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HomeMy WebLinkAboutMiscellaneous - 4 EVERGREEN DRIVE 4/30/2018 (2)I � N ' � A O < m n m . o O o m " N m m�. z o 0 C) 2 o < o m Date -(e. - .4. -. TOWN OF NORTH ANDOVER" 0, PERMIT FOR PLUMBING SA US This certifies that 41ev/q�,n /-1 .......... has permission to perform . ................ plumbing in the buildings of at. . .................. I North Andover, Mass. Fee. Lic. No.. .............. ............. PLUMBING INSPECTOR Check d 4:�,� , e 8654 �w MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location q j.5Vj2 G >a rN P�o� Date 1 "- Permit # _Owner 541211 V -,W IIIA sTA ✓A Amount /- New Renovation[] Renovation [ Replacement ® Plans Submitted Yes No Ti TY'Ti 1TQ �o (Print or type) Check one: Certificate Installing Company Name �, 1?TN' � D �i4 F rA):Z ❑ Corp Address Iii I AIfZLint�(O&.l A VWL ElPartner. Business Telephone g-7,7- '726 »y Firm/Co. Name of Licensed Plumber: Oso Arnelvgvz. Insurance Covera¢e Indicate thetype of insurance coverage by checking the appropriate box: a Liability insurance policy Other type of indemnity D Bond Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner � Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Mas$achusetts Stat��Iumbing Code and Chapter 142 of the General Laws. D (OFFICE USE ONLY of Plumbing License Master ® Journeyman ,yr The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 ky www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ADDlieanf Infarmof;n.. Naive (Business/Organization/Individual):_ '-I, ,4_ Pl Um f7.L1U9 ANA I,1cPArry 6, Address: JO/ A4,f i T A- Jr-- A I e..;,1 City/State/Zip: jj�A v Z_ Phone #: 97,F — 72 L 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).* 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. workers' comp. insurance. [No workers' comp. insurance S. ❑ We are a corporation and its required.) 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required] t officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.) "-Y aPPlicant that checks box Yl must also fill out the section heron" t she inHomeowners m safidavit _ 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' omp policy information. I am an employer that is providing workers' c information. ompensation insurance for my employees. Below is the policy and job site Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other Insurance Company Name: Policy # or Self -ins. Lic. Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as 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. Ido hereby /I certify under a pains and penalties of perjury that the information provided above is true and correct Sienaturd:�]i..� Date.: - ID lone #: 9 7,F - 726 1.33 Official use only. Do not write in this area, to be completed by city or town offrciaL City or Town: Permit/License # Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: 1 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 A necessary, supply sub -contractors) name(s), address(es) and.phone number(s) along with their certificate(s) of 1 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 pertmit 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 pmmit/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 hke 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 Inrestigafions 600 Washington Street Boston, MA 0.2111 Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE Fax # 617-727-7749 Revised 5-26-05 vcrvvu7.rnass..govfdia i Location No. �,- C2.36 Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ -,FYI B uilding/Frame Permit Fee $ I Foundation Permit Fee Other Permit Fee I Sewer Connection Fee $ Water Connect! on Fee $ TOTAL 1 10 08/11/94,1,3:46 $ 04 X2 -a4& .)W,Building inspector Dlv. Public Works (11�,Cation' Date TO,WN,,OF NORTH ANDOVER Certifi]b1ate of Occupancy $ e.o o .,13ulildii;g/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL Building Inspector 7351 biv. Public Works Location— V"r re e 4 Dr I -, I/C- I Ij f No. Date CHU A/P. Ns� 6491 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ g I tor �2111,710 Div ujAc Wor -s- PERIfff NO., ` �� _ APPLICATION FOR PERMIT TO BUILD -- NORTH ANDOVER, MASS. MAP 4-40la 7�y I LOT NO.. +? 2 RECORD OF OWNERSHIP IDATE BOOK 'PAGE ZONE SUB DIV. LOT NO.lz�r CATION� L -°°•e Yg�� ell_-- - "� (3 -1;j 3 ) ;13 1 5 PURPOSE OF BUILDING _ �ot� 2 OWNER'S NAME Fra ,h K`/f� /'Y NO. OF STORIES SIZE fJ /J. u Y /7'O� �a. - OWNER'S ADDRESS//SO,,, / (/ 7U' BASEMENT OR SLAB IJL as-- - em ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST •1 ,f /v 2ND •1 �/ J0 3RD O' /� BUILDER'S NAME GV n K /1 ` Sa rU� SPAN J j DISTANCE TO NEAREST BUILDING /h'j i �OOv DIMENSIONS OF SILLS o'i DISTANCE FROM STREET 0,30 ( "" POSTS rol. DISTANCE FROM LOT LINES - SIDES %�� REAR .3 tfj"e "" '" GIRDERS ', ` y 1 - W1/ y / I` lP VVCi AREA OF LOT %179 V �ut`r� FRONTAGE! +q J ! HEIGHT OF FOUNDATION ` THICKNESS !!Q f IS BUILDING NEW IS 1 / fi ( V SIZE OF FOOTING X a' �C OJ 19 BUILDING ADDITION MATERIAL OF CHIMNEY �, 0, , � _ C TOY, � �/vim L) n / rFILLED IS BUILDING ALTERATION hl d IS BUILDING ON SOLID OR LAND! WILL BUILDING CONFORM TO REQUIREMENTS OF BUILDING CONFORM REQUIREMENTS OF CODE vap Y IS BUILDING CONNECTED TO TOWN WATER BUILDING CONNECTED TO TOWN WATER 1/Ln�Ca 1No BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE �)IQ INSTRUCTIONS SEE BOTH SIDES+ �'• C� 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 FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED SIGNAILM OF OW ER�(t A70RIIZZE'D�AGENT .� FEE !� PERMIT GRANTED 19 OWNER TEL. 7d ,/ P?oo CONTR. TEL. #_5 CONTR. LIC. # „Pi i ° '•R - 5 X94 3 PROPERTY INFORMATION LAND COST v V o EBT. BLDG. COST B O EST. BLDG. COST PER SQ. FT: L10o p 6 EST. BLDG. COST PER ROOM V SEPTIC PERMIT NO. l0l C/ 4 APPROVED BY t BOARD OF HEALTH PLANNING BOARD s BOARD OF SELECTMEA - YUILmlmw INSR4TOR 1 OCCUPANCY SINGLE FAMILY 6 FRAMING�I II STORIES MULTI, FAMILY PIPELESS FURNACE OFFICES APARTMENTS FORCED HOT AIR FUI TIMBER BMS. & COLS. STEAM CONSTRUCTION 2 FOUNDATION W'T'R OR VAPO y �= WOOD RAFTERS 8 INTERIOR FINISH CONCRETEV _ B 1 2 CONCRETE BL'K. UNIT HEATERS 7 NO. OF ROOMS PINE GAS OIL ELECTRIC 2nd f Ist %� 13rd I BRICK OR STONE NO HEATING y HARDW D PIERS PLASTER _ _ DRY WALL _ 3 BASEMENT UNFIN. AREA FULL FIN. B M AREA 1/1 1/2 1/1 FIN. ATTIC AREA NO B M T FIRE PLACES HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 DROP SIDING CONCRETE WOOD SHINGLES EARTH ASPHALT SIDING HARDW'D _ _ ASBESTOS SIDING COMMON _ VERT. SIDING ASPH. TILE _ STUCCO ON MASONRY _ STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. & FLOOR BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME SUPERIOR POOR 11 ADEQUATE NONE 5 ROOF 10 PLUMBING GABtF I I HIP 11 BATH 13 FIX.1 ASPHALT SHINGLES !/ LAVATORY WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER / BUILDING RECORD 12 THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. r ` ' v 6 FRAMING�I II 11 HEATING j WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FUI TIMBER BMS. & COLS. STEAM STEEL BMS. & COLS.HOT W'T'R OR VAPO y �= WOOD RAFTERS AIR CONDITIONING _ RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL ELECTRIC 2nd f Ist %� 13rd I NO HEATING y BUILDING RECORD 12 THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. r ` ' FORM U - LOT RELEASE FORK INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: �l�/lyt K �• �GL i��-1 a Phone LOCATION:Assessor's Map Number La ;� 2 a Parcel Subdivision Lots). Street �si�v �Y2�St. Number ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS. Date Approved Conservation Administrator Date Reejected. Comments "`'`'•'ten\top , Date Approved q-( Town Planner Date Rejected V Comments Health Agent Date Approved Date Rejected Comments Public Works - sewer/water connections - driveway permit Fire Department ��` ��J•r.� �� /� - Received byBuildin g Inspector Date ,.E BRAY -5B94 i` �crj'd—t 94%iwFif g Town of North Andover BUILDING DEPARTMENT Homeowner License Exemption ('lease print) DATE JOB LOCATION/( Number SLreeZ Address "HOMEOWNER"5/,lz n A� VCLYGiez Name Home Phone ,�W/1 . t � ection of town Work Phone PRESENT MAILING ADDRESSIM YYeLA-e_ Rd . 6&1V11 � t Of j?U City/ own State Zip code The current exemption for "homeowners" was extended to include owner -eccuDied 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 lU°.l.l) DEF=NITION OF HOMEOWNER: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, oris intended to be, a one to six family dwell- ing, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable to the Bulding Official, that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned It assumes responsibility for compliance with the State wilding Code and other applicable codes, by-laws, rules and regulations. The uncersigned "'homeowner" certifies that he/she understands the 'rown of North Andover Building Department minimum inspection procedures and rirements and that he/she will comply with said procedures anu _:cu_re:nents. OF BUILDING OFFICIAL `+ole. 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