HomeMy WebLinkAboutMiscellaneous - 40 WILDWOOD CIRCLE 4/30/2018r,� I
Locatio n W I L7(0,nt_'�7Z�!0
No. C Date Z2
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
Sewer Connection Fee $
Water Connection Fe $ _fir
TGTAL $ S�
Building Inspector
a- Div. Public Works
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SIi E-Y PLAN said
LOCO l Ion: �(jr /�,U C'C� t• f r�•� � UAGE .-
f31on Noforonca: Being LJ �° P c►r ey gl� of Deeds a0Oh/_�fl de
Apt?/% Reror�!eef� - _ _ _ j_ -.L ----- —
1 cortily thoi the aC 1.a aruperl7 dues nit Ise wilh!h It's
Flood
}iaiord zone as doi,riated c)n, Cc i, +arm _1`11 ; (la. ��c�4i'�"_
Thia plan Is !or bantc�purposes oniy crd is not to be used io locate
street or properly Imes. I heret,y csrtlty tha+ the building(s) shown on
thle plan le/aro located opproxlmcAol heAaanUntd 7thot wheneyconalrucrted,�
VESIMONE SURVEYING SERVICES,
REG
TO f; 8 C' _,,,K
NORTH ANLOVER •
LL(L, 242-63
310 CXR 10.99
AN ['# Lb f l' tJJ DEF FdcNo.
(To be provided by DEP)
Form 8
North Andover
Appsxnc atricia McMahon
commonwealth 40 Wildwood Circle
of Massachusetts PARTIAL
Certificate of Compliance
Massachusetts Wetlands Protection Act, G.L. C. 131, §40
F_cm
the North Andove Issuing Authority
Patricia McMahon 40 Wildwood Circle, North Andover, MA 01845
To (Name) (Address) —
Date of issuance
January 18, 1995
This C }'Ticate is issued for work regulated by an order of Conditions issued
to N g le Realty Trust dated May 23 1979
and issued by the North Andover Conservation Commiasion
EY _ it is hereby certified; that the work regulated by the above -referenced
1 .;
Order of Conditions las been sat;sfactor__y completed.
�. C It is hereby certi_'_ed that only the fol'_owing porticns of the work
regulated by the above --referenced order of Ccncitiors have bee-
regulated
the certificate of com='iance does act
satisfactorily cc:apleted: --- -- �•)
inc'_ude the entire prcject, specify what :ortions are inc'_udec
car __t_ed t: at the work reg•. ='ed by the a'tc, 2 -re ere ae^
pr s o'_ Cos. _t_or.s was never com:,encec---T a order of C� ' �� has
'er �h - longer val_d. ao fut re wc_k suc=_egt to
lacsec arc �'_s ere_c_ no o. without y.l rc .a new
.;ct_.:a
t' ?.C- maV be r�m_ner �a,4 i t - .-
reg under he _
o: _ntert-rand receiving a new Order of Ccad_t_ons.
•...
.............................ea
(Leave SpaceBlark)
ATr"COPY
�Tovm clerk ,
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(Bile (IliiU111111 tttut111tttllit ��Iltlillti�llttll��llll r
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jet( DIVISMI-1 or- 1=IRE i311EVEI-!'1'toll
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_N. �ndov� 111. _lt95
1 , �J� - jC11r or 1a��u1 IU�ti o� Ilui)
CERTIFICATE of RITLiANCE
•
CHAPTER Ilia) SC,CTI01I 26f, Ij,1-1
1 -Ids Certified that: 016 property locatod At 40 Wildwood Circle
list heou 1lrlulppell ullh alyrovall unwAs
datactors and Stas foulut to be In compliance uitli.Chaptar 1,10 5acl•lon 26F, 11assachila,el•t•s
Gellara l Law.
Z4e4`.`.a✓ e
1n9pactlon/Tooting completed 0111 % � --
• `; I1lspacl�l�/
1'4e Pa1411 25.00 -- —
liaad of IIr0 nupartmant
110ticar 1111s certificate expires alxty (601 days'aftor datq.of lsgua. _
(seller's Copy)
4
Date ...7 .. ......
�o
o� �` TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ...�! ! /� /, f �� f�
has permission for- gas installation .. A.�'. �' � . `............ .
in the buildings of ... a )9A A C
at .. �.? .�... t ! . ...`. .. f? ..... , orth Andover, Mass.
Fee. 3.1 Lic. No.. l'. Y.I. ......� �Dlrl: 11...... .
GA� INSPECTOR
Check # 41 6f
7314
IOU
MASSACHUSETTS UNIFORM APPLICATON FORPERMIT TO DO GAS WrING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Locations
Owner's Name
NewEr 0
Renovation Replacement
Plans Submitted
Date
Permit #
Amount $
(Print or type)'' ++d/coi
Certificate Installing Company
Name �I Cl. A C r13 C �C � L,rp.
Address CA, =✓1'TP a:V.y'iLlt 6 IjA LJA Partner.
,2�
BusinessTe ep one C17K Firm/Co.
Name of Licensed Plumber or Gas Fitter P,C L w
INSURANCE COVERAGE Check one'
I have a current Iiability L--isurance icy or it's substantial equivalent. Yes No U
If you have checked des, please ' dicate the type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnityBond
Owner's Insurance Waiver: I am aware that the.licensee does not have the Insurance coverage required by Chapter 142 of -the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner E] Agent 0
- � -j ...,. ••;.r — au Vl Lua ucLau�, aiiu iuiuruiauon 1 nave suommea dor entered) m above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts Stte Gas o e and Chapter 142 of the General Laws.
!� t 11
City/Town
APPROVED (OFFICE USE ONLY)
'Signa a of Licensed Plumber Or Gas Fitter ^
u er `✓(
Gas Fitter 717-777 umber
Master
Journeyman
�SUB-BASEM ENT
==®®®=�����������e��
(Print or type)'' ++d/coi
Certificate Installing Company
Name �I Cl. A C r13 C �C � L,rp.
Address CA, =✓1'TP a:V.y'iLlt 6 IjA LJA Partner.
,2�
BusinessTe ep one C17K Firm/Co.
Name of Licensed Plumber or Gas Fitter P,C L w
INSURANCE COVERAGE Check one'
I have a current Iiability L--isurance icy or it's substantial equivalent. Yes No U
If you have checked des, please ' dicate the type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnityBond
Owner's Insurance Waiver: I am aware that the.licensee does not have the Insurance coverage required by Chapter 142 of -the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner E] Agent 0
- � -j ...,. ••;.r — au Vl Lua ucLau�, aiiu iuiuruiauon 1 nave suommea dor entered) m above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts Stte Gas o e and Chapter 142 of the General Laws.
!� t 11
City/Town
APPROVED (OFFICE USE ONLY)
'Signa a of Licensed Plumber Or Gas Fitter ^
u er `✓(
Gas Fitter 717-777 umber
Master
Journeyman
The Commonwealth of Massachusetts
` Department o fIndustrial Accidents
Office of Investigations
UT 600 Washington Street
Boston, ALL 02111
www.mas&gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le6ibly
Name (Business/Organization/Individual):
Address:
City/State/Zip:
Phone #:
Are you an employer? Check the appropriate box;
1. ❑ I am a employerwith
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet I
ship and have no employees
These sub -contractors have
working for me, in any capacity.
workers' comp. insurance.
[No workers' Comp. insurance
5. ❑ We are a corporation and its
required.]
3. ❑ I am a homeowner doing all work
officers have exercised their
right of exemption per MGL
myself. [No workers' comp,
c. 152, § 1(4), and we have no
insurance required] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
1 L ❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
r_ —___ De!oR� snowing f•_:"i 4:Or:erB' cQmp�satrQn p011ey in on,.a°iQn.
t fiomeowners who submit this athdavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
#Cont<actors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employe
information. es Below is the policy and job site
Insurance Company Name:
Policy # or Self -ins. Lie. #.-
Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided 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
6. Other
Contact Person:
Clerk 4. Electrical inspector 5. PIumbing Inspector
Phone #:
Information and Instructions x
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.m 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, onthe 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 co=npliance 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 certificates) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with.no employees other than the
members or partners,. are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the vrtf or town that the application for the peraitor license is being requested, not the Department of
Industrial Accident;. Should you have any questions regardi—mg 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 Off ce of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permittlicense number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only'submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business. or commercial venture
(i.e. a dog License or permit to bum leaves etc.) said person is NOT required to complete this affidavit. .
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investibatjions
600 Washing -ton Street
Boston, MA 002111
Tel. # 617-727-4900.ext4406 or 1 -877 -MAS -SAFE
Fax # 617-727-7749
Revised 5-26-05
wv rv,.mass._gov/dia
At
,
Location 'Yo wa wOod
No. 616 Date a8-0
MORTIy TOWN OF NORTH ANDOVER
i a OL
T
Certificate of Occupancy $.
�SJwcNuSEt�'
Building/Frame Permit Fee $ g
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ �—
i
Check # 6 q U 0
s
175A
AN4 f61 X- -
Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVAT& OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER:
68
DATE ISSUED:
1
JJA
SIGNATURE:
Building ColnmissionSEThsgEtor of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
�C
1, .�
Map Number Parcel Number
1.3 Zoning Information:
1.4 Property Dimensions:
Zoning Diacid Proposed Use
Lot Areas Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Required Provide Required Provided
Required
Provided
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information:
1.8 Sewerage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone ❑
Municipal ❑ On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
Historic District: 2S O
2.1 Owner of Record
Toter, IoL-�jc �e F�-(' �lv 0C/
Name (Print) Address for Service
Sign tTelephone
2.2 Olrvher of Record:
4
Name, Print Address for Service:
Signature Telephone
SECTIONS - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable ❑
Licensed Construction Supervisor: Duval Roofing
License Number
P.O. Boy. 637
Addr ss VA
l q"
/C7
/
Expiration Date
ignature Telephone
3.2 Registered Home Improvement Contractor
Not Applicable ❑
Company Name
Duval Roofing
P•n Box 637
Registration Number
Add re
Orth Readim& MA
iration Date
t1w
nature Tel hone
T
M
Z
O
NO
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 buildi rmit.
Signed affidavit Attached Yes ...... No ....... ❑
SECTION 5 Description of Proposed Work check all applicable)
New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑
Accessory Bldg. ❑ Demolition ❑ Other ❑ . Specify
Brief Description of Proposed Work:
l�
I SECTION 6 - F.STTMATFn CONCTUlTrTlnN rncTc 1
Item
Estimated Cost (Dollar) to be
Completed by pertnit applicant
r OFFICIAL USE ONLY
1. Building
(a) Building Perniit Fee
Multiplier
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
--
Check Number (o
br%-IIUi' is UWPIEKAUIIIUKLZAIIUTV IUIJEC:UMPLEIEDWHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
o , as Owner/Authorized Agent of subject property
Hereby authorize U 14 #_ to act on
My behal , ni all ers relative tooriz=10 ed y is building permit application.
Si e o Date-? y
E ION 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
�,efo r l.rh 0
Print
of Owner/Agent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TINMERS OT 2 ND 3RD
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DRVIENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHEVINEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Name Please Print
Name:
Location:
City _ ___ Phone #
I am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
I am an employer providing workers' compensation for my employees working on this job.
�13a
Company name:
Address
City: Phone #:
Insurance Co. Policv #
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to $1,500.00
and/or one years' imprisonment -as _wellas civil.,penattiesin-theformnfa STOP WORK_ORDER..and afine_of.($1D0.D0)_ailay against.me. I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
l do hereby certify under gins and penalties of perjury that the information provided above is true and correct.
Print
o?g
Phone # 97
Official use only do not write in this area to be completed by city or town official'
City or Town Permit/Licensing
0
Building Dept
❑Check if immediate response is required E]
Licensing Board
r-1
Selectman's Office
Contact person: Phone #.• F-1
Health Department
❑
Other
North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
Number is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c11,S150A.
The debris will be disposed of in:
(Lotion of Facility
Signature of Permi Applicant
/.-�9 '7
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
NOTICE
TO
EMPLOYEES
NOTICE
Qh
EMPLOYEES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Street, Boston, Massachusetts 02111
617-727-4900 — http://www.mass.gov/dia
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that
I (we) have provided for payment to our injured employees under the above mentioned chapter by
insuring with:
THE TRAVELERS INSURANCE COMPANIES
NAME OF INSURANCE COMPANY
ONE TOWER SQUARE
HARTFORD CT 06183
ADDRESS OF INSURANCE COMPANY
(7PJUB-73OK535-4-04) 02-17-04 TO 02-17-05
POLICY NUMBER EFFECTIVE DATES
ARGEROS INS AGCY INC 360 MAIN STREET
READING MA 01867
NAME OF INSURANCE AGENT ADDRESS PHONE #
DUVAL, KENNETH P DBA 184 PARK.STREET
DUVAL ROOFING
NORTH READING
MA 018G4
EMPLOYER ADDRESS
EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the
injured employee. The employee may select his or her own physician. The reasonable cost of the services
provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably
connected to the work related injury. In cases requiring hospital attention, employees are hereby notified
that the insurer has arranged for such attention at the
NAME OF HOSPITAL ADDRESS
006208 W20PIG02 TO BE POSTED BY EMPLOYER
RCDFI C
COUCTIO
CertainTeed ffl
r]0[posa 1
nevaIAL
Roofing
(781) 944-1994 (978) 664-2557
"The Areas Oldest Roofing Company"
P.O. Box 637, North Reading, MA 01864
Page No. of
Builders License # 58443
Home Construction Reg. # 109288
CertainTeed/Certification # 1911
GAF Certified Master Elite
PROPOSA SUB ITTEDTO �/I7/,r' ��� I PHONE - I DATE la s/U Y
M
C CITY, STATE WD ZIP CODER I JOB LOCATION
/�k p lootier I
We hereby submit specifications _ nd estimates for. Recommended
(Included in price)
✓ Rip & Remove all shingle debris from roof & job site: M 1 layer O 2 layers ❑ 3 layers or more —
✓ Repair/or Replace any roof decking; not to exceed 50sq. ft_ -
Install 8" aluminum drip-edge/and rake -edge along entire perimeter. Choice of mill hit or brown
✓ Install ICE & WATER underlayment along horizontal eaves, valleys, sidewalls and sky -lights & chimneys
✓ Install 30# felt underlayment between roof deck and roofing shingles
f Install 25yr CertainTeed/GAF/Tamko or Owens & Corning traditional 3 -tab roof shingles ❑ 30 year
• Install 30yr CertainTeed/GAF/Tamko or Owens & Corning architectural roof shingles
Optional
(Not included in price)
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BOARD OF BUiIN,l REGULATIONS � t
License: CONSTRUCTION U
CTI
O
N SUPE
R
VISOR
Number: CS 058443
Birthdate: 12/10/1966 I
Expires: 12/10/2005 Tr. no: 10052 !
Restricted: 00
KENNETH P DUVAL r
PO BOX 190/72 NORTH ST
N READING, MA 01864
Administrator
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G. Board of Building Reguiat:ons and Standards
HOME IMPROVEMENT CONTRACTOR
--:7--Registration: 109288
Expiration: 9/9!2004
Type: DBA
DUVAL ROCFING
If -o neth Duva!
PO BOX. 190172 NOU . ST
N. READING, AIF, 018`=4 Administrator