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Miscellaneous - 40 COURT STREET 4/30/2018
/ 40 COURT STREET J 210/095.0-0058-0000.0 _ r_ i UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid USPS Permit No.G-10 • Sender: Please print your name, address, and ZIP+4 in this box • NORTH ANDOVER HEALTH DPT. 1600 Osgood Building 20,Suite 2-36 NQnh And®vy,MA 01 845 Illttettt�l,IttlttlttltltlttttlfilttttitltlittttlltttttFllt}ttl SENDER: • •N COMPLETE THIS SECTIONON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Signatu item 4 if Restricted Delivery is desired. ❑Agent ■ Print your name and address on the reverse X G-- ❑Addressee so t that this can return the card to h you. iv�d by(F ted Nam/ C. Dat of elivery ■ Attach this card to the back of the mailpiece, ��, or on the front if space permits. D. Is deliv address different item 17 Y 1. Article Addressed to: - If YES,enter delivery address below: ❑No 3. SR'rfied Mail ❑Express Mail ❑Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. (rarisreF to `sW6 1g 6e6flF}3`.:, # :: X16 $,�..2 7 0360 PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540 Date.... NORTH TOWN OF NORTH ANDOVER ' PERMIT FOR WIRING ;,SSACMUSES This certifies that .............. f! 1Z� GEIT��G ........................... ....................... has permission to perform ........... l-E/)/ %/GL ................................ wiring in the building of......V....... / �5............................................ at... ................. ......................... North Andover,Mass. Fee.......`�........... Lic.No.L95.71.0........... .. .. .. . . .... ELECCRICALINSPECTOR ' . heck # DSI -l64 �. Ilk IN Commonwealth of Massachusetts Official Use Only � Department of Fire Services Permit No. ge44i BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] (leave blank F 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 PRINTW INK OR TYPE ALL INFORMATION) Date: /a X13/ o q City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 40 0-o U 9 f S r Owner or Tenant UI Al t:1=N r- LA-Af 0L/I S' Telephone No.97,p d,,tijy� Owner's Address 4() CoU2 r Sr Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Boz) Purpose of BuildingglLf bUtility Authorization No. Existing Service JAs Amps -------- -/ / ;-1 Volts Overhead Und d �' ❑ No.of Meters � New Service Amps ! Volts Overhead❑ Und rd g ❑ No.of Meters Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: / W J Com letion of the./ollowing..table may be waived by the Inspector of Wires. i No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool [Id.Abovd. e In- o,o ergency T g � Batte mUnits — 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. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: " Detection/Alertin 1,Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal '•;"� Connection ❑ Other No.of Dryers Heating Appliances KW Security Systems:* No.of Water No.of No.of Devices or Equivalent Y Heaters ICS' Si s Ballasts. Data Wiring: No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP ::]7N7o7!Wof unications Wiring: Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: /0"o (When required by municipal policy.) Work to Start: le /3 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C VE E:-Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under 7 -4 s and penalties of perjury,that the information on this applica FIRM NAME: tion is true and complete. Licensee: J S / & Si LIC.NO.: gnature LIC.NO.: (If applicable, enter "exempt"in the license number line) Address: Bus.TeL No.: Tel.No *Per M.G.L c. 147,s. 57-61,security work requires Department of Public Safety"S"License: Alt•Lic.No..: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑ owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE:$ �..,, t .._. /�//'J M I' ) /��� - . �. j, r The Commonwealth of Massachusetts Department of Industrial Accidents -• Office of Investigations 600 Washington Street i Boston, MA 02111 www.nxassgov/dia . Workers' Compensation Ins urance Affidavit: Builders/Contractors/Electricians/Plumbers Appficant Information Please Print LmAbly Name(Business/Organirafion/Individual): Address:City/State/Zip-Phone#: . Are you an employer?Check.the appropriate box: T of ' 1.13I am a employer with 4. ❑ I am a general contractor and I Type project(required): employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.E3 I am a.sole proprietor or partner- listed on the attached sheet. 7• ❑ 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. ❑ We are a corporation and its required.) officers have exercised their 10.El Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No-workers'comp. c. 1.52, §1(4),and we have no 12.[]Roof repairs insurance required.]t employees. [No workers' comp. insurance required.] 13•❑.Other ;Any applicant that checks boa'fi l must also f l out the section below showingtheir workers'compensation pensation 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. 4contractors that check this box must attached an additions!sheet showing the mane of d!e sub-cone d dei,v k—'comp_pol' information. I am an employer that is provWwg: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: fi( Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). t. 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 andpena&t u ofperjury that the information provided above is true and correct Signature: Dom, Phone#: EB:ardof only, Do not write in this area,to be completed by city or town official Town: Permit/License# hority(circle one): Health 2.Building Department 3.City/Town Clerk 4.Electrical inspector 5. Plumbing Inspector son: Phone#: e Information and Instructions l 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 ownerrof 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, MOL 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 A 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 t` insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required°to cant'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,not1he 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 Offrcisis 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 applicarit. 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 permittlicense 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 parson 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 Investiations 600 Washington Street Boston, MA 02111 Tel.9 617-7.27-4900 ext 406 or 1-8.77-MA.SSAFE Revised 5-26-05 Fax 9 617-727-7749 www.mass.gov/cUa 66 Date,/. :. /. ... . . Of a"ORTM 1ti TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION s �s '1 SACHU This certifies that . . . . . . . . . . . . . . . . . . . has permission for gas installation .. . . . . . . . . . . in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . -'�- :•. . , North Andover, Mass. Fee—% .n . . Lic. O�tR_. . . . . . . . . . . Cr GAS iNS�,. . Check# 6956 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: /0 MA. Date: /0 /C� Permit# Building Location: Y0_ —_ Owners Name: -- — - - - Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: M" ^ Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes❑ No❑ FIXTURES Lo iY Lu W Y rn Q D = O w W V fn � x H w I— J >. W Z H= (g W QZO conNaHO z w O O Nmo> w Q a w v a X LL W a W W za x w w > W w Z O J H F O Z .J O �- N Z H W W _ UTSIOE o ix Q w w Q > o O w z w Q Q Q V O D LL 0 0 x x - O a I— > > O SUB BSMT. T 1 FLOOR 2 NuFLOOR - 3 FLOOR 4 FLOOR 5 FLOOR 6 1H FLOOR --i'FLOOR 8THFLoOR V �� 01�� Check One Only Certificate# Installing Company Name: ---_—_—,L—� _— L�1 ❑Corporation Address:�_ �� i(Gity/Town:_ State: �.Q' U ❑Partnership eo Business Tel: -4/0 Fax:—_—_ ------------ ❑ Firm/Company ame of Licensed Plumber/Gas Fitter: /� 1 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes❑ No❑ If you have checked Yes,please indicate ype of coverage by checking the appropriate box below. 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box❑;I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my Knowledge and that all plumbing work an�lnstalns pe med under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Pe and hapter 142 of the General Laws. Ty License: By--- _----- Plumb Title_------_ ❑ Fitter (50�� ature of Licensed Plumber/Gas Fitter -- aster City/Town_ _ _ ❑Journeyman License Number: APPROVED OFFICE USE ONLY ❑ LP Installer -------- cod r) 7 i Qj c Date....4... ° '"° TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING 1.D This certifies that .............4.T.0.,ql S. oc ...... ............... has permission to perform ...... ..ad.d....... .......... wiring in the building of........V..k. ..................................'...5........ at............Y _ d9 .....�1 . ............ . ,NorthAndoveyass. A . ....... Fee....... .......... Lic.No..,.,67* .......... .. .. . .......40 ..... ...... ELECTRICALINSPECTOR Check # 5106 �SaN, THE C0W0NWE4LTH0FAf4YS4CHUSE77S Office Use only,_ DEPARTMENTOFPUBLIMFM Permit No. 59 BOARDOFFMEPRE[/EWONREGULATIONS527CjMR 12:100 occupancy&Fees Checked fY UVAPPLICATION FOR PERMIT TO PERFORMAECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECACAL CODE,527 CMR 12:00,— O (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date j Town of North Andover To the Inspector of Wires: I 'i The undersigned applies for a permit to perform the electrical work des 'bed bew. j Location(Street&Number) U"c Owner or Tenant xj 10, 1 Owner's Address 'P f Is this permit in conjunction with a building permit: Yes No © (Check Appropriate Box) 1 Purpose of Building P S/o�/;?cv� Utility Authorization No. 1 Existing Service Amps Volts Overhead 1:3 Underground M No.of Meters ' New Service Amps/ Volts Overhead Q Underground No.of Meters " Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work POUNfl 7767 L 7 b 77 7 b"l/77 7177- XIS lrm 4 No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total KVA No.of Lighting Fixtures Swimming Pool Above Below Generators KVA ground ground 17 No.of Receptacle Outlets No.of Oil Burners No.of Emergency Lighting Battery Units No.of Switch Outlets No.of Gas Burners No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones Tons i- No.of Disposals No.of Heat Total Total No.of Detection and Pumps Tons KW Initiating Devices No.of Dishwashers Space Area Heating KW- No.of Sounding Devices No.of Self Contained Detection/Sounding Devices No.of Dryers Heating Devices KW Local Municipal ® Other Connections No.of Water Heaters KW No.of No.of Signs Bailasis No.Hydro Massage Tubs No.of Motors Total HP OTHER h>StrarrceCovwa Rasua ttotherequaaner>LsafTvlassad1BMGeraalLaws Iha%eaaateirtl.iabtiayh r&=P0kYirdUdir1gCarqA&Ope0i=CoxrWcrisslibsfa<ti quiva- Y Nil Iha%esthnftdv*Iploofofsmrekrt vOffM YES U NO r7 If}auhatedredWYES,pimenhc*tixt Wofwmagebydakigtbe INSUI ANCE /� BOND OTf$R ft=SP*) E*umtiarDale Egftm dValaedUmt>xalWak$ WakbSlmt hWa:imDtfeReWc0d Ragh FmW 11,11Gl— elQ2 Z_ Si rxdunk"fiPr d ,/ FIRMNAME g/�'" Iioa>see//1/�Ei�T/yal ����� G ' ' Iloa>seNo �g oL �. cony Brs¢reisTd.Na g 78-6?6- �oZ� Ak.TdNh OWNER'SINSURANCEWANER;Iamaw drttheLmwdoesnotha�theil»r�oae aAssubstar�alegld asragl>IIedbylvl sadrlsethsGaraalL3ws r and�myernihispam�arr�+si�sthislegtmer>ent �,vJ ,#(Please check one) Owner M Agent a Telephone No. PERMIT FEE$ r t Location �° rT y X, No. 't5_0 4' Date 3-0c -© 7 NORTh TOWN OF NORTH ANDOVER Of tt.•o ,•,ti0 3� i • O AL Certificate of Occupancy $ cHusEt�' Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ a i , Check # A d QO 17150 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING f T1 OTHER THAN A ONE OR TWO FAMILY DWELLING t . a m � eTb13 SeCtIOII for Oficial Use oni . _� ra H x may.` € ; ic BUILDING PERMIT NUMBER: / DATE ISSUED: SIGNATURE: Buildin 6niihfssi6er or of Buildings Date 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 0 cow t _q- do fib' A/LkS f Map Numb& Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: v Zoning District Proposed Use Lot Area Fronts 11 1.6 BUILDING SETBACKS(ft) m Front Yard Side Yard Rear Yard Cu RegWred Provide Required Provided Required Provided 10 Z O I- 1.7 Zone Information: 1.8 Sew 1.7 Water Supply M.G.L.C.40. 54) �8e System: Public D Private ❑ Zone Outside Flood Zone ❑ Municipal On Site Disposal System ❑ �. 2.1 Owner of Record (1 Name(Print) _ Address for Service: rn Signatu n ^ Telephone 2.2 Authorized Ageht 7o Name Print JUAddress for Service: 0Z z Signature Telephone m 90 3.1 Licensed Construction Supervisor Not Applicable ❑ [r Pt9t�- 31 Address License Number O Licensed Con tion Supervisor. (��_ - p.l 7 G�, \., S'— � �v� Expiration Date a ignature Telephone o a 3 r 3.2 Registered Home Improvement Contractor Not Applicable ❑ Com N . " Company Registration NumbLT rn r Addre s nDZ.— �'Osi � r g` � �� Expiration Date ^^Z Signature Telephone Y! OMM 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. Signed affidavit Attached Yea...... No.......0 SEC1It)Ai $-P,R4> l$SSQNA I.I�IfiI#sk CtPSIIt )3t'11LS11H �A5 ` GONSTRI It3riI�G 3 flL 1" f t�` f 1 1 A � D 35 — 0_?0�C 5.1 Registered Architect: Name: Address Signature Telephone ;5.2 Re�sla�recli:PrnfeaSt�ln ash' � - Name: Area of Responsibility j Address: Registration Number Expiration Date Signature � Total Not applicable ❑ Name: Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address i- Registration Number z ti Signature Telephone r Expiration Date R Name Area of Responsibility. Address Registration Number Signature Telephone Expiration Date Company Name: Not Applicable ❑ Responsible in Charge of Construction e New Construction Existing Building ❑ Repair(s) Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: Lc,- U 71 (.ice rto�J� ✓1.k.e.�_ � X USE GROUP Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ IA ❑ A4 ❑ A-5 ❑ 1B ❑ B Business ❑ 2A ❑ C Educational ❑ 2B ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I histitutional ❑ I-1 ❑ I-2 ❑ I-3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: S Special Use ❑ 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: Proposed Hazard Index 780 CMR 34: BUILDING AREA EXISTING if applicable) PROPOSED Number of Floors or Stories Include Basement levels Floor Area per Floor s Total Area s Total Height ft Independent Structural Engtneenng Structural Peer Review Rapired Yes ❑ No ❑ SECTION 10a Owner Authorization- TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject property Hereby authorize 1prt ..,,L P ►L d' �c 5 to act on My behalf,in all matters relativi two work authorized by this building permit application Signature of Owner Date s 1' 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 andel penalties of perjury Print Name Signature of Owner/Agent Date ly Item Estimated Cost(Dollars)to be � Completed b t applicant P y P� PP _ 3 , 1. Building (a) Building Permit Fee Z ���� Multiplier 2 Electrical (b) Estimated Total Cost of Construction from(6) 3 Plumbing Building Permit fee (a)x(b) 4 Mechanical(HVAC) 5 Fire Protection 6 Total (1+2+3+4+5) Check Number y u i 4> f NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS lST 2No 3RD SPAN DEMENSIONS OF SILLS DEMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND I IS BUILDING CONNECTED TO NATURAL GAS LINE � � ti � �.^es..��r-�,�^'�.�v -�aa�',s��`• ,� � ; s'' •..Y'��.n� ��d ,,� -�r+'Y... -v-�?� �,2 ss s3 - .zY=.X"`.. .. �'•s, ��,3. a+y t r.n ..us3`^� t.� �- Li '$5�x `eYz w='+ � `w:�.._ ..,z�/=-� *3 � -!� �-�'�. I I r FORM - U - LOT RELEASE FORM 1 INSTRUCTIONS: This form is used.to verify that.all necessary approval/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. INN asBoom sW E a 1141 a am M1Y �S r�no ■�� ■Rita Nam■■s■■s■r■r■woman fr■■■■Nam aamaaaam0 APPLICANT c� PHONE %7 F'- 6 ff-J�3,7 ' ASSESSORS MAP NUMBER 0 9S� LOT NUMBER 0°S�- SUBDIVISION LOT NUMBER STREET 4 �� STREET NUMBER y 0 ■u�.sR:f■R■■sR■■ss■■aRs■s■ss■r.aas■s■■s■■ass■as■aaaaaa■aaaaaaa■as■sssss■aas■■ OFIIC><AL USE ONLY .■Newsome aman sowns arias.saa■■aaa■sitasa.aaaanBases aana.■n■a.saa0aa.■a■sss.■-■_■■a.■-s-■■ RECATIONS OF TOWN AGENTS gas■ nit■■■�a■asaas. ■ ■■/saa■s■ ■s■■saa�s■a■�ssaaasa■rasaa■a■aaaaa ■ssasasas DATE APPROVED 6 C NSERVATION ADMRM TOR DATE REJECTED CONIIvII NTS , f TOWN PLANNER DATE APPROVED DATE REJECTED CONMIENTS DATE APPROVED FOOD INSPECTOR-HEALTH DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED CONIIVIENTS PUBLIC WORDS-SEWER!WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPARTMQVT DATE REJECTED COhQAENTS RECEIVED BY BUILDING INSPECTOR - DATE The Commonwealth ofMassachusetts Department of Industrial Accidents Office ofinuestigatiens 600 Washington Street, 7 h Floor Boston Mass. 02111 Workers'Compensation Insurance Affidavit:Buildin /Plumbing/Electrical Contractors pglicdRUIifo>x"riia`il'o i . y K. ]' :Please ' ile lbly. ; name: N&.A M-e t" S In e,%a J address: 40 Coy,,,- " city �J&-rt 2A � � state: 1u�J zip: b(S 4�i phone# 17 F''6 kZ' 7 work site location(full address): J A` L' C— ❑ I am a homeowner performing all work myself. Project Type. ❑New Construction[:]Remodel ❑ I am a sole fetor and rhave no one working in any capacity. ❑Building Addition nn I am an employer providing workers compensation for my employees working on this fob �-. company name f"�1YM PO tfs C� `o i y address phone. insurance co CiiP= _ pohe # ' Y a y ❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensationpolices { J o company�name• ''� f .t Y =address J city phone +insurance co ,policy# ., J Company name•r r address. city. phone'# 1 i` insurance eo " .pohcy Attachaaddihonal�sheetlfaeeessary�„:s�.�a,,,.:a<�.: Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certi under thepains andpenalties ofperjury that the information provided above is true and correct. Signature Date M < 0 Print name Phone# ��$'��9,8—�3a7 official use only do not write in this area to be completed by city or town official city or town: permit/license# ❑Building Department ❑ check if immediate response ❑Licensing Board i r p s required equ Selectmen s Office ❑Health Department contact person, phone#- ❑Other (revised Sept.2003) ' Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law",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 section 25 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,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 in the workers' compensation affidavit completely,by checking the box that applies to your situation. Please supply company name,address and phone numbers along with a certificate of insurance as all affidavits 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. City or Towns 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. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you 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,7`b Floor Boston,Ma. 02111 fax#: (617)727-7749 phone#: (617) 727-4900 ext.406 From:EileenP.Har;,AAI At:Piazza Insurance Agency,a division of HUB Infl. FaxID:9789880038 To:For Family Pools Date:1/21/2004 11:25 Affil Page: 1 of i ACORD CERTIFICATE OF LIABILITY INSURANCE OPID E DATE(MI&OCvYM PRODUCE EAMIL03 01/21/04 R THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION The Piazza Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE C.J.McCarthy Insurance Agency HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 299 Ballardvale St, ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Wilmington MA 01887 Phone: 978-474-4200 Fax:978-988-0038 INSURERS AFFORDING COVERAGE NAICN INSURED INSURER.A CNA Insurance Co. INSURER B Family Pools & Patio Inc. INSURER 70 S, Broadway Lawrence MA 01843 INSURER D: INSURER. COVERAGES THE POLICIES OF I`JSURANCE LISTED BELOW HAVE BEEN ISSUED TO TIE INSUREC IJAMF.D ABOVE=OR THE POLICY PERIOD INDICATED NCTvYITHSTPNDING ANY REOUIREME!JT.TERFA OR CONDITION OF ANY CONTP.ACI OR OTHER DOCUMENT WITH RESPECT TC WHICH-IIS CE'-'T FiCATE MAY BE ISSUED OF: MAY PERTAIN,THE INSURANCE AFFORCED BY THE POLIO ES DESCRIEED 1EREIN IS SUBJECT-0 ALL-HE-ERMS,E;<C_USIO'vi AND CONDITIDNS CF SUCF POLICIES AGGREGATE LMiTS SHOWN MAY HAVE BEEN REDUCED SY PAID CLAMS. LTR NS TYPE OF INSURANCE POLICY NUMBER pA7E(MMIDDlYf) I DATE(MhVDD1YY) LIN73 GENERAL LIABILITY E.ACHOCCURR'ENCE 51000000 A X COMMERCIAL GENERAL-LABILITY C1098398230 12/31/03 12/31/04 PPEloil ES,Eaocourence S100000 C AIMS MADE FXJ OCCUR MED EXP!Anycm_person) q10000 X per prof agg / BI PERSCNALdADV INJURY 51000000 GENERAL AGGREGa,TE s2000000 GEN'LAr,GREPRITAPP_IESPER: F— I PRODUCTS-COMP/0PA33 $2000000 1 POLICY IECT L 0 C AUTOMOBILE LIABILITY �(Es SINGLEW IT1000.000 A ANYALFO 8414071 12/31/03 12/31/04 eociderr)ALL OW'JEDAUTO&Ix SCHEDULED ALTOS 0DIL"INJURY S (F..r persm! HIRED AUTOS I NON-OWNED AUTOS I IP Dr ac id,nINUti S (Par accid3nti PP.OPERTt CAh/AGE S (Par accidanti GARAGE LIABILITY ANY AU-0 &,UTO ONLY-EA ACCIDE'JT S OTI-`S THAN EA AC.= S AUTO ONLY: AGG S EXCE-SSIUMBRELLA LIABILITY I EACH OCCURP,ENCES OCCUR CLAh1s RADE -- AGGREGAIO S DEDUCTIBLE I I 1 S RETErT ON S WORKERS COMPENSATION AND B EMPLOYERS'LIABILITY _TCRY LIMITS ER ANY FROPRIETOR'PPRIIJER,E`(ECII-!VE WC7481901 12/31/03 12/31/04 E.L EA-Cf-ACCIDENT S 100000 OF-ICERWEMBER EXCL-CED? If yes,desoribaundr E.L DISEASE-EF.EvIFF-O(EEEE�j S 110-0000 OTHER ETHER PRGVIS'ONS Malo'x E.L.DISEASE-POLICY LIMIT IS j000OO i DESCRIPTION OF DPERATIONS/LOCATIONS/VEHICLES)EXCLUSIONS ADDED BY ENDORSEMENT!SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION NOMORT* SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOt.DER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHOPdZED REPRESENTATIVE ACORD 25(2001108) CORD CORPORATION 1988 ` "Ul 15 03 01 : 44p Family Pools & Patios Inc 9786881949 P. 1 1� .., �...R....��..o. ... . Aeo�ranwvecverai al's flu BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 010330 Birthdate:07/19/1960 ..,s Ewres:07!19/2005 Tr,no: 61 Restrictsd; 00 WILLIAM C POULOS 70 S BROADWAY LAWRENCE, MA 04643 Administrator —.. Board of Building Regqulations _ * One Ashburton Place, tem 1301 License: CONSTRUCTION SUPERVISOR Ma 02108-1618 Number: CS SE Birthdate: 07/19/1960 010330 Expires.-0711912008 Restricted To; 00 WILLIAM C POULOS 70 S BROADb1rAY LAWRENCE, MA 01843 Tr.no: 61 Keep top for receipt and change of address notification. • ' u s gZe -Comwwwweald of.Building Regula ions and Standards One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement,Contractor Registration Registration: 118204 Type: Supplement:Card Expiration: 2/13/2005 FAMILY POOLS & PATIOS INC ,4 I t' GLEN WIGGIN .; 70 S. BROADWAY LAWRENCE, MA 01843 Update Address and return card.Mark reason for change. Address ❑ Renewal Employment Lost Card �ie �ar�urza�zcueai o��aaaac�u�e Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Board of Building Regulations and Standards Registration:' 118204 One Ashburton Place Rm 1301 Expiration:;:2/13/2005 Boston,Ma.02108 :."Type:.'Supplement Card FAMILY POOLS&PATIOS INC ^ GLEN WIGGIN 70 S. BROADWAY LAWRENCE,MA 01843 Administrator Not valid without ni4e -7 r • f C 8-8'Plain Pari(08409-5) � � 3-7 Plain Panels(08416-5) ---F'- 4-2 Rocha[arn in Panelsrs(Mai -01 41) E-�-�-�—F G H J K J 06-1 ) 11 Tambo"Braces(08-214) SIZE A a C D E F G H K 1-Steel Hardware Krt(08.204) ti6r ts• sr r re- r t4•, s•e- 4•a' 4.6' r 4•r 8• 4� 1-1642 Straight Coping Set 6'Rachus(10-001) e,rmo-ae�..• . . . . 1-r Rocha Coping Corner Set(10.138) w«s+oa omo• i 3r S 6 r4 S 14 S 6 4'6 4 p ► 1-Yaryl Inver(see options below) SPACE YLIC t • 6'Step•Remove 1408409-5)8'panel and f - 1-(OB-016-5)4' ' a Insert 1401-006)6 step, 2408-017-5)3 �and 1408-214) * turnbudde brace. PANEL 4. 8'Step-Remove 1-(08-009-S)8'panel and 1406-016.5)4'poneL hurt 1401-002)8'step, °��`\�~ 2406-01.8.5)2'pooch and 1408.214) - " turnbuddebram wq 8• 4, ' Replace 4.8'plain (OB-009-5)rrithN G`h't�+� � w fk 2-8'Flet v+ 1.8'0ght pone)(08-012-5) • ,4 �. ,,,'_° .ia �.;v _sz'� �`P 'n".,ar lk. �v A:-'m: l'h - �;" 'x7' �.F'�'.". ,�''""�a'. �'3:. eyt,.,i7 _ • ^.Y t7 ,a,. / 'fie' -u.`'$2"yw a:-1 °' .. ey ,,.. .: ,�,i �kt. .G a�k�,''t� gn s� ' a''" 5'�T � _ .' ti .4 IE 'k � � v, t kSMrtrt„��kNp7, yc^.kN T r A _ 2 2 r 7 N PI �/� t � I M „ S ■ •rE II ,'� u' s '. J a)��r'ar e s �c•��" � fIY 2 f" 3u5, • •• • 4 F�.mJ Tex.. ry+c{j. a `;. T5u,, ,xcz ,5'i :i. '' �.„'-•�' c .w #,. ' v-'.' �'�" .BONI F . . _ 'P 4 } Y ;^ss .. 1u.� Zt-�..rg� ��;. �k,y ., yn:i�Jx•m .r ,a � ,� � y,... �t� �p�Y r,�} � %�rl.��. rr �i„�� R• � ;.. P1�'k`�''��� �,:�..� ��' ��" .L r ���If�P� W� .��e TOPAZ STEiEL)NG it.:STONEYlTE 1� (03-R03-Z) (03-P03- .f03•NO3• M1 NON DMNG LNIERSY F " +�+'4, ry 1—•�rOY!1•IPbM�il)'b M.I�tlf I�..OIIMr pe[�m�.Pewtl� fMlr s.�•r�:�y��b��W..�+n, OM�CCnn��Od�IOI � �' ��p.�: i`v H-6 03-R40-Y i'•��rM1�lglm.r d•PIO�1I�i1M�..k f 1.'. '�'.�a'u.G +.r.�+tif :'K'�1 ,T.i*x•P1.1�:5^„. M�5 it� .4C ,��.�, . .. • � �DRtUfSilnilvErtlb06E50r�L' �'�t� r r FOe3111T1ElOOLSQI..MCS1�eS1Y1/1@aetYR Yri�w�gp�rd.�sriwb'ir� ,..- y �'p'w"e"'r. �9�1's+d.� ��� JL���J�urwrw�r•at ��. � ��xt 71�• dwirrsr ..��rF�"e••uel '��i�'�'�'+0�0A'+ird�o•serd i�iei..rr+ :, iiMalYl�1f4N0{JW:'jZ1�14I3-fJ72� �v..a�e _ z rr. �.r•e.��mai yr , i •'fdMg6mdrs+Gibs•bb•.r.�l�•+hir•'P•ai. r`u'�M�� os./mreaer•iiy 76.'� w --,,,,^.,-., r msh it•s.mnls ir�•aar sd ir:Ple�ad 3Pr i ���e�r-- ��� ���' *�'?yi' "�, .•�w � �ii+r:0aD7 ,.ws ..�, 41�aerNl;+ ,�' Ynr•iri niwrw wdoid.pne►ae ispii,D _ ~•� K •Ldr m flr rwd algyrr iyb wn, M z :n �'� � y'x, radae6: e�oea�d11.i �� i"'nd;� �"'!' !r'�y"'�' ildr°'w•r��• ME 'Mwww..A6Wl,.d .VA 2231A-703/L�8-0OB7"r."„au�,,a, ,-. "M°"bi''q .'►}/_` _ r.•4 k u':7 FAMILY POOLS &PATIOS,INC. CSL#010330 sales • service supplies HIC#118204 "S'NC, 70 South Broadway,Lawrence,MA 01843 WC#4951074 Tel:(978)688-8307 Fax: (978)688-1949 LIAB#01098398230 1978 Namey y�rife + S A e, ke rg Date -L7 0 Address 0+ Citvlr� State l9__,�Zip U Home phone - U Work phone �i' 2$Cell phone Add'1# Cross street/directions 6v , Estimated start date Estimated completion date We propose to furnish and install one 7./1 )c_ $`t o'�y swimming pool for the sum of$ 1,50 tQ THIS PRICE INCLUDES: ? •Manual vacuum cleaner kit •Leaf net •8 Ft Steps •3-Step Stainless ladder •Wall brush •Handrail__ •Rope&Floats •Extension pole •Filter •Initial balancing chemicals •Test Kitplumbed no more than 2.5ft from pool •8 to 12 Wk supply of maintenance chemicals. •Surface skimmer(s)_�\ •Pump&motor `L•' � (supply depends on pool size) •Coping _ •Choice of liner __ T S PRICE ALSO INCLUDES THE FOLLOWING WO ECTRICIAN: Bond and ground pool-wiring of a 220'volt f install one 220 volt in oor time c outside wiring to be done in PVC ' o electrical from service panel to filter (*n over sixty feet will be subject to a extra charge,)T Initials .. IN ADDITION TO THIS PRICE,ADD EST HOURS OF MACHINE TIME AT$f3b� PER HOUR=$ . THIS PRICE DOES NOT INCLUDE: Initis Any.machine time in excess of that estimated above. Additional machine time to be billed at the same rate as above due with the second pool payment. All hours of trucking will be charged at$__-ZO per hour per truck due with the second pool payment. Any dumping costs incurred for disposal of ledge,large rocks,or soil-re-seeding of grass around pool- spreading of loam-trucked in water -patio or fence around pool or any accessories except as noted below-additional fill,if necessary,for proper backfill or reshaping of hole- dis- posal of large rocks-fuel connections-heater venting-fuel storage tanks-permits-repair of damage to sprinkler systems or any buried items(ex.dry well,electrical lines,cables,etc.)in the access and pool overdig areas-plumbing to filter in excess of 25 feet-stumping and/or Removal of stumps.brush or debris.homeowner is responsible for repairs of damage to known or unknown buried items. Water or soil conditions(ex.clay,peat,live sand,excessive rock,etc.)requiring a stone pack of the hole will be subject to an extra charge of$ 'I m,, minimum to$�—maximum, -Use of the above mentioned stone pack will be at the discretion of the job supervisor. Customers mast supply actress for all trucks and equipment. It is the.owner's responsibility to obtain the building and electrical permits or to assume the costs of necessary permits. _Initials Notes: _�`t°►M-C " fi a a 1 _ gate— f__ k.,--t�►s Wit' �- � s;�'. ,... tare- !�\•t.e— --- - S' OPTION TOTALS Diving board ( VC,... , _16-2) Basic Pool Price $ 1S'ta� Main drain R—' Estimated Machine Time A?.S-D Solar cover ( ) Options _ 41A-n — /22f- Pool 2Zf Pool light ( ) T cSrec ' Heater ( ) -^-• Subtotal Environpool PI hea 5%Sales Tax Caretaker w/Electronic Valve, 16hd � Additional floor heads( Z� ) Dov Total Polaris Vac-Sweep Less 10%Deposit r ZOzko Polaris retrofit only Balance of Contract ZKp,k$�_ ��_ 'Swimout/Buddy Seat _ PAYMENTS: 1 EXCAVATION 1/3 BACKFILL+EXTRAS 1/3 SYSTEM START-UP The buyer hereby agrees to pay,in full,the total amount of this transaction upon start-upof the installed ool.Your salesman or Job super- visor u ervisor will meet with you two to three weeks prior to excavation at which time all decisions including pool size,shape,liner print,and all options must be final. Changes after this date will be subject to extra charges where applicable. You,the Buyer,may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction.Credit card payments not accepted on contract amount. BUYER , Wit _ date 1't •-:,f., F ,� �-::�:.,- ..x gin.,. .:. v:.. r,. _' :.:.. - .. ......... .. .._R.':1+ N$8°35'30"E N86°00'30"E 124.55' 85.87' PROPO'_9 �UUL _0+-A7PON LO e'XiS11FOOL L'JCA�iCJN ! I ! I t I t I W 1 I I L_ 0 O moi, z !+.SAP 9E), LOT t3 .235 5 E7'EsCE� 0.947 Ac` o p CQ CQ CO 0 a V3 210.00' N89°23'30°'W -- �%k OF PI Ari REF=REN(.;r: P-AN #8347 ESSEX NCRTN - REGISTRY OF DEEDS V � N A'tE LF�� PROPOSED FOOL,LOCATION FLAN THIS PLAN IS F3P, THE USE OF THE BUILDING 40 'COURT STREET INSPECTOR OF THE TOWN OF No. A".DCVER, FOR THE NORTH ANDOVER, MA PURPOSE OF DE-ERMINAlI0jN :OF ZONiNG COIAPLI.N':CE THIS PAIN IS THE RESULT OF LIMITED r;EID SURVEY SCALE: 1" = 40' DA'I'E: MARCH 3, 2004 PER=ORtAED, AND MaNUMENT.4TION FOUND, !N JANUARY, 2004. BASED UPON PLANS ANC DEEC5 FOUND IN THE REG STRY OF DEEDS. ; NEW ENGLAND ENGINEERING SERVICES THIS PLAN DOES NOT REPRESENT A BOUN)AR" SUR'._Y, 60 BEECHWOOD DRIVE AND SHOULD NOT EE USED FOR COWEYANCE. NORTH ANDOVER, MA 078686-176a PLAN : r DRAWN --lC C . D 8Z� BY: SGC%' BY: NORT#q Town of Andover 0 _ 0 No. a LAK dover, Mass. COCKICMEMCK 7�AERATED S U ` BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System 'l BUILDING INSPECTOR THIS CERTIFIES THAT.......Y./.N.N.�C......�.....3. ? /�...........44-V d 0^.t........................... Foundation has permission to oW.:RI? PA.I r`........ buildings on .....' 0.... O.v. .....� Rough to be occupied as {17 0 V N pop( Chimney ................ . ............... provided that the person accepting this permit shall in every respect conform to the terms.of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the lnspectio , Alteration and Construction of Buildings in the Town of North Andover. 045f6-8 a,4 �► PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS UNLESS T � T ARTS ELECTRICAL INSPECTOR V i V LESS CONSTR �ON S X11 S Rough • tl .C .... Service ......... . . .. ..... .. ........ BUILDING INSPECTOR Final Occupancy PermitRequired to Occupy .Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Bumer Street No. SEE REVERSE SIDE Smoke Det. Location Co Ur S _ No. ! Date MORTM TOWN OF NORTH ANDOVER ? � _ SOC F 9 i Certificate of Occupancy $ Iss�cMUSBuilding/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ " j Check # t 9 36 14 u 1 2 Building Inspector 1 � r TOWN OF NORTH ANDOVER BUILDING.DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING -... ?s^ 4 art z�^`��� pa � � gz .,,.rte- '�.. :�.4 a:. bar �,`°�`q-�"'� yqg§_• z BUILDING PERMIT NUMBER DATE ISSUED: -6)00 SIGNATURE: A44( 62'-- Building Commissioner/I for of Buildings Date SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: cabt)V4 Map Number Parcel Number .1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area Fromm e ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided R red Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public 0 Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of Record / V, IZ c-ew� �wUl `eA S �0 COKOLA S� � 1 Name(Print) Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Tele hone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ e6 V,\ Dayho 6 6 o, ti Z Licensed Construction Supervisor: las- /T t I �n ,/ J License Number M d lj-Q i�,h c 1 v, 7'Vl.teC �iP.r Address 4� Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ e Z g (r 1 Company Name M -C j ( `N Registration Number rM Address ' S Expiration Date Si nature Tele hone 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. -Signed affidavit Attached Yes.......❑ No.......❑ SECTION 5 Descri tion of Proposed Work check au applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: fA ff4 nn SECTION 6-ESTIMATED CONSTRUCTION COSTS Item OD Estimated Cost(Dollar)to be C3Fk`ICIAL T7SlUNIFY 12 Completed by permit applicant _ Y 1. Building (a) Building Permit Fee Multi Tier 2 Electrical (b) Estimated Total Cost of 2 �/ o Construction 3 Plumbing Building Permit fee(a)X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 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 autArized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, 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 belief -rc) ., D o Ylr Print Name J — 7 — a l Si attire of Owner/Agent Date NO. OF STORIES SIZE n BASEMENT OR SLAB RD SIZE OF FLOOR TITVMERS 1 2 3 SPAN DMIENSIONS 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 Wood Page of Free Estimates 105 Haverhill Street r Fully Insured Methuen, MA 01844 THOWSON'S ROOFING (978) 691-1355 Shingles—Slate— Rubber Roof Single Ply— Copper Work PROPOSAL SUBMITTED TO PHONE DATE Vincent Landers 4-17-01 STREET JOB NAME 40 Court Street CRY,STATE AND ZIP CODE JOB LOCATION North Andover MA 01845 ARCHITECT DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: Strip off all roof shingles on house, garage, and all shed roofs Renail all loose boards Install aluminum drip edge around roof line Apply ice and water shield 3 ft. up all along edges and in valleys , and the entire back dormer roof Apply 151b. felt paper on rest of roof area Reshingle with a 25 year 3 tab shingle Install new flanges aroun&sbil _gipes Cut in a ridge vent On back flat roof fasten down i inch insulation, 4x8 sheets Apply . 060 Manville rubber fully adhered Rubber flash around skylights Install new metal around edges and flash to roof Glue and caulk all seams Repair weather vane over garage Remove all work related debris 25 year warranty on material 10 year guarantee on labor construction lic. #060112 improvement #128612 Option: If you decide to have a 25 year Architect** shingle it will cost $600 . 00 ( Six hundred dollars ) more** We propos hereby to fumish material and labor—complete in accordance with above specifications,for the sum of: Twelve thousand -------------------- 12 , 06@ . 00 $ Payment to be made as follows: dollars( �e C )• I_ All material is guaranteed to be as specified.All work to be completed in a workmanlike manner / according to standard practices.Any alteration or deviation from above specifications involving Authoriz extra costs will be executed only upon written orders,and will become an extra charge over and Signature above the estimate.All agreements contingent upon strikes,accidents or delays beyond our control. Owner to carry fire,tornado and other necessary insurance. Our workers are fully Note:This proposal may be covered by Workmen's Compensation Insurance. withdrawn by us if not accepted within days. RCreptance Of propozAI—The above prices,specifications and conditions are satisfactory and are hereby accepted.You are authorized to do the i �,� 16 work as specified.Payment will be made as outlined above. Signature i Date of Acceptance: v f O Signature CERTIFICATE OF LIABILITY INSURANCE �—• DATE 04.23.01 (MM/DD/YY PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS PELHAM INSURANCE SERVICES INC UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER 122 BRIDGE STREET THE COVERAGE AFFORDED BY THE POLICIES BELOW. PELHAM NH 03076- 1 N S U R E R S AFFORD I NG COVERAGE INSURER A: Liberty Mutual INSURED INSURER B: The Maryland Thomas Doyle DBA INSURER C: Thompsons Construction & Roofi 8 West St. INSURER D: Salem NH 03079 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT• TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN• THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR POLICY EFFECTIVE POLICY EXPIRATION LTR TYPE OF INSURANCE POLICY NUMBER DATE (MM/DD/YY) DATE (MM/DD/YY) LIMITS GENERAL LIABILITY FACH nfCURFLNCL $1,OCO.000 B [x) COMMERCIAL GENERAL LIABILITY SCP 34865353 04.17-01 04 15 02 FIRE DAMAGE (Any one fire) $ 300,000 [ ] CLAIMS MADE [x) OCCUR MED EXP (Any one person) E 10,000 PERSONAL & ADV INJURY $1,000.000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $2.000,000 [ ]POLICY [ ]PROJECT [ ]LOC PRODUCTS - COMP/OP AGG $2.000.000 AUTOMOBILE LIABILITY [ ) ANY AUTO COMBINED SINGLE LIMIT [ ) ALL OWNED AUTOS (Each accident) $ C ] SCHEDULED AUTOS BODILY INJURY [ ] HIRED AUTOS (Per person) $ NON-OWNED AUTOS BODILY INJURY (Per accident) $ C ] PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY [ ) ANY AUTO AUTO ONLY - EA ACCIDENT $ ( ) OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS LIABILITY EACH OCCURRENCE $ ( ] OCCUR [ ] CLAIMS MADE AGGREGATE $ [ ] DEDUCTIBLE $ ( ] RETENTION $ $ $ WORKER'S COMPENSATION AND [X] WC ST=ACCIDENT AA EMPLOYER'S LIABILITY WC2-31S-314995.019 04-21.01 04.21-02 E.L. EACHS 100.000 E.L. DISE $ 100,000 E.L. DISE $ 500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Job: Roofing Job at 6 MIDDLESEX ST. NO. CHELMSFORD. MA CERTIFICATE HOLDER [ ]ADDITIONAL INSURED: INSURED LETTER: CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE FRANK DEAMICIS THE EXPIRATION DATE THEREOF. THE ISSUING INSURER WILL ENDEAVOR 6 MIDDLESEX ST. TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,OR LIABILITY BUTIL OFANYKIUE TO NDUPONDo SOTHEHAINSURER, ITS OBLIGATION SIOR NO. CHELMSFORD, MA 01863 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE (7/97) ` a �. Page 1 of 2 i • r- a Town of North Andover tAORTH p, �t00y 16 r ,E 4, B 0 Building Department ® t 27 Charles Street _ North Andover, Massachusetts 01845 (978) 688-9545 Fax(978) 688-9542 "ATEO �SSACH�as�� 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 cl 1, s150a. The debris will be disposed of in/at: Facility location Signature of Applicant s- '7 - 0f Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. NORTH 01*XM 00 = over 0 No. / 90L, - T O -_- LA o dover, Mass., to COCKICKEWICK ADRATE D P` 5 S H � BOARD OF HEALTH PERMIT T Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT V V11rr 4,t*.09 t„ ...,5 ......... ............... Foundation . .. .......... has permission to erect...�g�1�.�... ......... buildings on......A10...... ..........................1 .................. ................ Rough -� ermo� N �� to be occupied as � �„��� a M V C �i/ .. Chimney ................... ...... ............................... .............. ........................................... ...... .......: ................ provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and nstruction of Buildings in the Town of North Andover. 4000)7 i►#4:� P %6 0% %60% fay, PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STAR&. - ELECTRICAL INSPECTOR C Rough ��� ........ ..- Service .. .. .. .. . .. ..... ..... ............. UILDING INSPECTOR Final Occupancy .Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT s Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det.