9781927-3000
URAWE
k FAX (978} 927-3002
wrandall@newenglandclaims.com
FORM OF NOTICE OF CASUALTY LOSS TO BUILDING
UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B
To: Inspector of Buildings
North Andover, MA
RE: Insured: Heidi & Michael Yoken
Property Address: 36 Patton Lane, North Andover, MA 01845
Cause of Loss/Date: Ice Dam/2-12-15
File/Claim No.: BOS53826 '
Claims has been made involving loss, damage or destruction of the above captioned property, which
may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143, SECTION 6, to
be applicable. If any notice under MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B is
appropriate, please direct it to the attention of the writer and include a reference to the captioned
insured, location, police number, date of loss and claim or file number.
Section 3B. No insurer shall pay any claims (1) covering the loss, damage or destruction to a building or
other structure, amounting to one thousand dollars or more, or (2) covering any loss, damage or
destruction of any amount, which causes the condition of a building or other structure to render section
six of chapter one hundred and forty-three applicable, without having at least ten days previously given
written notice to the building commissioner or inspector of buildings appointed pursuant to the state
building code, to the fire department or arson squad of the city of town and to the board of health or
board of selectmen of the city or town in which the same is located. If at any time prior to payment the
said city or town notifies the insurer by certified mail of its intent to initiate proceedings designed to
perfect a lien pursuant to section three A, or to section nine of chapter one hundred and forty-three, or
section one hundred and twenty-seven B of chapter one hundred and eleven, the said payment shall not
be made while the said proceedings are pending; provided, however, that said proceedings are initiated
within thirty days of receipt of such notification.
Any lien perfected pursuant to section three A, or to section nine of chapter one hundred and forty-
three or section one hundred and twenty seven B of chapter one hundred and eleven, shall extend to
and may be enforced by the city or town against any casualty insurance policy or policies covering any
loss, damage or destruction pursuant to which the proceeds to perfect the lien were initiated.
No insurer shall be liable to any insured owner, mortgagee, assignee, city or town, or other interested
party for amounts disbursed to a city or town under the provisions of this section, or for amounts not
disbursed to a city or town under the provisions of this section.
On this date, I caused copies of this Notice to be sent to the persons named above at the addresses
indicated above by First Class Mail.
Very truly yours,
ZIX z
?Jose Lantieri
Adjuster
jlantieri@sweetclaims.com
732-330-4295
Date .......... I-/- ........................
ORTH
TOWN OF NORTH ANDOVER
0
PERMIT FOR WIRING
This certifies that . . ..............................................................
has permission to perform. ...................................................................
wiring in the building of...... ...............................
at '7& ....... . . ................ North Andover -,-,Mass.
Fee.( .......... Lic. No
.............. i 9LE �ICAL INSPM
Check #
.r
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No.`r
Occupancy and Fee Checked
Lev. 1/07] (�ravr hlanlrl
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 INFORMATION) Date: 3 —&Q --H
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersignedgives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) �(1 ) r(l [ A h p
Owner or Tenant
Telephone No.
Owner's Address C,
IA t -
Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box)
Purpose of Building 0 \ky_ ( j !� Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
New Service Amps / Volts Overhead ❑ Undgrd ❑ No, of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: ,
Co letion ojth 11 bl b
No, of Recessed Luminaires
I o owm
:
No. of CeilSusp. (Paddle) Fans
to a may a waived by the Me of Wires.
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑ In ❑
o. o mergency ig g
rnd. rnd.
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
InitiatinLy Devices
No. of Ranges f
No. of Air Cond. Tons Tot
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Number
Tons..
KW.....
No. of Self -Contained
Totals:
Detection/Alerting Devices
No. of Dishwashers )
Space/Area Heating KW
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Water
No.KW No. of No. of
No. of Devices or Equivalent
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunicationswiring:
No. of Devices or Equivalent
OTHER:
��11 Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: l obb .�tl (When required by municipal policy.)
Work to Start: ae-N 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 5j� OND ❑ OTHER ❑ (Specify:)
I certify, under t ains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: ' �e C, �'d(f LIC. NO.. -_II a,34
Licensee: i & Signature LIC. NO.: a
(If applicable, enter "exempt" in the license number line.) Bus. Tel. No.
Address: Alt. Tel. No.• C l i
*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. J
Owner/Agent
Signature Telephone No.
FPERm,T FEE: $ t%
1\
4
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41
The Commonwealth of Massachusetts
s`� !
Department of industrial Accidents
have hired the sub -contractors
Office of Investigations
listed on the attached sheet i
600 Washington Street
Boston, MA 02111
d�; www.massgov/dia .
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plambers
Name (Business/Organization/individual):
Address:01110e `i-
city/state/Zip: Q j j 1_� f 0J i3l Phone
Are you an employer? Check the appropriate box:
1. ❑ 1 am a employer with �,
4. ❑ I am a general contractor and 1
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 mein 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. [Nonworkers' comp.
c. 1.52, § 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. ❑ Deritoiition
9. ❑ Building addition
10.0 Electrical repairs or additions
11. [1 Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
•Any applicant that checks bort# 1 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 subcontractors and their workers' camp. policy infomtation.
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. Lie. #:
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 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 cell , under the pa viand penalties of 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 #:
i
Information and Instructions VV
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 certificates) 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 r
be returned to the city or town that the application for the permit or license is being requested, noVthe 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..
The 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. # 617-7274900 ext 406 or 1-8.77-MASSAFE
Revised 5-26-115 Fax # 617-727-7749
www.mass.gov/dia
...
Date......
...........
TOWN OF NORTH ANDOVER
• PERMIT FOR GAS INSTAL;;;;O
ti
This certifies that.
has permission for gas installation --r- �. ...............
in the buildings of ....... . . .................................
at L ......................... North Andover, Mass.
Fee X0. Lic. No. �A .... ................
AS I CTOR
Check .4
6386
MASSACHUSETTS UNDDRM APPUCATON FOR PERMIT TO DO GAS FTrnNG
(Type or print) Date
NORTH ANDOVER, MASSACHUSETTS
/
Building LQ�ations 6 ��"l�C- .tJ LV Permit # a
Amount $ 6/0
Owner's Name Uri
New ❑ Renovation ❑ Replacement ❑ Plans Submitted ❑
(Print or type)nn Check one: Certificate Installing Company
Name N AXA C L cprAr L-1 Corp
Addre _ 20 02.1.5 j� tl.L" � � 13 Partner.
Business Telephone 97A 1/23[:] Firm/Co.
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE Check one:
1 have a current liability Insurance, policy or it's substantial equivalent. Yes ❑ No❑
If you have checked yes, please indi5atgAhe type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnity ❑ Bond ❑
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner ❑ Agent ❑
{.o ..�.:. ..�:G. aL _. _11 _1 1_
_• _ , , •,.., . — — �La a 4ll Al I uiauuu , nave suommeu (or emerea) in above application are true and accurate to the
best of my knowledge and that all plumbing work and insta ation perfor d under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachuse Sta� C�a� �Tde�and Chapter 142 of the General Laws.
By:
Title
City/Town;
APPROVED (OFFICE USE ONLY)
Signaturf of Licensed lumber Or Gas Fitter
❑ Plumber a f0 q 6 k
❑ Gas Fitter License Number
❑ Master
ffl—ourneyman
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Date..��'� 48
C**, t TM,4, TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
41
�. SACMUS�
y This certifies that ............... ..... "...."'."''.' ..�
has permission to perform ;,� .. �.................
plumbing in>the•buildings of ....�.................
ate... `, .�. .... , North'Andover, Mass.
Fee. Lic. No .....G.............:............ .
1 f PLUMfi1N�G .INSPECTOR
Check N %c3�
7697
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
�nA ' Date0-7
Building Location 3; c q.l L4 Owners Name I�`��[ �pVl1� Permit ` %o
Type of Occupancy Amount
)'d
1
New rl Renovation Replacement L—:.1 Plans Submitted Yes No
(Print or type)n� Check Certificate
Igstalling Company Name T�q-. �Corp.
Addressr 1 S S L L'
� Partner.
k
usmess Telephone ., Qa 3 6 5 7 Cj Firm/Co.
Name of Licensed Plumber: hAl-LO) Oet—ccyv%t_
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy IT Other type of indemnity ❑ Bond ❑
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
threeinsurance
Signature Owner ❑ Agent ❑
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installatiqps performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massa h tt to Plumbing Code and Chapter 142 of the General Laws.
By: ignaur 101 Zicens'e—d'mumoer
Type of Plumbing License
Title "% g6fo
lCity/Town'11�icense um er Master Journeyman ❑
APPROVED (OFFICE USE ONLY
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MMMMMMMOM
MWOMMMMOMMMONOMN
(Print or type)n� Check Certificate
Igstalling Company Name T�q-. �Corp.
Addressr 1 S S L L'
� Partner.
k
usmess Telephone ., Qa 3 6 5 7 Cj Firm/Co.
Name of Licensed Plumber: hAl-LO) Oet—ccyv%t_
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy IT Other type of indemnity ❑ Bond ❑
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
threeinsurance
Signature Owner ❑ Agent ❑
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installatiqps performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massa h tt to Plumbing Code and Chapter 142 of the General Laws.
By: ignaur 101 Zicens'e—d'mumoer
Type of Plumbing License
Title "% g6fo
lCity/Town'11�icense um er Master Journeyman ❑
APPROVED (OFFICE USE ONLY
Date. ..,.:—. !J .. .......
j.ao ,°aryl
° 0TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
K"_.
This certifies that
has permission for gas installation ...%.. L L f .
in the buildings of ............................
at . k, ..... ..... ; North -Andover, Mass.
Fee.. . ? :... Lic. No.. ...... ........
GASINSPECTOR
r
Check#
3671
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
Wfint of Typal
t, nttr. .Mass.
G
Date Cs ' i.S_ -� 1 - Permit #
Building Location _ 'Owner's Name .
Type of Occupancy s ,�
New Renovation [j Replacet�t.40 , Plans Submitted: Yesp ° No p
Installing,Crampany Name CALLAHAN AIR CONDITIONING & BEATING
Address 91 BELMONT STREET
NQ - ANDQVFR . MA _ n t RA 5
Business Telephone 978=689=9233
Name of Ucensed•Plurnber or Gas Fitter
K.
1Check one:
L�/Corporation
•0 Partnership
0 Flrm/Co.
Cerfflcate #
1�ZL C
INSURANCE COVERAGE--
I
OVERAGE;i have a current HabBly Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes IS No O
If you have checked ym please indicate the type coverage by checking the appropriate box
A Iiabfiity Insurance policy fad' Other type of Indemnity O Bond 13
OWNER'S INSURANCE WAIVER: I am aware that the licenses does not have the Insurance coverage required by
Chapter 142 of the Mass. General Laws. and that my signature on this permit application watves tuts requtrcmcnL
Check one:
Ownerp Agent p
Signature at Owmet of ownst s Agent -
I ha eby eeftity that aq of the details and Infofination I gars submitted for entwedi in above application are true and awnts to the best of my
knowledge and that aH pkmibing work and Installations pedotmed under the permit Issued for this APPttcatten wlll be in compliartee with All
pertMent Provisions of the Massachusetts State Gas Cade and Chapter 142 of the , eras
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Plumber nil to c LRwised Pkfmber or Gas FAter
Title Gasfitter M=3440
Master dense Number
City/Town .fowneyman
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SUB-8SMT.
8ASEMENT
1ST FLOOR
2ND FLOOR
3RD FLOOR
4TH FLOOR
STH FLOOR
6TH FLOOR
7TH FLOOR
8TH FLOOR
Installing,Crampany Name CALLAHAN AIR CONDITIONING & BEATING
Address 91 BELMONT STREET
NQ - ANDQVFR . MA _ n t RA 5
Business Telephone 978=689=9233
Name of Ucensed•Plurnber or Gas Fitter
K.
1Check one:
L�/Corporation
•0 Partnership
0 Flrm/Co.
Cerfflcate #
1�ZL C
INSURANCE COVERAGE--
I
OVERAGE;i have a current HabBly Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes IS No O
If you have checked ym please indicate the type coverage by checking the appropriate box
A Iiabfiity Insurance policy fad' Other type of Indemnity O Bond 13
OWNER'S INSURANCE WAIVER: I am aware that the licenses does not have the Insurance coverage required by
Chapter 142 of the Mass. General Laws. and that my signature on this permit application watves tuts requtrcmcnL
Check one:
Ownerp Agent p
Signature at Owmet of ownst s Agent -
I ha eby eeftity that aq of the details and Infofination I gars submitted for entwedi in above application are true and awnts to the best of my
knowledge and that aH pkmibing work and Installations pedotmed under the permit Issued for this APPttcatten wlll be in compliartee with All
pertMent Provisions of the Massachusetts State Gas Cade and Chapter 142 of the , eras
t3y
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Plumber nil to c LRwised Pkfmber or Gas FAter
Title Gasfitter M=3440
Master dense Number
City/Town .fowneyman
MTr10Yt:
Location Z i`-',--777-�,u
No. I94, Date T1,A71
oi..
N°"7" TOWN OF NORTH ANDOVER
p Certificate of Occupancy $
►, ,' Building/Frame Permit Fee $
f ssACNUSEt
Foundation P it Fee
$
e e %ooL
a
$ S.5
p�,p®
%ewer Conpection Fee
$
�late';C31�n�nection Fee
$
M TOTAL (Q11ep $ �'
Building Inspector
Div. Public Works
IPERJIIT*NO.� I D
APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS.
PAGE 1
MAP d40.
LOT NO.
2 RECORD OF OWNERSHIP IDATE
BOOK "PAGE
ZONE
SUB DIV. LOT NO.
—
LOCATION 3 iO�D/.�
PURPOSE OF BUILDING 1
4 j C_ , _ _ _ _
rX
OWNER'S NAME £ f1 r, 1
WltOWNER'S ADDRESS f 1u r1vkVm
NO. OF STORIES SIZE
BASEMENT OR SLAB
JeS I cr
i
ARCHITECT'S NAME
SIZE OF FLOOR TIMBERS IST 2ND
3RD
/
BUILDER'S NAMESOvTti CjlOe���4
j'.0 Poo[ �l,
�f
SPAN --
DISTANCE TO NEAREST BUILDING yP
DIMENSIONS OF SILLS
---
DISTANCE FROM STREET
`-
POSTS
DISTANCE FROM LOT LINES SIDES 11 �/ ,� i�,p'
Y Q
REAR
V
GIRDERS
AREA OF LOT J:� +
FRONTAGE "2 ,+ -
V
HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW L S
SIZE OF FOOTING X
IS BUILDING ADDITION
��11 �1CC Y
'✓Dry
{` �V
MATERIAL OF CHIMNEY
IS BUILDING ALTERATION
W
IS BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE
Gsi C „6 9[`�1
CO L
IS BUILDING CONNECTED TO TOWN WATER
BOARD OF APPEALS ACTION. IF ANY
IS BUILDING CONNECTED TO TOWN SEWER
IS BUILDING CONNECTED TO NATURAL GAS LINE
INSTRUCTIONS
SEE BOTH SIDES
PAGE 1 FILL OUT SECTIONS 1 - 3
PAGE 2 FILL OUT SECTIONS 1 - 12
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FI ED Np APPROVED BY BUILDING INSPE// R
DATE FILED
SIGNATURE OF OWNEFF OR AUTHORIZED
i
FEE 19S '—'
PERMIT GRANTED
m 19 g
3 PROPERTY INFORMATION
LAND COST
EST. BLDG. COST // va fl 00
EST. BLDG. COST PER SQ. FT.
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
BOARD OF HEALTH
PLANNING BOARD
BOARD OF SELECTMEN
BUILDING INSPECTOR
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