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HomeMy WebLinkAboutMiscellaneous - 380 BOXFORD STREET 4/30/2018r� Commonwealth of Massachusettscp lugCity/Town of . System Pumping -Record TOWNOF Form 4 HEALTH Nor"' AR���r VFR DEP has provided this form for usez by local Boards of Health. Other forms may'be'used, but the information must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted ;to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left /Right front of Nous Leigh ear of Nous. , Left/ right side of house, Left / Right side of building, Left / Right front of building, Left / Righ rear of building, Under deck Address Citylrown State Zip Code 2. System Owner. Name' Address (if different from location) City/Town ' State Zi Code © Telephone Number .B. Pumping Record ' p 1. Date of Pumping Date 2. Quantity Pumped: Gallons 4 3. Type -of system. ElCesspool(s) eptic Tank F-1 Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑Ye s a o If yes, was it cleaned? ❑ Yes ❑ No, 5. Condition of System- I n , 6.. System Pumped By: Neil. Bateson Name i Bateson Enterprises Inc Company 7. Location w ere contents were disposed: Waste Water F5821 Vehicle License Number Date —fl t5form4.doc- 06/03 System Pumping Record • Page 1 of 1 m o m w N U � ao C.0 U R. •ti a 0 0 . X43 o� v oq o 1A U tp w N U p 0 q '•= N N O F'i Fa 0, ,� O O v a�. q �y � cC coy .n ,o ,q ,y a, w o +a. "+-•' ~ C H a o ro o d o •cl � �'''� b 0 00 N °'o �n ado 002+ c�'a>ocH o p q .� GOi ro O h K S-. 0Pd o.'o o a d p ca, qjEj s:4 r ; ,�, �, JU sn a� :rJ O •N O b td O o$oo acC�a�.S 3 o o o � A ' o y o N o wO o F F a4a's� 00 .0 9 7 9 U TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that...... .................................................................................. has permission to perform.................`w....................... lis............................ — wiring in the building of ........ ...�!.�.....:.......................................................... EX0�OXFo�j 5� ... North Andover, Mass. Fee .30.`"x'"' Lic. No.77�f X!—'........... .... .... . 4 ELEcmcAL ImpEc on Check .a J Commonwealth of Massachusetts �- ofr�;a1 tT1 only Department of Fire Services PerrnitNo. We BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked kwtt:5,1 [Rev. 11/99] (leave blank APPLICATION eFORrrPErdance wit], tile Massachusetts Electrical All work to be pformed RMITTOPERFORM !ELECTRICAL WORK Code (MEC), 527 CMR 12.00 (PLEASE, PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of. — �� _ By this application the undersi ne R�,._ To the Invpector of Wires. —` g givs r her intention to perform the electrical work described below. Location (Street & Number)��- Owner or Tenant , IL Owner's Address Telephone No. �_-CJ��( Is this permit in conjunction with a building permit? Purpose of Building Existing Service Amps 1 Volts New Service _ _ Amps _Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Yes ❑ No (Check Appropriate Box) Utility Authorization No. Overhead ❑ Ilndgrd ❑ No. of Meters Overhead ❑ Und€;rd ❑ No. of Meters Copt �letion o the fo!loivt. table nIay be waived by the Ins pe -,*of GYirescto No. of Recessed Fixtures No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers Tota No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool Above ❑ In-Elo. o ..mergency ig mg 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 _ No. of RangesInitiating Devices No, of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Number Tons I{W Na. ofSelf-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 WaterNo. of Devices or Equivalent KW Heaters No. of No. of Signs Ballasts Data Wiring: No. Hydromassage Bathtubs No. of Devices or Equivalent g No. of Motors Total HP Telecommunications Wiring: OTHER: of Devices or Equivalent INSURANCE COVERAGE: Unless waived by the owner, !no pegrit fior the performanceoof ele trical work may issue unless the licensee provides proof of liability insurance including `completed operation" coverage or its substantial equivalent. The certifies that such coverage is in tbrce, and has exhibited proof of same to the permit issuing office. Cl IECK ONE': INSURANCE BOND ❑ OTHgK ❑ (Specily:) Estimated Value of Elec4 ical Work: (Expiration Wtc) (When required by municipal policy.) Work to Start: j� ��— Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under naps and penalties off err'ury, that the information on this !application is true and complete. FIRMNAME:C�e ,p ;���,,,�� LIC. NO.:�/\ Licensee: �I~� LwQ �, _ Signati re�.ac �cQ a – -�0� �J�j (J/'applicahle en er rxenipt'• in the license mnnLer litre J --- --C. NO.: dg5% Address: �rna 2 9Bus. Tel. No.OWNER'S INSURANt """ ---- Alt. Tel. No. .y +� v a>e. ram aware that the I_requiee 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) EJ Owner/Agent ❑ owner's agent. Signature Telephone No. PERMIT FEE. $ r The Commonwealth of Massachusetts Department of Industrial Accidents 44 3 Office of Investigations 600 Washington Street F Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):Cwtxh edii) &' "-"" 'xS (-u Address: N5 lerru U tp: SOIf1 , t�} 0505Phone #: Are you an employer? Check the appropriate box: IN I am a employer with 13 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors ?. ❑ 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. employees and have workers' [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its i. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t 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 10. El Electrical repairs or additions 11. E] Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other *Any applicant that checks box #I 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 state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. I Insurance Company Name:wehrcl) Policy # or Self -ins. Liicc..�#: V)C Qq 412AW Expiration Date:_1 Job Site Address: S �J &Y_*Yzi'k 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 4 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 andpenalties ofperjury that the information provided above iV true and correct Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # M 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 #: 10363 Date....// TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that l;.r, ..... ....... .............. has permission to perform ....... d.k.! zv.A4.r4 plumbing in the buildings of........ at..,?,�o .... 9Ckt.Q,.)j ... ................... .......................... Fee -3;t.-4 .... Lic. No. Check # Y8 F ,...........1..... . /.. North Andover, Mass. ...................................................... PLUMBING INSPECTOR I p MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK POWNER TYPE OR PRINT CLEARLY CITY _,► __jj MA DATE[Z'( PERMIT# JOBSITE ADDRESSOWNER'S NAME P 1 ADDRESS TELL] IFAX OCCUPANCY TYPE COMMERCIAL p EDUCATIONAL Q RESIDENTIAL NEW: 0! RENOVATION: REPLACEMENT: Q� PLANS SUBMITTED: YES 0 NO 01 FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM _ (€ _ -T ( T _J.__ 1 T_� --J=== DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM I ... ..... J _.__.J DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/ AREA DRAIN J _.__..A ____ ___._J ___--_M INTERCEPTOR (INTERIOR) 1 ____.._.1 ___J ____" ____l ( _.__ri _____I KITCHEN SINK i _____J ____J _( _.___i __._.._ __.___E ___.! __._. __j LAVATORY E ( ( [ (-----___1 __.__..l __J1 11. _j ROOF DRAIN 1 = __._J _--i _I _._J ____.__.( .____.i ._..__j .__1--._1-_.._._..� SHOWER STALL SERVICE / MOP SINK TOILET URINAL 1 ..._.._ .__� _.._-� l ._ a J ..._____.J .___.._I ...._. _i __..__...! _ f WASHING MACHINE CONNECTION { _._..__S i � _.__...__� _ ___j WATER HEATER ALL TYPES WATER PIPING OTHER _ _ _� ( i _-_._.__.t INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES R_< Q IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Er-, OTHER TYPE OF INDEMNITY © BOND X1.1 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER © AGENT 101 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are trueand accurate to th t of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compli ce with all Per'eovision of e Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 9. PLUMBER'S NAME> h _ LICENSE # SIGNATURE MP El JP U CORPORATION Q#PARTNERSHIP ED LLC COMPANY NAME �st 1 d .J ADDRESS CITY�JmQ�p---_.__..._..._..__I STATE ZIPFAX CELL cr siQ-�. _ EMAIL L ►1 w o rl z m� The Commonwealth of Massachusetts Department ofIndustrigl 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 LeLyibiy Name (Business/Organization/Individual): / ,fir + `�1 ✓ sL Address: City/State/Zip: Phone #: 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 er"loyees (full and/or part-time).* 2. am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. ❑Remodeling 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. El We are a corporation and its 1011 Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12. E] 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. 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 checkthis 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 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 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 cert un r the pains dpenalties ofperjury Aat the information pro vided above is true and correct. Signature: Date: 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. PIumbing 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 loeal 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 maybe 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 perrmittlicense 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 (ifnecessary) 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. Anew 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>andustrial .Accidents Office of Investigations 600 Washington Street Boston, ASA, 02111 Tel, # 617-727-4900 ext 406 or 1-877,7MA.SSAFB Revised 5-26-05 Fax # 617-727-7749 www. ass.govfdia #9 — _ #S :ompany. �t person's guardian) Date Date vaccine administered: ,.n: jL� Date on VIS: �_ Vaccine lot number: �Q ANDOVER HEALTH DEPT. 1600 Osgood Street Building 20, Suite 2-36 North Andover, MA 01845 75`J Date..��l`1./..I�....... a 1(( x. - -.to ' TOWN OF NORTH ANDOVER A -� PERMIT FOR GAS INSTALLATION N This certifies that .... � ' .S�-4 ► ... l "Ew � . ..., .... has permission for gas installation ....�e;!✓ ........ in the buildings of .. �; = < <.'._. ... �(( C: �6_14.;.0, <.� ,%............. at :r::....:'.k ..G`:�.� .... `��i' .. , North Andover, Mass. Fee. -? .'? U. Lic. No. .1'.?. a`f .. ......:::�J,,r,,i� GASINSPEC TOR Check # Cel MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) NORTH ANDOVER ,Mass. Date DEC. 10, 2010 Permit # Building Location 380 BOXFORD ST. Owner's Name BRETT BELONGIA Owner Tel# 978-975-1903 Type of Occupancy RESIDENTIAL New W1 Renovation❑ Replacement Plan Submitted: Ye[] No[:] FIXTURES Installing Company Name Eastern Propane & Oil, Inc Address 131 Water Street Danvers, MA 01923 Business Telephone # 800-322-6628 Name of Licensed Plumber or Gas Fitter Rb�,t-,, Y- W �, : --e Check one: Certificate Corporation Partnership Firm/Co. INSURANCE COVERAGE: I have a cures liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes ✓ I No ❑ If you have c ecked yes, please indicate the type coverage by checking the appropriate box. A 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: Owner ❑ Agent ❑ Signature of Owner or Owner's 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 m, iowledge and that all plumbing work and installations performed under the permit issued for this application will in compliance with all ertinent provisions of the Massachusetts State Gas Kbe and Chapter 142 of the Geneva s. By Typnse: • Signature of Licensed Plumber or Gas Fitter Title *NGas fitter -Waster License Number 1?% -lel City/Town • -Journeyman APPROVED (OFFICE USE ONLY) Location'�� No. Date -- r TOWN OF NORTH ANDOVER ' Certificate of Occupancy $ s'•••° • E scHus Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ r Check # ti 13 ',- ss i Building IrLf�6ctor E f r TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOy VATE, OR�� ,DE�MpOLISH A ONE �OR TWO FAMILY DWELLING � ;,�`r � :� .�.��n �� a:�R?.�i�s *��.OLV.�r�V� � ,� '�`j'r����'�"°' �%%; g ''.,¢�w ,7tp '�'3-< „r � "✓�sr�... sn.�,,,,, BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: wwr.- Building Commissioner for of Buildin Date — } SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: ©6,jp Map Number Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage 11 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Re wired Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Public ❑ Private ❑ Zone Flood Zone Information: Outside Flood Zone 0 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT I 2.1 Owner of Record 19 (,P- \Z E' i�3 vee ► 0 �h_� C t f' r- Name P) Address for Service: Signature Telephone 2.2 Owner of Record: 4 Print A �y Address for Scr p'ce: SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: Address Signature Telephone 3.2 Registered Home Improvement Contractor Company Ndme Q in License Number Expiration Date Not Applicable ❑ Registration Number c 'b- N Expiration i )ate SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) , Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Si ned affidavit Attached Yes .......0 No ....... 0 SECTION 5 Description of Proposed Work check all applicable) New Construction 0 Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition 0 Accessory Bldg. ❑ Demolition 0 Other Specify Brief Description of Proposed Work: .retia o ce A✓tJ 1%= (4 I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I Item Estimated Cost (Dollar) to be �'I QFFICIA , Completed leted b ermit ap2licant 1. Building (a) Building Permit Fee Multi lier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 S7 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, 1?n' Lin, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and b of Pr' me (f) wiii o Si g•iariue of Owner/Agent Dat ZZESM 6 1-11 1111 NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1s 2 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE ol us M td CD M O z �¢ w x 0 v z z �. • O oQ`Q �� 0 `NG r a o w a v a w z z w a o w° p cin ,.� or. w° ao' U is w ' ao a°- w W 92 CO w c� a°4 , w x w a 61 w' o z cn v Q cn tf 1 lWob �. • O oQ`Q �� • `NG r H CIO LU W cc W CO3 _ O •N C o ca C N O C O V V •n'fl O. C W W c 4D C := O CD o CD :Ea C �m = w o. N O3 CD -- C.2 i C C NIS R N Cos CD 3 n m : N W N CD i �-v N m 4:,3. �— = o CM o¢ N CL c O O r - cc Z u oL no H m N c m d r t0 t r-. m O -0 :5 CL c _ z .� r,-0IN O O m:C C z $ nw m E a N r N O N c O v cm CD cc cm 32 m 0 cm c �c N m t 0 Z O s Cl CO 0 f� O O E L _ O O s Z CD C. O y C C CD cm Iw\ -0 W CA m m 0 CD CD � O.a O � C O CD L Q CL cc Q CL 0- C! Q CO2 O _ C _v ev CIO J `a �C.. O .CD C CD CL C.3 V2 O C c .y C y I Town of North Andover e� NORTH pati Building Department 0 27 Charles Street North Andover Massachusetts 01845 2 (978) 688-9545 Fax (978) 688-9542 09 `°` " TED DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and a condition of Building permit # the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, sl 50a. The debris will be disposed of in /at: 9 F Facility location Signature of Applicant 1�& Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. Location 380 _B01-1POLk S f No. ) ° cr Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ 50, Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # I a la f 66,-6 A/1y I Building Inspector The Commonwealth of Massachusetts a3a ' State Board of Building Regulations and TOWN OF NORTH ANDOVER Standards BUILDING DEPARTMENT Massachusetts State Building code p / /\ 780 CMR Zoning District APPLICATION TO CONSTRUCT REPAIR, RENOVATE, CHANGE THE USE OF OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING nuuamg re=1 iNumoer: / &-� 7 I nate Issued: 7 -r -aa 3 of Cvjri"nw i_ errr nurnDMAirr v 1.1 Property Address: a3a ' 1.2 Assessors Map and Parcel Number: Address: _ 17 Signature Map Number / C/h�s- Parcel Number 1.3 Zoning Information: p / /\ 1.4 Property Dimensions: Zoning District Proposed Use Lot Area (sq) Frontage(ft) 1.6 Front Yard Side Yard Rear Yard Required Pmvided Required Pmvides Required Pmvided 3 > 30 -30' 3 0 3-6 3 0 7 3c7 107 Watcr Supply 9M.G.L.C.40.454 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public O Private 11 Zone O Outside Flood Zone ® Municipal Q On Site Disposal System 2.1 Owner of Record efz1 c, a3a ' Name (Print) Address: _ 17 Signature Telephone 2.2 Authorized Agent: Name (Print Address Signature Telephone CF.[TTAN'i -- 3.1 3.1 Licensed Construction Supervisor: Not Applicable Q Licensed Construction Supervisor: I ) r -4e P ? icense umber Address 10 Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor: Not Applicable Q Company Name Registration Number Address Expiration Date signature Telephone SECTION 6 - DESCRIPTION OF PROPOSED WORK check all applicable) New Construction Q 1 Existing Building Q 1 Repairs Q r Alterations Q Addition Q Accessory Bldg. Q 1 Demolition E3 1 Other Q Specify Brief Description of Proposed: C -0,P ° � L S '-f 15 (o -4- a P e X--) 't> -e C- K ID G <Z,e P LA -C `G k -t --L 4J v -n_ -4-0 CO I't A--0 a —n , R-1 R-2 R-3 S Storage Q S-1 S-2 U Utility Q SECTION 7 - USE GROUP AND CONSTRUCTION TYPE USE GROUP Check as applicable) A Assembly A-1 A-2 A-3 A-4 A-5 B Business Q E Educational Q F Factory Q F -I F-2 H High Hazard Q 1B 1 Institutional Q I-1 I-2 I-3 M Mercantile Q 2B R Residential Q R-1 R-2 R-3 S Storage Q S-1 S-2 U Utility Q Specify: M Mixed Use Q 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 (sf) Total Area (sf) Total Height (ft) CONSTRUCTION TYPE IA Q 1B Q 2A Q 2B Q 2C Q 3A Q 3B Q 4 Q 5A Q 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 I Oa - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 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. Signature of Owner Date revised bldg form/state JMC SECTION IOb - AGENT DECLARATION 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 Signature of Owner/Agent Date SECTION 11 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be completed b permit applicant 1. Building 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1+2+3+4+5 Official Use Only (a) Building Permit Fee Multiplier / (b) Estimated Total Cost of Construction from (6) Building Permit Fee (a)x(b) Check Number Z0'd ltl101 � °! ATeS.. . NORTIA "'p�? t t t a'f't• � �� f�i:�.i�!:r y� �Z1 2• S y. , Jo � =S '�':': Ali •, a . ; d�:�! AL oil :r:�§ '.i..1n.14' I. i. -4.L Lo—r ��- � FORM U - LOT RELEASE FORM B `� ` 03 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 %�' tt �e /� a PHONE 9 %8' 975�– 1 �o3 124 Ga LOCATION: Assessor's Map Number SOS C PARCEL �3"v tl�w ICC WI SUBDIVISION LOT (S) _ STREET__ pX '-f0+"�__- ___ ST. NUMBER_3 SO USE ONLY***"**"*****"******* RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINIS'KATOR DATE APPROVED _ DATE REJECTED /+AwAAAG\ITC /.,i17..._.I� i. ✓.'.. 1!i/1�� nYn nrn.. v�� Q�.S`T,.fr�GlnrP r 175-0 :) 1 U ®n t!XiS _co►uGrth bms - 0 0.S.0,0 TOWN PLANNER COMMENTS INSPECTOR -HEALTH DATE APPROVED DATE REJECTED_ DATE APPROVED DATE REJECTED SEPTIC INSPECTOR -HEALTH DATE APPROVED DATE REJECTED ONG COMMENTS PUBLIC WORKS - SEWERIWATER CONNECTIONS-- DRIVEWAY ONNECTIONS_ DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR — DATE Revised 9197 jm Town of North Andover Building Department 27 Charles Street North Andover MA 01845 Tel: 978-688-9545 HOMEOWNER LICENSE EXEMPTION Please print. DATE v n esu% 3 7 JOB LOCATION 3 e �O K ` `_ ,� 'k Number Street Address Section of Town "HOMEOWNER Number PRESENT MAILING ADDRESS .City Town ZC__ -t --P,— Home Phone Work Phone State Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings of six 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 109.1.1) 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 to six family dwelling, attached or detached structures ac- cessory to such use and and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) 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 minimun " comply with said procedures HOMEOWNER'S SIGNATUR APPROVAL OF BUILDING OFFICIAL Note: Three family dwelling 35,000 cubic feet, or larger, will be required to comply with State Building Code Section 127.0 Construction Control. 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. 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