HomeMy WebLinkAboutMiscellaneous - 404 ANDOVER STREET 4/30/2018 / 404 ANDOVER ST
210/024.0 0038-0000.0
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North Andover Board of Assessors Public Access Page 1 of 1
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Sroperty Record Card
Click Seal To Retum Parcel ID :210/024.0-0038-0000.0 FY:2013 Community :North Andover
SKETCH PHOTO
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Summary
Residence
Detached Structure
Condo 404 ANDOVER STREET
Commercial
Location: 404-406 ANDOVER STREET
Owner Name: CARROLL,THOMAS
CARROLL,MARY,E.
Owner Address: 404 ANDOVER STREET
City: NORTH ANDOVER State: MA Zip: 01845
Neighborhood:5-5 Land Area: 0.55 acres
Use Code: 104-TWO-FAM-RES Total Finished Area: 1162 sqft
ASSESSMENTS CURRENT YEAR PREVIOUS YEAR
Total Value: 281,300 275,200
Building Value: 99,800 85,000
Land Value: 181,500 190,200
Market Land Value: 181,500
Chapter Land Value:
LATEST SALE
Sale Price: 99 Sale Date: 10/20/2011
Arms Length Sale A-NO-FAMILY Grantor: CARROLL
Code:
Cert Doc: Book: 12660 Page: 0068
http://csc-ma.us/PROPAPP/display.do?linkld=2251119&town=NandoverPubAcc 3/26/2013
Residential Property Record Card
PARCEL ID:210/024.0-0038-0000.0 MAP:024.0 BLOCK:0038 LOT:0000.0 PARCEL ADDRESSA04-406 ANDOVER STREET FY:2013
PARCEL INFORMATION Use-Code: 104 Sale Price: 99 Book: 12660 Road Type: T Inspect Date:_ 03/30/2004
Tax Class: T Sale Date 10_/20/11_ Page: 00_68 Rd Condition: P Meas Date: y03/30/2004
Owner: __ - - -----
CARROLL,THOMAS Tot Fin Area: 1162 ' Sale Type 'P �'Cert/Coc: Traffic: M Entrance: �X
CARROLL,MARY, S Tot Land Area: 0.55 Sale Valid: A Water: Collect Id: m RRC
Address: Y Grantor- 'CARROLL Sewer: Inspect Reqs: C
404 ANDOVER STREET Exempt-B/L% ! Resid-B/L% 100/100 Comm-B/LP/o Indust-B/L% / Open Sp-B/L% /
NORTH ANDOVER MA 01845
RESIDENCE INFORMATION LAND INFORMATION
Style: RN.,Tot Rooms: 6 Main Fn Area: 1162 Attic: NBHD CODE 5 NBHD CLASS 5 ZONE R4
Story Height: 1.00 Bedrooms: 3 Up Fn Area: Bsmt Area: 1162 "y Seg Type Code_ Method Sq Ft Acres Inffu Y/N Value Class
m. - - _
Roof. G Full Baths 2 Add'Fn Area: Fn Bsm 1 P 104 SN 24061 0.552 - 181,458
4 Area:
Ext Wall ....__. AB Half Baths: - Unfin Area: Bsmt Grade VALUATION INFORMATION t
Masonry Trim_ Ext Bath Fix: 0 Tot Fin Area: 1162 Current Total: 281,300 Bldg: 99,800 Land: 181,500 MktLnd: 181,500
Foundation: CB Bath Qual: T RCN LD: 99805
Kitcti Qual: Yr Built: 1970_m`Mkt Adj: Prior Total: 275,200 Bldg: 85,000 Land: 190,200 MktLnd: 190,200
TEff " _
Heat Type: HW Ext Kitch: Year Built: 1900 Sound Value:
Fuel Type: -O -Grade: FA Cost'Bldg: 99,800
Fireplace: 0 Bsmt Gar Cap: Condition: A AttStr Val 1:
Central ACS—N""`-"Bsmf Gar SF:--`Pct Complete: Att Str Val2:
- Att G6FSF___ - %Good P/F/E/R /100//72
Porch Type Porch Area Porch Grade Factor
E 292
P 48
SKETCH PHOTO
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401 ANDOVER STREET ,..
8 152 SgFi 8
Parcel ID:210/024.0-0038-0000.0 as of 3/26/13 Page 1 of 1
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: -//:?— Date Received
Date Issued: rzq
IMPORTANT:Applicant must complete all items on this page
LOCATION n _ �1-'• -----_
Print /
PROPERTY OWNER
Print 100 Year Old Structure yes
MAP NO: PARCEL:- ZONING DISTRICT: Historic District yes rano
'z I V Machine Shop Village yes (nog
?_talo3 g
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑Addition 1<rwo or more family ❑ Industrial
❑Alteration No. of units: Z ❑ Commercial
epair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District
mater/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
4
Identification Please T e or Print Clearly)
OWNER: Name: ef��r-r Phone:
Address:
CONTRACTOR Name: Phone:
Address:
Supervisor's Construction License: Exp. Date:
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT.$1200 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $_T�Sry FEE: $
Check No.: Z Receipt No.:
NOTE: Persons co tracting with unregistered contractors do not have access to the guaranty fund
Signature,of Agent/Owner - Y �` • -( Sigpature of contract ±
Plans Submitted ❑ PI ns Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
Location
No.J M Date�-
• - TOWN OF NORTH ANDOVER �r
Certificate of Occupancy $
Building/Frame Permit Fee $
: Foundation Permit Fee $
Other Permit Fee $
TOTAL $
T.
Check# - S 4t
r t r
2 J L+ j -A, Building Inspector
f
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
i
TYP "OF.SEWERAGEDISPOSAL f
Public Sewer 1' Tanning/Massage/Body Art ❑... Swimming Pools ❑
Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑
Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑
I
i
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
r '
v
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes .-
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature& Date Driveway Permit
Q-_
DPW To` o Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTME=NT =Temp Durnoter on site yes_. no
Located at 124 Mair, Street
Fire Department signature/date '
r.
COMMENTS
I
Date 6 /30/13 Invoice # 110
Farr Better Renovations
George Farr
1150 Salem St.North Andover,MA 01845
Cell (978)457-1609
cgfarrj@verizon.net
Tom Carroll
Andover,MA
404 Andover St
North Andover,MA
Demolition and disposal of old porch windows,doors, and surrounding trim.
Disposal via trailer to local dump. Framing in of 4 smaller window units .
Installation of new windows(52H X 48W casement),door and surrounding trim.
Initial payment due at start $ 3,000.00
Due upon completion $ 2,750.00
Total $ 4750.00
THANK YOU
George Farr
I
Massachusetts -Department of Public Safety
Board of Building ng Regulations and Standards
Construction Supervisor
License: CS-052671
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AIL SE OLL •�' ` ,
LANDOVER MA (1810
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Expiration
Commissioner 04/03/2015
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 Leizibly
Name(Business/OrganizatiorAndividual):
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
mployees(full and/or part-time).` have hired the sub-contractors
2 I am a sole proprietor or partner- 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. 9. ❑Building addition
[No workers' comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roofrepairs
insurance required.]t employees.[No workers'
comp.insurance required.] 13.❑Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
T Homeowners who submit this affidavit indicating they tie 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'comp.policy information.
lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:-
Policy#or Self-ins.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 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.
Y do hereby certify under thepains andpenaldes ofperjury 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 Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other - - -
Contact Person: Phone#:
NORTH
Town of 2Andover
o - �+
No. I
I I
ver, Mass
0
QCoc"Ic Ntw1c.t
S V
BOARD OF HEALTH
PERMIT T LD Food/Kitchen
Septic System
THIS CERTIFIES THAT ....... Com.«,�r, I� ......... .... BUILDING INSPECTOR
has permission to erect .. Foundation
.... ................... buildings on .....��.Y........ ����..................,....
r / Rough
to be occupied as .......( ... .1�1,R '!t./J.'...... ��......PD..@..Aw..................................... Chimney
provided that the person accepting this permit shall in every respect conform to the terms of the application Final
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and
Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR
Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit.
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCT S TS Rough
Service
............ .. ........................................................... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building 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. Burner
Street No.
Smoke Det. '
SEE REVERSE SIDE `
TM
C.'An'
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
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 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. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that-the-affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any giren year,need only submit one affidavit indicating current
policy y mformahon(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 CoMM.onwDalth of Massachusetts
Department of ladustrial Accidents
Offlee of Investigations
600 Washington Street
Boston?M.A,02111
Tel,#617-72.7-4900 ext 406 or 1.-877:MASSAFE
Revised 5-26-05 Faz,#617-727-7749
WWW.Mass,govfdia
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions._
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A-F and G min.$100-$1000 fine
NOTES and DATA— (For department use
El Notified for pickup - Date
Doe.Building Permit Revised 2010
Building Department
The fohowing is a list of the required forms to be filled out for the appropriate permit to be obtained.
RoofirA,g, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the apw-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be subm_tted with the building application
Doe: Dor—Building permit Revised 2012
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: I Date Received
Date Issued:
IMPORTANT:Applicant must complete all items on this page
LOCATION J.
----��-- Print.
PROPERTY OWNER OIyI
/'� Print 100 Year Old Structure yes no.
MAP NO: V_PARCEL:ZONING DIS;IRICT: Historic District ye no
Machine Shop Village y no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑Addition , "Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
,KRepair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District
❑Water/Sewer
DESCRIPTION OF WORK TPJBE RMED:
4 S
Identification Please Type or Print Clearly) /�
OWNER: Name:_ lG _ f� f Phone:'?7y-7y--Z'l )or)
Address:
ll ff �/
CONTRACTOR Name /`.Pr L�'� _ �a y� Phone:(or3z7le(r
Address: yZ I 1/�Aey0 tLl� e/73
r
t Supervisor's Construction LicenseiC5067gS q ' Exp. Date: e�S Off- pZe)r/5
Home Improvement License: 6 7F6 Exp; Date:
ARCHITECT/ENGINEER Phone: -
Address: Reg. No.
FEE SCHEDULE:BULDING sal 01,T.-$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ [S��/ � 0�
1 FEE: $
CO
Check No.: 1-:2
ReceiP t No.:
I
NOTE: .Persons contractin ith un i er contractors do not have access to e gu r n f n
Signature of Agent/Ow Ig iature of contract
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
f�
Location 4W AiJom 5�,t P6)
No. '— Date_1
15
a s
I
• - TOWN OF NORTH ANDOVER
._ Certificate of Occupancy $
� Building/Frame Permit Fee $
° Foundation Permit Fee $
, � Other Permit Fee $
TOTAL $
P
Check# 02&
2662 Building Inspector
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF.SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑
Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑
Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
. DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
�t Conservation Decision: Comments
Water & Sewer Connection/Signature Date Driveway Permit
DPW'J<owo Engineer: Signature:
Located 384 Osgood Street
FIRE-DEPARTMENT Temp Dumpster on site yes no
Located at 124 Mair,., Street
Fire Department signature/date
COMMENTS
t%O R'rh
Town of ndover
t
No. � �� lot
soh ,h ver, Mass, 7 S
coc«ic"RwJcw yq.
AORATE1) PP�,`'�5
S u
BOARD OF HEALTH
Food/Kitchen
Septic System
THIS CERTIFIES THAT BUILDING INSPECTOR
......PERMI
. Q!.M... ..... .................. .....
Foundation
has permission to erect.......................... buildings on .464A. 1.. . ...................
Rough
to be occupied as .....1� .......... .. ........................................................................ Chimney
provided that the person accep ng this permit shall in every respect conform to the terms of the application final
on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and
Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTI TARTS Rough
...................... Service
.......... ...... .. ..... ...... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building 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. Burner
Street No.
Smoke Det.
SEE REVERSE SIDE
LHIS
/12/2013 12:45 16038826137 FRENCH INSURANCE PAGE 01/01
DATE(MM/DDIYYYY)
CERTIFICATE OF LIABILITY INSURANCE 07/12/2013
ERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the pollcy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder In lieu of such endomement(s).
PRODUCER Co TA T RHONDA PHELPS
NAME:
FRENCH INSURANCE AGENCY, INC. PHONE (603) 882-95:32 WO o.(603) 96R-6137
12 DERRY STREET E-MAIL
INSURER 3 AFFORDING COVERAGE NAIC 0
HUASON NH 03051— INSURERA:PROVIDENCE MUTUAL EIRE INS CO
INSURED GODBYR, FREDERICK A INSURF-R 6;TRAVELERS INSURANCE COMPANY
FRED GODBYR CABINETS & CARPENTRX INSURFR 0:
INSURER D:
22 MONT VERNON DRIVE INSURER E
PELF M NH 03076^ INSURFRF:
COVERAGES CERTIFICATE NUMBER; REVISION NUMBER:
THIS IS TO CERTIFY THAT 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,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSRLTR TYPE OP INSURANCE POLICY NVM9 POLICY EFFYYYJ POLICY EXP LIMITS
A GENERAL LIABILITY ROPOO62770 06/25/2013 06/25/2014 EACH OCCURRENCE $ 500000
X COMMERCIAL.GHNRRAL LIABILITY / / / / Ed oeeu nce $ 50000
CLAIMS-MADE 17x OCCUR / / / / MED EXP(Any one ereon $ 5000
PERSONAL R ADV INJURY $ 50000_0
GENERAL AGGREGATE $ 1000000
GENT.AGGREGATE LIMIT APPLIES PER; / / / / PRODUCTS-COMP/OP AGO 6 1000000
X POLICY 7 T& LOC / / / / 6
AUTOMOBILE LIABILITY / / / / COMBINED UINULE LIMIT
n dea de 1 _
ANY AUTO / / / / BODILY INJURY(Per peraon) S
ALL OiNNED ALITSCHHOEBULED / / / / BODILY INJURY(Per accident) S
NON-OWNED / / / / PROPERTY DAMAGE $
HIRED AUTOS AUTOS n
UM5RF-LLA LIA9 OCCUR / / / / EACH OCCURRENCE $
EXCESS UAB CLAIMS-MADE / / / / AGGREGATE $
DED RETENTIONS
$ WORKERS COMPENSATION 61(UB4a45P51112 08/31/201208/31/2013 X I WCSTATU- OTH-
AND EMPLOYERS'LIARIUTVORYLIM81
ANY PROPRIETORIPARTNER/EXECUTIVE Y/N / / / / E.L.EACH ACCIDENT S 100000
OF EXCLUDED7 N/A -
(Mnndetory In NH) / / / / E,L,DISEASE-EA EMPLOYE $ 100000
Iryne do.ollheurlder
DESCRIPTION OF OPERATIONS below / / / / E.L.DISEASE-POLICY LIMIT R 500000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Addltlorml Romnrlw 8chadula,It morn apacn In rnqulrnd)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE T14EREOF, NOTICE WILL 13E DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS,
FAX 978-688-9542
BUILDING DEPT. AUTNORIZEDREP SAT) ,,�,,,,,///���
NORTH ANDOVER, MA — CHIIN RAN C
ACORD 25(2010/05) ®1988-2010 ACORD CORPORATION. All rights reserved.
INS025(201005).01 The ACORD name and logo are reaistered marks of ACORD
V07/12/2013 12:41 16038826137 FRENCH INSURANCE PAGE 01/01
CERTIFICATE OF LIABILITY INSURANCE 07/12/2013I,
7/1a/20131
CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the poliey(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER NAME CT RHONDA PHELPS
FRENCH INSURANCE AGENCY, INC. PHONE (603) 8ee-9532 FAX o.(coal eel-s13�
12 DERRY STREET EMAIL
INSURER(S)AFFORDING COVERAGE NAIC 8
HUDSON NH 03051-- INSURERA:PROVIDENCE MUTUAL k'IRZ INS CO
INSURED GODBYR, FREDERICK A INSURER a:TRAVELERS INSURANCE COMPANY
FRED GODBYR CAHZNETS & CARPENTRY INSURER O:
INSURER 0:
22 MONT VERNON DRIVE INSURER C;
PELHAM NH 03076^ INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
NTRR ADVLSUBR TYPE OF INSURANCE POLICY NUMBER POLIFT EFF MMIlDDK rr LIMITS
A GENERAL LIABILITY ROP0062770 6/25/2013 06/23/20111 EACHOCCURRENCE $ 500000
X COMMERCIAL GENERAL LIABILITY / / / /
_PREMI ES -ooccurro co 5 50000
CLAIMS-MADE Fx_]OCCUR / / / / MED EXP(Any oneperson) $ 5000
PERSONAL BADVINJURY $ 500000
GENERAL AGGREGATE 6 1000000
GEN'.AGGREGATE LIMIT APPLIES PER, / / / / PRODUCTS-COMPIOP AGG $ 1000000
7 POLICY PRO- 40C / / / / a
AUTOMOBILE LIABILITY / / / UUMy1NF'IJ WNOLE LIMIT'
Ee accident
ANY AUTO / / / / BODILY INJURY(Por pre-on)
ALL OWNED SCHEDULED / / / / BODILY INJURY(Per eccldent) S
AUTOS AUTOS _
HIRED AUTOS DON AWNED / / / / PROPERTY DAMAGE S
UMBRELLA LIA9OCCUR / / / / EACH OCCURRENCE $ _
EXCESS LIAB HCLAIMS-MADE / / / / AGGREGATE $
D RETENTION 5 / / / / S
H
WORKERS COMPENSATION 6PCUB484SP31112 08/31/201208/31/2013 X WCSTATU• OH,
ETR EMPLOYERS'LIABILITYTORY
YIN
ANY PROPRIETOR/PARTNER/EXECUTIVE / / / / 6,L,EACHACCIDFNT $ 100000
OFFICER/MEMBER EXCLUDEO? N/A
(MendetorylnNil) / / / / E1,DISEASE-SAEMPLOYEE $ 100000
if D RIPTI�s
SLIIPTIONOF OPERATIONS belew under / / / / E.LDISEASE•POLICYLIMIT $ 500000
O
DESCRIPTION OF OPERATIONS I LOCATIONS r VEHICLES(Attoch ACORD 101,Addltlonal Remarks schedule,if mora speeo in requlrod)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE[DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
FAX 978-688-9542
13UILDING DEPT. AUTHORIZED REP ATIv
NORTH ANDOVER, MA - CHIN ItANC
ACORD 25(2010106) ®1988-2010 ACORD CORPORATION. All rights reserved.
INS025(201005).01 The ACORD name and loco are registered marks of ACORD
The Commonwealth ofMassachusetts
I
Department of IndustriqlAccidints
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 Legibly
Name(Business/(jrganization/individual):
i
Address:_ or, o, 114 l ze:e_1-AUIV
City/State/Zip:&A 61 IV,ff, Phone#: 60 3 " iLel S/ 3,3
T
Are you an employer?Check the appropriate box: Type of project(required):
IM I am a employer with 4. ❑ I am a general contractor and I
6. El Now construction
employees(full and/or part-time),* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7• ❑Remodeling
ship and'have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9, ❑Building addition
[No workers' comp.insurance 5. ❑ We are a corporation and its -
10.❑Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12,KRoofrepairs
insurance required.]t employees.[No workers'
comp.insurance required] 1313T]Other
*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 check this box roust 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 Name:.
Policy#or Self-Ins.Lie.#: Expiration Date:
Job Site Address.: 2✓& / 141,,- ,ity/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 maybe forwarded to the Office of
Investigations of the DTA-for insurance coverage verification.
Ido hereby er under the 10171117dp les of erjury that the information provided above is true and correct. -
Sip-nature: 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.Plumbing Inspector
6.Other -
Contact Person: Phone#:
Information and Instruction's
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,•
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced-acceptable evidence of compliance with the insurance coverage required"
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-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 confrn ation 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 Depattmeriflias-pf6vided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to burn 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:
Tho Commonwealth.of Massachusetts
Department of f dustdat.A midonts
office of Investigations
6.00 Washington Street
Boston,M,.A.02111
TQL#617-7274900 ext 406 or 1.-877:MASSAF'F
Revised 5-26-05 Fay,4 617-727-7749
wwwmass.gov/dia
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction.Supervisor
License: CS-092009
FREDERICK A GO'DB . -
22 MOUNT VERNON)UU
s i
PELHAM NH 03-076 I
I
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-2./5l `. " "�`' Expiration
Commissioner 05/05/2015
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Rome 7Gm -ove>nnemt Same
This f-O=Sa'�SEes all basic'requirements oi'the state's Home Improvement Contractor Law
Ianguage to protect homeowners. Seelc legal advice if necessary. An (MGL chapter 142A),but does not include standard
so
lviassachusetts Consumer Guide to Home Improvement"before agreeing to easy workPlanning g homur residenrOvce.You may obtain free obtain a b p cabin the
Office o£Con sumer Affairs and Business Regulation's Con sumerinformationHotline at 617-973-8787 or 1-888-283-3757 or on copy by
'
11olne0wner WoIPIIIlD agion
Contractor Information
I�TaTnn `
Company Name Q
Street Address(do notuse aPo Office Box address
) Contractor/Salesperson/OwnerName J
City/Town State Zip Code Bur�siness Address(must include.a street address)
Daytime Phone
BveningPhone City/Town
r15'_0 State Zip.Code
Mailing Address(It different from above)
Business Phone federal Employer ID or S.S.Number
AomeImpmvementContmcrorReg:Number
nwregnires
—r0�� o�✓/ CEJ,/ xtl�atmostliome Expiraflondnte
improvement contrnctorshave 1 O
I valid registration n"inher l� /(/ /n �� 0� ✓p`
The Contractor agrees to do the foIIowing worlt for the Homeowner:
(Describe in detail the worlcto completed,specifying the type,brand,and grade of materials to be used,Ilse add*•ional sheets ifne ssa
91
Required Permits-The following building permits are required Proposed Start and Completion Schedule-*The following schedule will
and will be secured by the contractor as-the homeowner's agent: be adhered to unless circumstances beyond the contractor's control arise
(GvMers who secure their own permits'vVM be
excluded from the Guaranty Fund provisions of
tt when contractor will begin contracted wozlc.
MGL chapter 142A.)
t Date when contracted work will be substantially completed.
Total Contract Price and Payment Schedule
The Contractor agrees to perform the work,furnish the material and labor specM-ed AM,for the total sum of-
Payments
£Payments will be made according to the following schedule:
upon signing contract(not to exceed 1/3 of the total contract price or the cost of special order ita ms,whichever iseater
by / / or upon completion of
--------__ by / / or upon,completion of
completion ofthe contract. (Law forbids demanding full payment until contract is Completed to both
P party's satisfaction) .
The following material/equipmentmust bespecial $
ordered before the contracted work begins in order to be paid for
to meet the completion schedule.(.M.) $
• to be paid for
NOTES:('1°)Including all finance charges(**)Law requires that any deposit or down payment required by the contractor before worlcbegins may
not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material
which must be special ordered in advande to meet the completion schedule.
Bxures----s Warl'•tn t y_-Ts an c xp rus warrant bei-n rovided b tha contractor?
Subcontractors The contractor agrees to b.e solelyxespoisitilefir completion of tNO he work described regardless ofthe actions of my t' rd fymiy
party/subcontractor utilized by the contractor. The contractor filrther agrees to be solei responsible for all a y
materials andlaborunderthis a Bement y p payments to all subcontractors for
ContractAcceptance-'upon signing,this document becomes a binding contract under law. Unless otherwise noted withfia this document,the
contract shall not imply that any lien or other security interest has been placed on the residence. Review the Following cautions and notices
carefully before signing this contract.
O Don't be pressured into sifining the rDri:•^.Ct.Taloa time to read and fully understand it. Ask questions if something is unclear,
_ ,...,
vluice sul e the contractor has a valid Home 7m rovement Contractor Registration. The law requires most home improvement contractors and
subcontractors to be registered with the Director ofI Tome Improvement Contractor Registration, you may inquire about contractor
registration by writing to the.Director at 10 ParkPlaza,Room 5170,13oston,MA 02116 or by calling.617-973-8787 or 888-283-3757.
o Does the contractor have insurance? Ask the Contractor for his insurance company information so that you can,eonfum coverage,or isle to
see a copy of a"proof of insurance"document.
o Flow your rights and responsibilities. Read
Guide to the Rome Improvement Contractor the Important Information on the reverse side of this form and get a copy ofthe Consumer
Law.
You may cancel this agreement if it has beer,signed at a place other than the contractor's normal place of business,provided you no' the
contractor in writing at.his/her main ofi"ice or branch office by ordinary mail,posted,by telegram sent or by delivery,not later than midnight ofthe
third business day following the signing oftWs agreement. See the attached notice of cancellation form for an e planation ofthis right
D®NOT'SIG1�T T I][S ®NT]2ACT]I'1'aCP�
Two identical copies ofthe contractmust be completed and signed. one c BLANK��1�C][;�"f T 1
opy should go to the lom er. The offer cop shouldbe kept by the contractor.
Homeowner' Signature
nttraactor's Signature
'Date �• � / � /"Z" A71T1
Date
C®:mi actor.A.t bif ration
The l Tome Improvement Contractor Law provides homeownexs with the right to initiate an arbitration action(as an
alternative to Court action)if they have a dispute with a contractor. The same Tight is not automatically af,£ordedto a
contractor,however. The contractor would have to resolve any dispute he/she has viz+h a homeowner.in.court unless
both parties agree to the optiona]1 clause provided below. This clause would give the contractor the same right to
arbitration as is afforded to the homeowner by the Nome Ymprovement Contractor S,aw.
The contractor and the homeowner hereby mutually agree in advance that in the event the contractor has a dispu:�e
concerning this contract;the contractor may submit the dispute to a private axbitration C which has been approved by
the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required
to submit to such arbitration as provided In.Massachusetts General Laws, chapter 14.2A..
Homeowner's Signature Contractor.s -
Signatlure
NOTI[C]E:The signatures ofthe parties above apply only-to the agreement of the parties to alternative dispute
resolution initiated by the contractor: The homeowner may initiate alternative dispute resolution even where this
section is not separately signed by the patties,
Mlomeowner's Rights
A homeownex's rights under the Nome Improvement Contractor Law(MGL chapter 14.2A) and other consumer
Protection laws G.e.MGL chapter 93A)may not be waived in any way,"even by agreement. however,homeowners
may be,excluded from certain rights if the contractor they choose is not properly registered as prescribed by law.
Homeowners who secure their own building permits are automatically excluded from all Guaranty Fttrod provisions of
the Home Improvement Contractor Law. The contractor ig responsible for completing the work as described,in a
timely and worlcmanlilce manner. Homeowners may be entitled to other specific legal rights if the contractor
guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties
provided by the contractor, all goods sold-in Massachusetts cavy an implied warranty of merchantability and fitness for
a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree may be
added to the terms of the contract as long as they do not restrict a homeowner's basic consumer rights. Hyou have
questdons about your cuasumer/homeowner rights, contact the Consumer 7iCormation I iotline(listed below).
]Execution of Contract-
The
ontractThe contract must be executed in duplicate and should not be sign d u dh a copy of all exhibits and referenced.
documents leave been attached. Pai tit,.s are also advised not to sign the document until all blank sections have been
filled in or marlced as void, deleted,or not applicable. One original signed copy of the contract witth attachments is to
be given to the owner axed the other kept by the contractor. Any modification to the,original,contract must be in writing
and agreed to by both parries, Contracted work may not begin until both,parties have received a fully executed copy of
the contract,and the three day rescission period has expired.
Accelerated Payments
A contractor may not demand payments in advance of the dates specified on the.payment schedule in cases where the
homeowner deems himlherself to be financially insecure. However,iu instances where a contractor deems him/herself
to be financially insecure,the contractor may require thattbe balance of funds not yet due be placed in a joint escrow
account as a prerequisite to continuing the contracted work. Withdrawal of fiands:From said-account would require the
Signatures of both parties.
Additional Information
.If you have general questions or need additional iuff rmation about the Home Improvement Contractor Law or other
consumer rights, or if you wish to obtain,a free copy of "A Massachusetts Consumer Guide to Home Improvement"
contact
Consumer I&ormata on Hotline
Of(ice of Consumer Affairs and Business Regulation
10 Park Plaza,• Rn'
617-973-8787,'888-283-3757 or''visit•Ehe OCABRw b �02116
site at lam://www mass zov/neabi•/
if you want to verify the registration of a contractor or You have questions or need additional information sped Clcally
about the contractor registration component of the Home Improvement Contractor Law, contact:
Director ofl-1ome Improvement Contractor Registration
Office of Consumer Affairs and-Business Regulation
Id a
,Room 617-973-8787, 888-283- 757 Or visit theRC$bsiteoston'at l�it1.02��v.7
Hass.Dov/ocabr/
Go online to view the status of a Home Improvemelt Contractor's Registration:
ht-17�://dU.state.ma t2s/ho7neimtrovement/Iicettseelist.as
For assistance with informal mediation of disputes or to register formal complaints against a business
call:
Consumer Complaint Section
Office of the Attorney General
617-727-8400
AND/OR
Better Business Bureau
S08-652-4800,50&.755-2S48 ox 4.13-734-•3114•
Version 2.1-1]L9.2/9mn
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of s
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A-F and G min.$100-$1000 fine
NOTES and DATA— (For department use
i
® Notified for pickup - Date
Doe.Building Permit Revised 2010
J
Building Department
I
The fol .awing is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
❑ Building Permit Application �
o Workers Comp Affidavit
I
o Photo Copy Of H.I.C. And/Or C.S.L. Licenses
o,-Copy of Contract
o Floor Plan Or Proposed Interior Work
o Engineering Affidavits for Engineered products t
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
Li Certified Surveyed Plot Plan
j ❑ Workers Comp Affidavit
o Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
ij Engineering Affidavits for Eingineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
o Building Permit Application
o Certified Proposed Plot Plan
o Photo of H.I.C. And C.S.L. Licenses l
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (if Applicable)
❑ Copy of Contract
❑ Mass check"Energy Compliance Report
o Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the apw-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submAted with the building application
Doc: Doc.Buil sing Permit Revised 2012
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: UDate Received
Date Issued:
EUPORTANT:Applicant-must com fete all items on this page
LOCATION �y +a `✓ S `V ' ! 4
Print
PROPERTY OWNER M ►�I Unit#
Print
MAP NO: PARCEL: ��ZONING DISTRICT: Historic District yes no
Machine Shop Village yes no
100 year-old structure yes no
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non-Residential
❑ New Building ❑ One family
❑Addition B'I°wo or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
We air, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
f---Y erIr,
L ...:: " ."•'r "`! y ..`
Septic, i®Well ❑Floodplama D+Wetlands}l. , ; O Watershed District, ,
h ; t
.. _
4. ®Water/Sewert
DESCRIPTION OF WORK TO BE PERFORMED:
���� � fig ✓��'S
(Identificati n Please Type or Print Clearly)
OWNER: Name: Phone• -47i j,,
r
Address:
CONTRACTOR Name: �2/b f�aN/2 Phone:
Address: 6��' w�.s't'Vl P��''+ Y4-VA, N
Supervisor's Construction License: d-1 S�-(0 ( Exp. Date: — -3—b/3
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
Total Project Cost: $ f S FEE:
Check No.: �� Receipt No.: y�
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
nature of/Adent/Qwner Signature of cont acto �^-
-- - - -- -- --- r
Location F a/ � "'� '� ''�� s-
No.
! V / Date
�ORT� TOWN OF NORTH ANDOVER
F41
S
Certificate of Occupancy $
CH
u
s'• ttt' Building/Frame Permit Fee $
swcNs
Foundation Permit Fee $ � —
Other Permit Fee $
TOTAL $
Check # elf
2441. 4
Building Inspector
iJ I
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer Tanning/Massage/Body Art ElS��' mg Pools ❑
Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑
Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
i
PLANNING & DEVELOPMENT ❑ ❑
I
COMMENTS
CONSERVATION Reviewed on
Si nature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS - -
Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
G Water & Sewer Connection/Signature&Date Driveway Permit
tl
" DPW Town Engineer: Signature:
. Located 384 Osgood Street
FIRE DEPARTMENT -Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Town
NORTH
of
_ .
0
C' LAKE dover, Mass.,
�•
COC MIC 4/E WICK �
%d AERATED f` �
7 S BOARD OF HEALTH
Food/Kitchen
Septic System
PERMIT . T D
BUILDING INSPECTOR
THIS CERTIFIES THAT.....
............................... ...... . . ............................................................................................ Foundation
A �o
has permission to erect........................................ buildings on ........�C�.. . ........ �!`........5....... ........... Rough
14 1�,a(��,,,� --� Chimney
to be occupied as............. . .. ......:....... ........................................ ..........................................................
...
..
provided that the person accepting this permm 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 Construction of
Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS
ELECTRICAL INSPECTOR
UNLESS CONSTRUCTI S ARTS Rough -
...................... Service
BUILDING 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
Until Inspected and Approved by the Building Inspector. Burner
Street No.
SEE REVERSE SIDE Smoke Det.
Nlass:tchusctts- Depat-tmcnt of Public SJON
Board of Building Regulations arttl St.tntlat-ds
Construction Supervisor License
License: Cs 52671
THOMAS M CARROLL '
11 BAILEY RD l
ANDOVER, MA 01810
Expiration: 4/3/2013
t ommissiuncr
Tr#: 13406
f -
I
Dimension
Number of Stories:_Total square feet of floor area, based on Exterior dimensions.
Total land area, sq. ft.:
ELECTRICAL: Movement of Meter location, roast or service drop requires approval of
Electrical Inspector Yes No
DANGER Z®NE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA— For department use
El Notified for pickup - Date
Doc:.Building Permit Revised 2011 June/mi
J
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
Q Building Permit Application
o Workers Comp Affidavit
o Photo Copy of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
o Engineering Affidavits for Engineered products
MOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
.addition or Decks
❑ Building Permit Application
o Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (if Applicable)
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require.sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
o Building Permit Application
o Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
j ❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
MOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg .Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
nest be submitted with the building application
Doc: Doc.Building Permit Revised 2008mi
i
1
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER. DATE ISSUED. c2 0
ic
SIGNATURE: /vL ( ic
Building Commissioner/I for of Buildings Date Z
SECTION 1-SITE INFORMATION O
1.1 Property Address: 1.2 Assessors Map and Parcel Number:
4( (� a
11. 0� n V ,, r— Map Num Parcel Number
1.3 Zoning Information: �%( 1.4 Property Dimensions:
Zoning District 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: n
Public ❑ Private ❑ -Zone Outside Flood Zone 0 Municipal ❑ On Site Disposal System ❑
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M
2.1 Owner of Record
Name(Print) Address for Service:
2 7S-- .-1 I --
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service: O
Z
M
Signature Telephone M
SECTION 3-CONSTRUCTION SERVICES 70
3.1 Licensed Construction Supervisor: Not Applicable ❑
Licensed Construction Supervisor: O
A License Number
Address
i'
Expiration Date �
Signature Telephone r
3.2 egistered Home Improvement Contractor Not Applicable ❑ v
,�,✓ 20() F
Company Name 13 3 07r- M
Registration Number r
Wes 02�C Expiration Date `/�
Telephone V
r
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 Description 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: /
Ori f Bo,g 2 42 S %/eZ� -- Z-�Ct l✓�ti e� 5���/!J
SECTION 6-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollar)to be OFICIAIL USE{}NLy
Completed by permit applicant
1. Building (a) Building Permit Fee
Multiplier
2 Electrical (b) Estimated Total Cost of %000
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 authorized by this building permit application.
Signature of Owner Date
SECTION 76 W R/AUTHORI ED AJGENT DECLARATION
r
I, as Owner/Authorized Agent of subject
prope y
Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief
ZIA
P Na E' p
0 'D 2
Si attire of Owner/A ent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS IST 2ND 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
Location t-10 7 SYN dULt/Z
No J Y3 Date
�oRT►, TOWN OF NORTH ANDOVER
� s
Certificate of Occupancy $
4-1v
�'* s•a° E<�' Building/Frame Permit Fee $
�cMus
Foundation Permit Fee $
' Other Permit Fee $
TOTAL $ 140
Check # ( � /
16370 -
Building Inspector
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers'Compensation Insurance Affidavit
Name Please Print
Name:
Location:
I
I
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 em oyer providing workers'compensation for my employees working on this job.
Com an name: O
Address S V
City A40 (�(� /Z / / Phone#- a CCC/
Insurance.Co. Policv#
Company name: ,
Address
Cify Phone#
Insurance Co. Policv#
Failure to secure overage as required under Section 25A or MGL 152 can lead to-the wrgmition of criminal
penaihes or.a fine up to$1.500.00
and/or one 'i
Years mprisorurrent_as_vrell as_civil pmasJnlhelmnWaSJ9PYY9f2KDRDFR andf
a
- xre�_j,3]DA.OD)_aliatr,agsias3me. 1
understand that a copy of this statement may be forwarded to the office of Investigations of the DIA for overage verification.
I do hereby certify under Me pains and penalties of perjury&W the Mormabon provided above is true and correct
Signature pate
Print name Phone.#
Official use only do not write in this area to be completed by city or town official'
City or Town
Permit4kensinq
Building Dept
[]Check if immediate response is required p Licensing Board
El Selectman's Office
Contacterson:
P Phone#:
F, Health Department
Ei Other
I
♦ I
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 Perrnit
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
c 11, S.150 A..
The debris will be disposed of in:
(Location of acild,
Signature of Permit Applicant
Date
NOTE: Demolition permit from the Town of North Andover must be
obtained for
this project through.the Office of the Building Inspertor
Board of Building Regulations and Standards
One Ashburton Pface - Room 1301
Boston, Mas husetts 02108
Home Improvement-(contractor Registration
- Registration: 133221
z
4 Type: DBA
Expiration: 05/23/2003
KEOHAN ROOFING y
MIC-O,HAEL KEOHAN
54 ELM;ST. ---
N.ANDOVER, MA 01845
- Update Address and return card.Mark reason for change q
I-1 Address -1 Renewpl ---I F innlnvmPnt F--1 Los*Card
'HUDUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION,ONLY AND
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE
DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
T. r WARD INSURANCE AGENC` INC POLICIES 8ELOW.
403 FRANKLIN ,.STP.ELT COMPANIES AFFORDING COVERAGE
MELROSE MA 02176 COMPANY
LETTER
A HERMITAGE INS . CO.
-- COMPANY I3
' INSURED LETTER
mICHAEL KEOHAN COMPANY r.
LETTER
54 ELM ST COMPANY
LETTCR D
NORTH ANDOVER MA D104S COMPANY E
LETTER
�. �.�;•_• '.f••:i� v.P.r, 'T.�:,•;. nr.F,«^, ?,i�� :.e`1:1 JY•'J.!1•.'wi.:- - - ,
:Oti/ERAGEsi' :c,� -iji.:;� I:�f .n.: `r-91,.r�i.... '+,. � ?i: � :�{ n: ':�'•:: -
'I:atXf_ .i' ';>�i'i�t ::< = .tPJ .b d...�el`11C:�.,_: ••".`�'. ...J b....;• ':!ip-:^"r�Y ""THIS IS TO CERTIFY THAT THE POLICIES OF INSU;iANCE LISTED L�ELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED,NOTWITHSTANDING ANY REOUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY DE ISSUED OR MAY PERTAIN,•THE INSURANC:-AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL'FFIr• TERMS.
E-KCLUSIONS AND CONDITIONS OF SUCH POLICIC3. LIMITS SHC..'!N MAY HAVE BEEN REDUCED BY PAID CLAIMS.
U POLICY EFFECTIVE POLICY EXPIRATION Pr
TYPE OF INSURANCE POL.CYNUMBER .�'MlLIMITS
r q DATE(MODIYY) •DATE IMMJDDlYY) - ,
GENERAL LIABILITY GENERAL AGGREGATE S]- 000 , OOO
I_X_ COAIMCRCIAL GENERAL LIAOIL.I TY HGL4 3 E'16 9 05/20/02 05/20/03
PRODUCT scoMProP Acca il.`r 000 , 000
_-^ (CLAIMS MAOE OCCUR. PERSONAL b ADV.INJU[lY iS O O , 000
OWNERS d CONTHACTOH'S PROT. EACH OCCURRENCE f5 O O 000
—J FIRE DAMAGE(Any one luo) $50 000
MED.EXPENSE(Any ono p.*on) i] OH
O
AUTOMOBILE LIABILITY
COMBINED SINGLC S
ANY AIIT.l LIMIT
ALL OWNTD AUTOS -'
BODILY INJURY _
SCHEDULED AUTOS (Par pnrEon)
HIREO AUICS -
RY
NON•OWNCO AUTOS PCOoeCI aILY nO S.
GARAGE LIAHILIIY
PROPERTY DAMAGE i'
EYCESS LIABILITY EACH OCCUFTnENCE S
IUMORCLLAFORM AGGREGATE i
�OFHER THAN UMBRELLA FORM ( ��7 1' ' "'• ' '
WORKER'S COMPENSATION STATUTORY LIMITS a�•�'S.:;?! ;:';`'?:, !'..'
AND
EACH ACCIDENT S
OISEASE—POUCV LIMIT L
F.NPLOTERW LIABILITY
DISEASE—EACII EMPLOYGrs i
OTHER at I a
� F x� + f,•Y
SCRIPTION OF OPERATIONSILOCATIONSNEHICLES/SPECIAL ITEMS
:DOPING - COMMERCIAL
:RTIFICATE'HOL'Dfi I: :,`..- �:, til;-:.;_ c,v��a�•:
F7:; •.K: :.z;;.:'.�i. �-: .r:�.T:EA' CELS �yil.l Ti: 3" '• ra�r•:::;ILK +�I ;!)•.;I' :�• ,
•7 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE !
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
MAIL 1 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
LEFT. BUT FAILURE TO MAIL SUCH NOTICE SHALT. IMPOSE.NO:OBLIGATION OR..
LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIV
2S'S / :' ?=s• y s i i f,..�:; ;y..�• 4 r ). ; �• r' �; :+ f
�. 1:.• •E r.�st"..s::,�.'rC•.cct<•r....:�Ie:•:....k; .•:�7�,'� :1!,r :1• .I_ et
TOTf4L P.01
NOTICE OF ASSIGNMENT
EMPLOYER: MICHAEL KEDHAN DBA KEDHAN ROOFING COMBO I.D. STATUS OF EMPLOYER
54 ELM ST 000004064 Individual
NORTH ANDOVER, MA 01845
COVERAGE GROUP
0004064
The Waiver of Our Right to Coverage under this assignment
Recover from Others Endorsement applies__to. Massachusetts
is available on Pool policies. operations only. For coverage
Contact your agent for details. outside of Massachusetts, contact
the -appropriate Pool or Plan for
that state.
AGENT T F WARD INS AGCY INC INSURANCE COMPANY:
OR 403 FRANKLIN ST TRAVELERS INDEMNITY CO
PRODUCER: MELROSE, MA 02176 MS JACKIE DENNIS .
P 0 BOX 3556
ORLANDO, FL 32802
(800) 443-4404
AGENCY FEIN:042895924
CLASSIFICATION OF OPERATION CLASS ESTIMATED RATE ESTIMATED
CODE TOTAL ANNUAL PREMIUM
REMUNERATION
ROOFING-NOC-& DR 5545 $0 33 .29 $0
EMPLOYERS LIABILITY 100/100%500 9845
LOSS CONSTANT 0032 $50
STANDARD PREMIUM $50
EXPENSE CONSTANT 0900 $122
. RISK MINIMUM PREMIUM 0990 $500
ESTIMATED ANNUAL PREMIUM $500
DIA ASSESS. 4.5% OF STANDARD PREM. $17
EST. ANNUAL PREM. PLUS ASSESSMENT $517
INSTALLMENT BASIS: Anniial REQUIRED DEPOSIT PREMIUM $517
COMMENTS
Coverage effective 12 :01 AM on 02/26/03
DATE OF NOTICE: 02/.27/03 PREPARED BY: Joanne Shea
EXT 530
* * SERETIGING-7 C2LT IER ASSIGNMENT
LETTER ID: 378353 COPY: EMPLOYER
The Workers' Compensation Rating and Inspection Bureau of Massachusetts
101 Arch Street - Boston, MA 02110
(617)439-9030- FAX(617)439-6055-www.wcribma.org
NORTH
Town OE - / Over
0 vM.rw ..V.yr4•' j �'
No. � '�
h �9►-�00
o� COCHI': y dover, Mass., S 3
ADRATED PP��
BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT.... ..... ........C./o..�.! ..re. .............
.t ........................................................... Foundation
A
has permission to erect...S.f 69 1 g .1 14...... 4 V'�,r^
........................ buildings ....... ... . Rough
to be occupied as � Ird R�..4..�v ........................ Chimney
p' ...................................................
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 th Inspection, Alteration and Construction of
Buildings in the Town of North Andover. ^ PLUMBING INSPECTOR
4244136 sio
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
PERMIT EXPIRES IN 6 MONTHS Final
UNLESS CONSTRUCTION ST TS ELECTRICAL INSPECTOR
C Rough
............................................................................ Service
00
/01* BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
SEE REVERSE SIDE Smoke Det.