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Miscellaneous - 41 COPLEY CIRCLE 4/30/2018
41 COPLEY CIRCLE 210/046.0-0098-0000.0 Location �l/ "- ! ►� No. "�� Dateof g00tTh TOWN OF NORTH ANDOVER F w 9 a y + i Certificate of Occupancy $ 9 Buildin /Frame Permit Fee $ s+cMuse Foundation Permit Fee $ Other Permit Fee $ _ TOTAL $ ft6• y~ Check # r^e"10 Building Ins, TOWN OF NORTH ANDOVER r BUILDING DEPAR'TMEN'T APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING . D&3 00 BUILDING PERMIT NUMBER: DATE ISSUED: � X SIGNATURE: Building Commissioner/I for of Buildings Date SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Nu—"- C 19 l� Map Number - Parcel 0 Nuber 1.3 Zoning Information: 1.4 Property Dimensions: Zoning DiAric—t Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided R red Provided t \� 1.7 Water Supply M.GL.C.40. 54) 1.5. Flood Zone Information: 1.8 Sew a Disposal System: Public Private ❑ Zone Outside Flood Zone Municipal On Site Disposal System ❑ SECTI N 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT HistoriC District Yes_No M I 2.`1_Owner of Record _ LA Name rint) Address for Service r . -�A k I r� r Sign a Telephone 2.2 Owner of Record: Name Print Address for Service: z Signature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction �Supervisor: Not Applicable ❑ Licensed Construction Supei o�� y�3 U_( �� License Number VdressExpiration Date Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number rM ddress z � S4�_ Expiration Date M "V Ap� Signature Telephone 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 all appficable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant 1. Building C , (a) Building Permit Fee v' Multiplier 2 Electrical (b) Estimated Total Cost of Construction _3 Plumbing Building Permit fee(,) 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, S u`t l I ,as Owner/Authorized Agent of subject property Hereb authorize 1��Z t-x,sd. !? to act on , My b alf,in 11 ma r relative to worta�morized by this building permit application. �� St ature of Owner Date -SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, `C- '`✓v- 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 Si a e of Owner/A ent Date NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINIBERS 1 t J 2 3 SPAN / DIMENSIONS OF SILLS t- DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION ` THICKNESS SIZE OF FOOTING kk X 2 t MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE i � r i F ter?�''.�'� /� • 169 Boxford Street �'�i :i' I i �vm^� 1 �, North Andover,MA 01845 • PH:978-UB-W36 Building Contractor FAX:978-U8-7207 Proposal To: Sue Willis&Dora 41 Copley Circle Al Home tmprovernent Contractors and Subcontractors engaged In tome improvement contracting,unless North Andover, Ma. 01845 specifically exempt from registration by Provisions of Chapter 142A of the general Iaws,must be registered with the CommornNealth of Massachusetts.Inquiries about registration and Status should be made to the Director,Home Improvement Contract Registration,One Ashburton Place, Frmnw Kevin Murphy Room 1301,Boston,MA 02108.(61 7-r727 8M cc: Date: 2/14/2004 .lob: Half bath in basement Date of plans: 11/03 Architect: none 31 Z( V Location: same • Section I-Work Schedule Contractor will begin the work or order the materials before the third day following the signing of this agreement, unless specified here in writing contractor will begin work on or about 311/04. Barring Delay caused by circumstances beyond Contactors control,the work will be completed by 4/15/04.The owner hereby acknowledges and agrees that the scheduling dates are approximate and that such delays that are not avoidable by the Contractor shall no be considered as violations of this agreement. Section 11-Warranty The Contractor warrants that the work furnished hereunder shall be free from defects in materials and workmanship for a period of 1 year following completion and shall comply with the requirements of this Agreement. In the event any defect in workmanship or materials, or damage caused by the Contractor, his subcontractors, employees or agents, is discovered within one year after completion of any job, including cleanup,the Contractor shall,at his own expense,forthwith remedy,repair correct,replace,or cause to be remedied,repaired,or replaced, such damage or such defect in materials or workmanship. The foregoing warranties shall survive any inspection performed in connection with the agreed-upon work. r , ' five Page 2 of 4 MU2141 oV ca=t aCUM 169 Buxford street North Andover,MA 01845 PH:9786865335 FAX 97668&)000( Section 111-Scope of Work —� We hereby submit specifications and estimates for work to be performed and materials to be used: Building Frame materials will be provided to build half bath in existing basement. Bath will be approximately 5x8. Plumbing Plumbing required to add sink and toilet will be provided.An allowance of$300 has been included for fixtures. Electrical Electrical work required to add fan/light,gfi plug,vanity light will be provided. Heating/Air Conditioning No allowance has been made to add airconditioning in bath .Heating will be provided from existing system. Plaster Bath walls will be plastered,ceiling will be suspended? Interior Trim/Doors Interior trim will be provided to match existing. Bath door will be provided by contractor. Closet door to be provided by owner. Painting Painting will be provided by contractor,colors to be determined by owner. Flooring Bath floor will be tiled.An allowance of $300 has been included for file material. Waste Removal All construction debris will be disposed of by contractor. Items Not Included There has been no allowance made for vanity/countertop. ma AMj rnm=L n4'y Paae 4 of 4 ` mutu mg Ca *VO=*av 169 Borfford street North Andover,MA 01845 PH:978566-5335 FAX 978688-XXXX Section IV-Price Schedule We hereby propose to furnish material and labor-complete in Accordance with above specifications for the sum of... ... ... ... ... ... ... ... ... ... ... ....$ 11,500 Payment to be made as follows: Percentage/item Description Amount 1 bathroom framed $3000 2 plastering complete $5000 3 job 100% complete $3500 Total 3 $11,500.00 '"Notice:No agreement for Home improvement contracting work shall require a down payment(advanxe deposit)of more that ore-third of the total contract price of the total amount of all deposits or payments which the contractor must make,in advance,to order andlor otherwise obtain delivery of special order materials and equipment,whichever is greater Contractor: Kevin Murphy 169 Boxford Street No.Andover,MA 01845 Registration No: 101874 Section V—Acceptance Acceptance of Proposal—I have read this document and accept the prices, specifications,and conditions stated. I understand that upon signing,this proposal becomes a binding contract.You are authorized to do the work as specified. Payment will be made as outlined above. You the buyer may cancel this transaction at any time prior to midnight on the third business day after the date of this transaction cancellation must be done in writing O NOT SI(N THIS CON RACT IF THERE ARE ANY BLANK SPACES I< � Signature Date G Signature Date The Commonwealth of Massachusetts Department of/ndustlial Accidents Office of Investigations Boston, Mass. 02911 v= Workers`Compensation.Insurance Affdavit Name Please Print Name: 1�. `- Location: mc �-k City K j z. Phone # -J0 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 worldng on this job. Comnanv name: Address t b _D 5��.�-�. QW, r.. -�' Insurance.Co. C ��-�` } Pa' # )-,VL., CornwM name: Adds: . Insurdnce,C,.o. . Paicvr.� fear'tiue to seo"co vwage as required wider Sermon 2M or MSL 1512 carrteait tdttre i ipos"i%*C1i i/wal=ponamm 4:arfine andtor ane years'hryxiaairnent:es s�i,peana�les�os6etomQ�ot��Ii 1tR �e�# L���F :a understand that a copy d this statement may^be forwarded to the orrice of fines igations ef the DW for wwerage verrcauon. dohereby thepains of Me' proMedaboveistrueandcor►ect Signature Ike U Print name �e,,,•� /�. Phnns �li?-S-3� (17 Of xia! use only do not write in this area to be campleted by city or town driewr City of Town dna. ElCheck Y nm►edkde response is requked ❑ S�/eC�77aty': Contact person: Phone 4. (� ktealth Dep t] 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: (Location of Facility) WZA ignature of Pe Ap licant Qate • NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector tAORTH Town of Andover 0 W No. S71 dover, Mass., WaW /Oro o LAK COCHICHEWICK A ��S RATED )`" U BOARD OF HEALTH Food/Kitchen M Septic System So • BUILDING INSPECTOR PER IT T D THIS CERTIFIES THAT .... .......... ......................................................... IFoundation -A-A has permission to erect........................................ buildings on ... ....................... ............ ........... . ................. Rough Chimney to be occupied als. ........ ............................... provided that the ;;rsoWacc�p6�iiiis permit all in every r ct conform' to the terms of the application on file in Final r1w. this office, and to the provisions of the Codes and By-Laws Got ng 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 N 6 MONTH'S ELECTRICAL INSPECTOR UNLESS CONSTRUCTION T S Rough ................................................................................................................ Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough 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. Date. . .I. . `. . . NORTH TOWN OF NORTH ANDOVER 00 MW PERMIT FOR PLUMBING SSA�Mus� This certifies that . .t- . . . . . . . . . . . . . . . . . z" has permission to perform . . �.`.�`�.."S �' T. . .a ` S` l plumbing in the buildings of . . . t�`' at . . . y (. . . C, o .. . . ., North Andover, Mass.r Fee.3?.• Lic. No.J.54U. . . . . . PLUMBING INSPECTOR Check # 2 ( MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO DO PLUMBING CITY/TOWN i °int ,�, APPLICATION DATE: JOB ADDRESS: w Q J .�..., �" �" C�_� -�.,,�: PLANS SUBMITTED: YES NOF] POCCUPANCY TYPE: COMMERCIAL RESIDENTIAL NEW ALTERATION ._........ REPLACEMENT REMOVAUDEMOLITION:.... t PLUMBING: PIPING—FIXTURES-FIXED APPLIANCES—APPURTENANCES 7 ENTER TOTAL AMOUNT FOR EACH SELECTION(LIMITED TO FIVE(5)NUMERALS ALTERNATIVE TECHNOLOGY DISPOSER SINK: MOP SERVICE ASPIRATOR DRINKING FOUNTAIN STERILIZER DRAIN: AREAD EJECTOR ❑ STORAGETANK BACKWATER VALVE O EMBALMING U AUTOPSY H URINAL BAPTISM:FONTO SACRARIUM FOOD CHEST MISTING SYSTEM VACUUM DRAINAGE SYSTEM BAR SINK GLASS WASHER WATER CLOSET E-7:1 BATHTUBLJ WHIRLPOOLL] ICE MAKER WATER HEATER:ALL TYPES I BIDET INTERCEPTOR:ALL INTERIOR C J� WATER PIPING: �] CROSS CONNECTION DEVICE KITCHEN SINK T OTHER NOT LISTED 7 DEDICATED: ACID WASTE SYSTEM LAUNDRY CONNECTION 1 E== DEDICATED: GASIOIUSAND SYSTEM LAVATORY 0 DEDICATED: GREASE SYSTEM PIPE RELINING WORK ONLY [ DEDICATED:RECLAIMED WATER ROOF DRAIN DENTAL FIXTURE 1 EQUIPMENT SINK: 1-2-3 BAY PREP. DISHWASHER SINK:CLINIC F]FLUSHRIMO = � PLUMBING INSTALLER—FIRM-COMPANY INFORMATION CHECK ONE ONLY NAME:I .�. a. y :�� ADDRESS: t /- e` Corporation Business#� �e �� i I = — - Partnership Business#C�� CITY: �� o „ � ,..�...., STATE: . ZIP: _w,[��G-�.�,..C,�. _,.,..� ( ..___. ---- D LLC Business#E-- � TEL: i. .7 FAX: EMAIL: - IPIBA 1 Unincorporated NAME OF LICENSED PLUMBB017F3616-61 id ER: LI--- -- -V—o1 C.19 P`con3� 'S 7 INSURANCE COVERAGE 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' dicate the type of coverage by checking the appropriate box below. A liability insurance policy Other type of indemnity Bond El OWNER'S INSURANCE WA ER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that signatur o t ' er it application waives this requirement. CK ONE ONLY OWNER AGENT Signature of Owner o�r1 ner's_Ag-M OWNER'S NAMETEL:I ..__ "_.. e__... — FAX: 1 hereby certify that all of the details and information I have submitted(or entered)regarding this permit application is true and accurate to the best of my knowledge.I certify that all plumbing work and installations performed under the permit issued,will be in compliance with all pertinent provisions of the Massachusetts Uniform State Plumbing Code,and Chapter 142 of the General Laws. (Opct ICE USE ONLY) TYPE OF LICENSE: Permit# 'ff Npumber ] Signature of Liced9d Plu r Inspector S 1/ ❑Master `— License Number: ...... .9.,�i..( , Fee: 3 ASU Pourneyman a ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES COMMONWEALTH OF MASSACHUSETTS LICENSED AS A JOURNEYMAN PLUMB ISSUES THE ABOVE LICENSE TO:'' - ' EDWARD A CASE 113 CRYSTAL LAKE RD U)l HAVERHILL MA 01832-1062 -05/01/12 - --,981662 19612 + C 7 u ,_ Date. . . . . . ... .. ,apRTN TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION SACMUSE� This certifies that . . has permission for gas installation . .r v rAc . . ?c�?o? in the buildings of . .i�.1 .-?.:�. . . . L.J. L C�;4, ( . . . . . . . . . . . . at .�1.�. . !?�.��. . . . . . . .t.�.. . . . . . . . . , North Andover, Mass. Fee 3P o J . Lic. No.0� 4—. .4- i, C. .: y GAS INSPECTOR Check# 6; MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO DO GAS FITTING CITYITOWN: 1._--A-T J9-Ad STATE:MA APPLICATION DATE: .o ` JOB ADDRESSI a OCCUPANCY TYPE: COMMERCIALE] RESIDENTIAL PLANS SUBMITTED: YES D NO[:] NEW[] ALTERATION REPLACEMENT REMOVAUDEMOLITION[] T- NATURAL&LIQUEFIED PETROLEUM GAS:PIPING-EQUIPMENT-APPLIANCES-SYSTEMS 7 ENTER TOTAL AMOUNT FOR EACH SELECTION(LIMITED TO FIVE(5)NUMERALS AIR ROTATION UNIT FURNACE: ALL TYPES TEMP HEATING EQUIPMENT BOILER:ALL TYPES GAS PIPING F THERMAL OXIDIZER BOOSTER GENERATOR(STATIONARY ENGINE) TURBINE BROILER ILLUMINATING APPLIANCE UNIT HEATER BURNER: ALL TYPES INCINERATOR WATER HEATER: ALL TYPES CO-GENERATION UNIT INDUSTRIAL AIR HANDLER { EQUIPMENT OVER 12,500MBH COFFEE ROASTER INFRARED HEATER rOTHER NOT LISTED? COOK APPLIANCE HOUSEHOLD KILN 1 GLORY HOLE/CRUCIBLE COOK APPLIANCE COMMERCIAL LABORATORY COCKS DECORATIVE APPLIANCE MAKEUP AIR UNIT DIRECT VENT APPLIANCE MECHANICAL EXHAUST EQUIPMENT DRYER: ALL TYPES OVEN: ALL TYPES FIREPLACE:VENTED I UNVENTED POOL HEATER FRYOLATOR ROOF TOP UNIT FUEL CELL ROOM HEATER-VENTEDNENTLESS PLUMBING/GAS FITTING FIRM INFORMATION CHECK ONE ONLY Corporation Business# � ADDRNAME• ESS: , C3QS't�l/� p�C� y,,. ... .�. -- -- ------ -------- - r--- __ - -.— -- Partnership Business# CITY: __t a..s/d�2_ !�_ll_.____- __... __ __ STATE: MA ZIP. I _ _-. _ _ ___._ !! ___ ._. LLC Business#�---^� b TEL: �'�__ D -1 FAX:L � EMAIL:I ,-„,____.__,,,„,—_ PPBA 1 Unincorporated NAME OF LICENSED PLUMBER/GAS FITTER: INSURANCE COVERAGE have a current liabilit insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES® NO If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy Other type of indemnity Bond El OWNER'S INSURANCE W ER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that w&signature on this permit application waives this requirement. . ^ DQ. HECK ONE ONLY OWNER AGENT ignature of Owner or Owner' Ag t _ OWNER'S NAME:T .Q.��►.... e uC--P06A--- TEL: FAX L_._._._._..___-- I hereby certify that all of the details and information I have submitted(or entered)regarding this permit application is true and accurate to the best of my knowledge.I certify that all plumbing work and installations performed under the permit issued,will be in compliance with all pertinent provisions of the Massachusetts Uniform State Plumbing Code,and Chapter 142 of the General Laws. (OFFICE USE ONLY) Type of License: Permit# �� s lumber 0 Gasfitter Inspector ❑Master urneyman Si ature of Licensed Pl er/Gas Fitter fro � LP Undilute Installer License Number: --,�- -_ Fee: � � Limited LP Installer ROUGH GAS INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES Date............/............... . NOR7M °`< °;•�"� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING SSACMUS� This certifies that .....................:....................:................................................. has permission to perform :.:..................................................... wiring in the building of . ................................................................................... at...:....................... .............":.............................. ,North Andover,Mass. a Fee �.�................ /Lic.No/.`<.'`:.. ���.......... ... ".:.. ELECTRICAL INSPECTOR a Check # r ' � i) :: �) 1 Commonwealth of Massachusetts Official Use Only Q�- " Permit No. r� Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leaveblank 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 PRINT IN INK OR TYPE ALL INFORMATION) Date: ///Z> /10 g( 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) c/ Ctit, Owner or Tenant Sp.SLJ-1 Ij,s Telephone No. Owner's Address / n ole Cc ti Is this permit in conjunction with a building permit? Yes F'rNo ❑ (Check Appropriate Box) Purpose of Building �Ps �-- Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: i 9001L /42/ktvc 6 Completion of the ollowin table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceff.Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators K-VA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting rnd. rnd. Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pump Number Tons KWNo.of Self-Contaed Totals: """ ..................... inDetection/Alerting Devices r No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start:����a$� Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liabili nsurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cov ge is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: E.A .7'njc - LIC.NO.: �7y��A- LIC. 411--aa- ,,,L- Signature c_ LIC.NO.:/7 (If applicable, enter"exempt"in the license number line.) Bus.Tel.No.: l07 Z Address: P o. 3�l MhPr�i- /(Jf}. 63,0-3 / Alt.Tel.No.: Co 3 5P46 *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: 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: The Commonwealth of Massachusetts Department of Industrial Accidents Dee of Investigations l. i• 600 Washington Street Boston, MA 02111 tai www.ntass.gov/dia . Workers' Compensation Ins tranee Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information qq Please Print Legibly Name(Business/Organization/individual): Address: P c)_n b l & City/State/Zip: #A54- N D3d�l Phone #: . (moo 3 679 `S3 Z Are you an employer?Check the appropriate box: Type of project(required): I.l�-Yt am a employer with y 4. ❑ 1 am a general contractor and 1 6. ❑New 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• 23-1 odeling ship and have no employees These sub-contractors have 8. Q Demolition working for mein any capaci workers' comp. insurance. h'� 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.Q I am a homeowner doing all work right of exemption per MGL 1 I.Q 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 boz#l must also fill out the section below showing their workers'compensation 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. ;contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their worker;'comp.policy infnmtation. I am ann employer that is prcgviding workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ' 1/1 #4A4- 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 5250.00 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 c under the pains and penalties of perjury that the information provided above is true and correct SignatureGZ Dat Ill'-146s- Phone D 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 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-contractor(s)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 cavy 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 permittlicense 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 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 Investigations 600 Washington Street Boston, MA 02111 Tel. #617-72.7-4900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia Date,.. . ,C. . . . .1. MOR7H tiTOWN OF NOR ANDOVER p� ,�•o y sp ° PERMIT FOR PLUMBING i SACHUS� f This certifies that ,�; az�C . .�''�l c ...`�. .'=1. . . . . . . . . . . " has permission to perform � !J�. . . . . . . . . . . . . . . plumbing in the buildings of .��. . �!. . .f-l.��... . . . . . . . . at .f f . . ����lt. G !z L. . . • • • • • • . • •, North Andover, Mass. Fee. .�� r.Lic. No.. .-�� Dor . . . . . . . . . . . . . . . . . . . . . . . . ;� . . . r PLUMBING INSPECTOR Check .N �L) MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Date -A-�1-�,-Or� Building Location 1- e,� 6j f G Owners Name C' `� _n cA -2(4l L Permit# -IjAmount Type of Occupancy New Renovation Replacement Plans Submitted Yes NoEEC ❑ FIXTURES z � Cn F W a x � F� x z Q w x � wW 3 a A H a A a a ca M HIO(R 1 M FLOCIR M FLOCIR 4M FLOCR 5M 1AOCR 6M FLOCR 7MRD R M H-0m (Print or type) Check one: Certificate Installing Company Name c)C-2— �c..\,U, ;�5�-� (�uw► J Corp. ' Address a Gb 1 ���c A c7 W�5 O Partner. U usmess Telephone (9-7%) Firm/Co-. Y Name of Licensed Plumber: RJ t-()"— Insurance Coverage: Indicate the!Xpe of insurance coverage by checking the appropriate box: Liability insurance policy 1_.:.1 Other type of indemnity 11 Bond ❑ Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Musetts State Plumbin and Chap 42 of the General Laws. By: Title Type of Plumbing License .��a�� City/Town cense um er Master ❑ Journeyman APPROVED(OFFICE USE ONLY The Commonwealth of Massachusetts Department of Industrial 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 Legibly Name(Business/Organization/Individual): !�ojc_pJ /�/M�r.hc•� �,� r �s� ��� �``�k Address tom" City/State/Zip: Phone.#: Are you an employer?Check the appropriate bog: 1.❑ I am a employer with D I 4. Type of project(required) oyees(full and/or part-time). ❑ I am a general contractor and I l —* have hired the sub-contractors 6. ❑New construction 2. I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-con-tractors have g, ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition workers' comp.insurance comp.insurance. required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doingall work officers have exercised their 11.El Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL insurance required.]t C. 152, §1(4), and we have no 12.E]Roof repairs employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeow:ens who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractorshave employees,they must provide their workers'comp,policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#:' Expiration Date: Job Site Address: �- c .�C, City/State/Zip: Attach a copy of the workers' compeAsation 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 Investiations of the DIA for insurance coverage verification. I do hereby certify under the pains and pen of perjury that the information provided above is true and correct Si afore: Date: Phone#.: Officia6 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 61.,Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership, association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the.occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"ever state or local licensing agency shall withhold the issuance or renewal of a license or permit to,bperatte-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 fm the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary, supply sub-contractors)name(s),address(es) and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC) or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. ' Please be sure to fill in the permittlicense 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 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: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 604 Washington Street Boston,MA 02111 Tel.#6.17-727-4900 ext.406 or 1-877-MASSAFF ` Fax# 617-727-7749 Revised 11.22-06 www.mass.gov/dia + Date. NORTM TOWN OF NORTH ANDOVER O� 1ti '• O PERMIT FOR PLUMBING • � M SSACNUS� � M This certifies that . . . . / has permission to perform . . . plumbing in the buildings of . . . . . . . . . . . . . . . at . . . . . . .(dy. . `. . . , North AndovSr, M Fee. Lic. No,v c 0-3. . . . . `\ G:��-� PLUMBING INSPECTOR �f• j�r Check # J MASSACHUSETTS UNIFOR APPLICATION FOR PERMIT TO DO PLUMBIN (Type or print) NORTH ANDOVER,MASSACHUSETTS l r Date Building Location Cri �2 G Owe Name `� ��C Permit# F or Amount 3 y1ccupancy Type of New Renovation Replacement Plans Submitted Yes No ❑ FIXTURES H cc w ` SWESW >�afNr / ]S>C FLOOR H1= �m FLOOR 4IH FLOOR 5M FLOOR 6TH FLOOR M FLOOR 8M FLOOR (Print or type) r Check one: Certificate Installing Company Name L G�i/t n"IC/f �) 0 Corp. Address Partner. 24 Business Tee one ? p 19--firm/co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity 11 Bond Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner F1 Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massac etts`8 e P i g 26 Md Chapter 142 of the General Laws. By: SignaTure or mcenseaum er Type of Plumbing License Title City/Town77-cense IlumSer Master ❑ Journeyman APPROVED(OFFICE USE ONLY Location /Jr � No. LS Date 0 EE "CRT" TOWN OF NORTH ANDOVEN Cf 0? • , ` OOR A Certificate of Occupancy $ Building/Frame Permit Fee $ a 4"Q ACMUFoundation Permit Fee $ JSE --� Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ —o TOTAL $ Building Inspector 4 =� Div. Public Works Lot 1 Location P-2—J, No. - Date -. 0 o, OLD ti TOWN OF NORTH ANDOVERa O? +'' _ "•• ods r „ Certificate of Occupancy $ 0 Building/Frame Permit Fee $ Foundation Permit Fee $ � sic usa Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $e'q- !� Y a V- l Building Inspector Div. Public Works Location � '�q r Date W f HORTM, TOWN OF NORTH ANDOVER „ Certificate of Occupancy $ }"^°+799 Building/Frame Permit Fee $ Eta Mus Foundation Permit Fee $ s�c .� Other Permit Fee $ Sewer Connection Fee $ d Water Connection Fee $ /a-??- } TOTAL -Buil tor ryrr i^ * Diy Pu orks x. u PERMIT NO. � �� APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 MAP K40. I LOT NO. 2 RECORD OF OWNERSHIP IDATE BOOK :PAGE — •ZONE SUB DIV. LOT NO. �+G� LOCATION 4 Od �4//}} / rC p //7� // PURPOSE OF BUILDING S �Q ZcdB, OWNER'S NAME ©�/ u{ �TC�jy/ ,J � � BASEMENT ORNO. OF LAB � SI �� v b / o OWNER'S ADDRESS 1- ^l y,,A_ Ink, ARCHITECT'S NAME /, {b SIZE OF FLOOR TIMBERS IST 2ND �. k`v 3RD BUILDER'S NAME Via' L J 4 lam ' SPAN DISTANCE TO NEAREST BUILDING I• L/ N}� DIMENSIONS OF SILLS DISTANCE FROM STREETrr]J iT POSTS 7 DISTANCE FROM LOT LINES-SIDES /l ) REAR GIRDERSa- 'AREA OF LOT /.X ")� 3 FRONTAGE /}r-T HEIGHT OF FOUNDATION J �j THICKNESS /D ` IS BUILDING NEW y 5 SIZE OF FOOTING ,71 �j �f X sf� IFS BUILDING ADDITION J ��/ MATEWAL OF CHIMNEY sax r (J IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND So/j d WILL BUILDING CONFORM TO REQUIREMENTS OF CODE s IS BUILDING CONNECTED TO TOWN WATER K e-5 H BOARD OF APPEALS ACTION. IF ANY ,�/ /� IS BUILDING CONNECTED TO TOWN SEWER l Y,e S IS BUILDING CONNECTED TO NATURAL GAS LINE t -es INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST /. n/ (/7v SEE BOTH SIDES PERMIT FOR FOUNDATION ONLY -EST. BLDG. COST I(as PAGE 1 FILL OUT SECTIONS i - 3 REGULATED BY PARA. 114.8-S. B.C. EST. BLDG. COST PER SQ. PAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER ROOM DATE FEE PAID �-_' SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING c4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS a� �V PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILEDy�(/ ��/ / ILDING INSPRCTOR SIGNATURE OF OWNER OR AUTHORIZED EN Q F E E O�O ^ OWNERTEL.N C- PERMIT FOR FRAME/BUILDING PERMIT GRANTED CONTR.TEL.# 19DATE: . ._FEE PAID CONTR.LIC.# ��, H.I.C.N L.S.t'."_'�PERNJIY (-OGG— =� ({(M�(1JFE�!�'p(�f� RUE f Wi'iCX PERN,IT 8, r u CW) BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY sroRIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES _ LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION I 8 INTERIOR FINISH CONCRETE _ B 1 2 .I3 CONCRETE BL K. PINE _ BRICK OR STONE HARDW 0 PIERS PLASTER _ _ DRY WALL UNFIN. 3 BASEMENT AREA FULL ` •FIN. B MT AREA _ '/, 1/1 '/, FIN. ATTIC AREA NO B M T FIRE PLACES' _ HEAD ROOM MODERN KITCHEN 4 WALLSI 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE X �_ WOOD SHINGLES EARTH _ ASPHALT SIDING HARD"J 0 ASBESTOS SIDING _ COMI,ICN VERT. SIDING ASPH.TILE _ STUCCO ON MASONRY _ STUCCO ON FRAME- BRICK RAME-BRI K ON MASONRY ATTIC STRS. & FLOOR _ BRICK ON FRAME CONC. OR CINDER BLK. STONE Of4 MASONRY WIRING STONE ON FRAME _ SUPERIORPOOR _ ADEQUATE I NONE 5 ROOF 10 PLUMBING GABLE I HIP BATH 13 FIX.) _ GAMBRELMANSARD TOILET RM. (2 FIX.) FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE _ FORCED HOT AIR FURN. TIMBER BMS. &COLS. _ STEAM STEEL BMS. &`COL& _ HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS FE AS I L ....r-...�.r..� B'M'T 2nd _ LECTRIC - r 1st 13rd I O NORTH Town of r 4Andover A No. 134 _ -- 41 y vrt lover, Mass., Ts -- 19'�V COC HICHE.WICK A � ORATED PPa\ �GJ BOARD OF HEALTH ' Food/Kitchen PERMIT T D Srpric System .............. ------------ [3U1LllINC: INSPECTOR CERTIFIES THAT. .4 -SZU1`1 ,... �?#�5►.1.1a ....� C.�t�... ............................. ` .• Foundation ....�� has permission to erect.t�QGX�...��fl�°. buildings on ..4..I....��apc-,�.`(••-•�=��.•••.-..•-.•••-•••• Rour �.-••••••• �,h to be occupied as?ieikst 1 ,..���(h14�. Ss 4 ....,Z.�A�R. •... 4R�Ila+l .......................I............. chimney thprovided that theecce ting this permit sAhallineve rasped conform to the terms of tho application on file in };in,ai is 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. PERMIT FOR FOUNDATION ONLY PLUMBING INSPECTOR REGULATED BY PARA. 114.8-S. Q.C. VIOLATION of the Zoning or Building Regulations Voids this Permit. 1kough �p � dRi-FEE PAID � ? Final PERMIT EXPIRES,IN 6 MON-[*I . cELECTRICAL INSPECTOR UNLESS CON8TR C��I 1 S ~ Rough `���G /............ .. .., Service 00 BUILDING INSPECTOR F• ��� �Q Occupancy Permit Required to Occupy Building Qti�6 SPECTOR Display in a Conspicuous Place on the Premises -- Do Not Remove P,� ? gal No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. TIRE DEPARTMENT Burner PLANNING FINAL CONSERVATION _ —FINAL Street: No. Smoke Det. SEWER/WATER FINAL DRIVEWAY ENTRY PERMIT • FORM U — WT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ************C * t ***Applicant fills out this secion***************** APPLICANT: Phone ' LOCATION: Assessor' s Map Number Parcel Subdivision ( , Af- S5r0k72 (�/�-0SSIP1 Lot(s) Street CD G St. Nu::tcer 41 Use RECOMME2TDAS O TO AGE 2ZTS: Date Ancroved Cons ration Ad::inistrator Date Resected Cc=ert5 ri 9 r8ag=" Date Approved IaAq Town Planner Date Rejected Coru ser.:s Date Approved Fcod :nspec=_-r- ealth Date Rejec=ed Date Apprcve•d Sent_c 1nsne=.,_-He3_t:: Date Rejec:e_ Corner. Puh=-c Wcrt:s - se:aer,'water connections _ �� zz1/�-g� - dr'_veway pernit � -� —�,J Fire Decarzment Received^,by au' lding Inspector Data E — OaC.V SIt�C6 QFST�/GT/O�/ N � O � 1 � tia Po bb. 00 'do i S A/"65)" CE.cT/Fy 7V Tye T/T(_E 1A1SelXO C ANO �` or T1J -Ale BAN,r T.s�gT T,yEOwEGt/.�t/3'LG�c'ATEO Oc/ M6,447110 /IV IY/T/1 Tii/E�•"'� Of/�.�4.�/�" ZON/.vG ,c�E6�/GAT•t9,t/S ,QLr6rI�C0/.t�, JE7'�.IC.t'S OZOM STPEETS f LOT U•t�ES."' /�lQ �N�a yE,Zc+ 5$ LOG4TE0/S/ T ETFEGIE�G FiC� H Z•O O A.PE oT ��A�✓/� /FDiP ' S�1awk O/V FfMA' COMMI/�/�rY P.�NGG '� COeB�,sJTo.vf CeOSS/NG' ZSGb98 G�3 e �EVECO•oin�. OATE,p G/�/9,3 C'a,eP. O.47W HUMANN � e 'o #36381 90f6 °Q os� 1wellP ��`yTGy'o'0� ANODYE� �1.4S.S.4�,�1/SETTS O/8/D Location `-l' No. � -"�- Date A Is N°RT" TOWN OF NORTH ANDOVEFf p Certificate of Occupancy $ zu • + Building/Frame Permit Fee $ ,ssACMUSEt Foundation Permit Fee $ Other Permit Fe� L'y� $ 2IU Sewer Connection Fee $ a+ Water Connection Fee $ —T TOTAL $ . J UL.- �. � Building Inspector - Div. Public Works �rory.ti KAREN H.P. NELSON or' °`n Town of 120 Main Street, 01845 Director NORTH ANDOVER ' (508) 682-6483 BUILDING • •;'Ss•c E`4y. CONSERVATION DIVISION OF HEALTH PLANNINGPLANNING & COMMUNITY DEVELOPMENT CHIMNEY APPLICATION AND PERMIT DATE PERMIT # ' � r LOCATION OWNER' S NAME a BUILDER' S NAME MASON ' S NAME MASON ' S ADDRESS MASON ' S TELEPHONE � d��, MATERIAL OF CHIMNEY INTERIOR CHIMNEY EXTERIOR CHIMNEY NUMBER AND SIZE OF FLUES dg:��0,�– THICKNESS OF HEARTH /e2 Will chimney or fireplace conform to requirements of the code and have rules and regulations been received: DATE z � SIGNATURE OF MASON .moi- s- CONT . LIC. # EST. CONSTRUCTION COST/CONTRACT PRICE f PERMIT GRANTED dt", — F E Z�/ " ROBERT TA, BUILDING INSPECTO(,4,a � A�� INSPECTED I�.�'£'� REMARKS SOLID BRICK REQUI_RED THIS PERMIT MUST BE DISPLAYED ON THE PREMISES ' Town L NORTIy of An; er No. 134 l 0 dower' Mass. 'Pel _ lg 19C`r T O •- LAKE �, ' COC M ICKEWICK V ,9 ADRATED BOARD OF HEALTH 1 PERMIT T D Food/Kitchen {� Septic System g BUILDING INSPECTOR01 r THIS CERTIFIES THAT. .4���1`1 ..... .... ►�.11��b►..... ...�.1�►Cr'R�. ............. "" Foundation i has permission to erect.S,)=...Mft . buildings on ..4..1....CaPUL- ....cu=ka................... ••••19 Rou t 4%v Cot L, -- t0 be Occupied a8.. l . �. ... �4 ......� ....Z.i�AL....4"94 .«.................................. Chimney 3 thprovided that the ersoh acceptin this etmlt shall In eve respedtconform to the terms of the application on file In 7 is office, and to the provisios of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings In the Town of North Andover. PERMIT FOR FOUNDATION ONLY PLUMBING INkPEPR REGULATED BY PARA 114.8-S. B.C. /1,7;VIOLATION of the Zoning or Building Regulations Voids this Permit.PERMIT EXPIRESINS 6 MON \ FEE PAID • ` cS2) ELECTRI INSPE OR UNLESS CON8TR CTI TS ' oug U �C`1. PERMIT FOR FRAMEAUILDING •.. ............... .. . ....... .... ..•.... .... ...... Service BUILDING INSPE OR na 7� ! !3 'HATE: E PAID• ccu ancy Permit Required to Occupy Building GAS INSPEC R Rough Display in a Conspicuous Place on the Premises — Do Not Remove No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. Burner FIRE EPA RTMENT - PLANNIKGrff t�a INAL CONSERVATION AW 05Af`A treet No. g Smoke Det. SEWER/WATER FINAL DRIVEWAY ENTRY PERMIT ''� CERTIFICATE OF ,. USE & OCCUPANCY Town of North Andover, _ + • � - �3� Building Permit Numberq� Date THIS CERTIFIES THAT I . 1 r THE BUILDING LOCATED ON v MAY BE OCCUPIED ASg�", �-T-• �� ��� �� 2�� �Q• IN ACCORDANCE a WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND ! SUCH OTHER REGULATIONS AS MAY APPLY. r , CERTIFICATE ISSUED TO 04 4 e "��� ` '� ode ADDRESS '133 Manrc� s CH.* � Building Inspector ' ���ACNUb� . ae.��':s.-.r..+W-:sW+oyt.. +,fY ?rlf� ..� ..,..-- - - - __ „ .. ,- ..a ,.. �....s�.. ......ww «na..a•.+.v..:::..r.....r.. -_ , •"• ...•......--.3:.,,��,,,,..�.. .._. .vr`w+�.d'^'� y., `� ,�"�..� `� i�J � -..,.-.. .s��. �` r ' r .t - { ,e�. `t �r�V�1 Rr 7���>•r"7�S �� s�� a { � .G ti{.r. ' � � g ,..�r c k�...�•' " ,. 1" r t t � s, it .. ( tir E! � 1 Location 'No. ` Date 01NORTH TOWN OF NORTH ANDOVER t.. o , +.y0 ` Certificate of Occupancy $ Building/Frame Permit Fee $ suMusE Foundation Permit Fee $ Other Permit Fee $ TOTAL $ / Check # U Building Inspector t TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TOCONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING T1gIS, i6mki'd utlt VIII _... BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: C Building Commissioner/Ifor of Buildings Date SECTION 1-SITE INFORMATION I.1 Property.Address: r, 1.2 Assessors Map and Parcel Number: �tP ot.A. Z � t Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zonmg District Proposed Use Lot Areas Fronts aft) 1.6 BUTLDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Re 'red Provided a�'e �JD� 1.7 Water S W tvt.G.L.C.40. 54 1.3. Flood Zone Infomution: 1.8 Sew Disposal System: 1� uPp. ) Sewerage Dns sal S tem: Public ❑ private ❑ ZO°e Outside Flood Zone ❑ Municipal ❑ On Site Disposal System SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT rn 2.1 Owner of Record Name(Pont) Address for Service I (� Signature G� --�—� Telephone 2.2 Owner of Record: (� w 1/V b Name Print Address for Service: O z ii nature Tele hone M iECTION 3-CONSTRUCTION SERVICES ,a 9 t.I Licensed Construction Supervisor: F[icense e ❑ .icensed Construction Supervisor: cito-3:30 O -7u � ' w� 1��� ` � �G� � er dd,ess d Expiration Date gt�fa.�ir Telephone 2 Registered Home Improvement Contractor Not Applicable ❑ 0 ?(ry LJ 4-- (7c, )mpany Name t 1.91 Zp V Sp Registration Number '..� (d re Expiration Date ^ ;nature Telephone Y 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....:.X No.......0 ffSECTION 5 Description of Proposed Work check all applicable nstruction/k Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. 0 Demolition 0 Other 0 Specify Brief Description of Proposed Work: l s -N IZ—, C. wc` f 5 k s3 i C m , SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be �� ,z fi$ Hca Completed by permit applicant 1. Building !,/ (a) Budding Permit Fee `� Multi lier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(,a)x (b) 4 Mechanical HVAC 5 Fire Protection 6 Total (1+2+3+4+5) i4/p Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR.CONTRACTOR APPLIES FOR BUILDING PER I, �f�S-,— l� r 4 i S as Owner/Authorized Agent of subject property Hereby authorize �"�^� -i Pis,A S + �g `y to act on M- ,If in al�tt�ela iv 'to r authorized by this building permit application. i nature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION R 1, CA 1-2 as Owner/Authorized Agent of subject properly Hereby declare that the statements information on the foregoing application are true and accurate,to the best of my knowledge and belief _ n Print Na Signature of Owner/A ent ( Date "N�O. OF RIES SIZE EBASEMNT OR SLAB SIZE OF FLOOR TlIVIBERS OT 2 ND3 RD SPAN Mv1ENSIONS OF SILLS D[vIENSIONS OF POSTS DIIvtENSIONS OF GIRDERS I ff IGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CI-IIIvvINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE FORM - U - LOT RELEASE FORM 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. ............................................................................ APPLICANT6"s ^ l(.3 PHONE ASSESSORS MAP NUMBER ro LOT NUMBER SUBDIVISION Pmf Ce/ �� LOT NUMBER STREET Coeler cle STREET NUMBER OFFICIAL USE ONLY ............................................................................ RECOMMENDATIONS OF TOWN AGENTS ..... ..................................................................... DATE APPROVED 7 X CONSERVATIONADMINLS TOR DATE REJECTED COMMENTS No G72NWs1:, /0�7' o� prr,/��ed rjvwev � '?00, toC& gip', s �/2�•J 0 A fR � & w 0 s a reR ��v� iu�� J✓ y DATE APPROVED C E I!� E T 9 / DATE REJECTED 0 � COIR IVIENTS ✓ Cl a n ( �v►�1 SVNORTH ANDOVER /t,, -Tel 61UZC/c�CPLANNIN6 DEPARTMENT DATE APPROVED FOOD INSPECTOR-HEALTH DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPARTDffiNT DATE REJECTED CONVIIVIENTS RECEIVED BY BUILDING INSPECTOR DATE a The Comrrlonwealth of Massachusetts d Department of Industrial Accidents Office of investigations Boston, Mass. 02111 Workers'Compensation Insurance Affidavit Name Please Print Name: ��SCtvt LJ Location: CiPhone # q N-- 0 67 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. Company name: U.vl -E-- c, Address7D Sb tt. �Y-b ti City: v ?�- 6��- (f.3k� Phone#- Insurance.Co. G`N�' mss' Go - Policv# L D /931 ?Z. 3 0 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 weU-as_civil.penattiesin-theloun of-a-STOP]NORK ORM2-and-afine_o(-$1110-00)-a dW against-me f understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature Date P fid. d 3 Print name r) 1 / Phone.# - Official use only do not write in this area to be completed by city or town official' City or Town rising � Check if immediate response is required Building Dept .0 Licensing Board p Selectman's Office Contact person: Phone#: ❑ Health Department Other r " s DATE ACORD CERTIFICATE OF LIABILITY INSURANCE Fad� oi il�� PRODUCEn THIS CERTIFICATE IS ISSUED A;A MATTER OF INFORMATION ONLY AND CONFERS NO FRIGHTS UPON THE CERTIFICATE C.J.McCarthy Insurance Agency,Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR C/O Piazza Insurance Agency,Inc. ALTER THE COVERAGE gFFORDfaD BY THE PQLiCIES BELOW. One Elm Square, Andover,MA 01810 INsuRED _ INSURERS AFFORDING COVERAGE NAIL# INSURGR A: CNA Insurance •C Cos. ... Fatnil 9907.8 & Patio Inc. INSURER 8: American Inte,�ational Orou B 11 Cindi Gianopoulos INSURER C; 7 S, Broadwayy Lawr&nce MA OZ8,13 IN$UAERD: - INSURER SURER E: THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO TK INSURED NAMED ABOVE FOR TWE POLICY PERIOD INDICATED.NOTvVITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERT71CATS MAY R;ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED 13Y THE POLICIES MCRIM HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF•SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAV;REFN REDUCED BY PAID CLAIM$, INSR D'r6ENEFAL _. LTR NSRNSURANCE POLICYNUM9flR L1GYCr XP i LIMITS ATE IMNMMD Y DATE M1 Y A GePIERALLIABILITY 01098398230 I EACH OCCURRENCE 614Q0000 _ 12/31/02 12f31/03 p�REMI9C8 �acwren 9100000 _ ADE OCCUR$2K MEDEXP(Ahy onePersn) $10000 PeREONAL&AOVINJURY $1000000 Addl --ins. I —•-• GENLA013REOATELIMITAPPUIESPtR GENERALA0GRt0 T, $2000000 -- POLICY X JE LOC PRODUCTS•COMPIOPAGG $2000000 AUTOMOBILE LIABILITY A ANYAUTD '1'Bb 12/31/02 12/31/03 co1.IalNr;pSINGLELIMrr S 1000000 (Ec-Odent) ALL OIANEDAVTO6 __... X SCHEDULED AUTOS lO CIPLeY INJURY X HIREDAUTOS X NPN-OWNED AUTOS BODILY INJURY S T (Per acxideM) PROPERTY DAMAGE (Pern=ident) $ GARAGE LIABIUT'T AUTO ONLY-EA ACCIDENT S ANY AUTO — OTh THAN .• •'EA ACC` 8 A ONLY: AGG 1.3 EXGESSIUMBRELLA LIABILITY EACH OCCURRENCE S OCCUR C�CLAIMS MADE Ii AGGREGATE _ S DEDUCTIBLE _ 6 RETENTION S _ S WORKER¢COMPENSATION AND $ 8 EMPLOYERS'LIARtUTy TO Y LIMITS ANY PROPRIETOP/PARTNERlEX6CUTTVE BINDER I 12/31/02 12/31/03 E.L.EACH ACCIDENTT: .•"'', $100000 OFFICERIMEMBER EXCLUDED? i I y��deneribeunCer F.L01SEASC.PAE,IGIptOYE 6100000 SPE�,IP,L PROVI910NS below •. OTHER E.L.0:$WE-POLICY L IMIT s500000 i DESCRIPTION OF OPERATIONS!LOCATIONS I Vri iii ES!EXCLUSIONS ADDGD IaY CCN°ORSEMEN:1 E F 11Ig4 PROVISIONS For Informational purposes only, CERTIFICATE HOLDER CANCELLATION NOMORT+ SHOULD ANY OF THE A DC,SCRIBED POLICIES gE CANCELLED BEFORE THE EXPIRATION DATE THEREOF.TME ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAY$WRMM NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO$0 SHALL IMPOSE 110 OBLIGATION OR LIABILITY KM UPON THP INSUR91%ITS AGMM OR REPRESENTATIVES, AUTHOR 2E.REPRESENTATIVC AC ORD 25(2001108) The Piazza Ins, e r U.MCCarhy llf8t>fS11C0 RATION 1888 TA(Ifal WT Tli: i CUT V77{iTI CtYliRliAl& VVI 17'AT TV.7 (•A/!T/TA 91te -� Board of Building Regulations and Standards One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration i r Registration: 11.8204 Type: Supplement Card i Y, Expiration: 2/13/2005 > F FAMILY POOLS & PATIOS INC t F - GLEN WIGGIN. 70 S. BROADWAY LAWRENCE, MA 01843 Update Address and return card.Mark reason for change. --. .... ---------- - -- - __. -. . E] Address ❑ Renewal � Employment r-] LostCard ---- -- -- - - - - \ 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 BuildingRegulations and Standards Registration 118204 g Expiration 2/13!2005... One Ashburton Place Rm 1301 JyPe_'Supplement Card Boston,Ma.02108 FAMILY POOLS&PATIOS GLEN-WIGGIN I t 70 S.BROADWAY LAWRENCE;MA 0.1843 Administrator Not valid without Atnje -- r liv 1t7i 1'' „>1.1�IntdF.dt§.4 'kd •. fip i�++ 3`Yrh lAs�� Wr Pp R+, HIM15w2x3S` j},+5{5{5�`�,76,.���`�� �tt11Si § d�.f�!a-�r7``f�r,.�''� "� r�'Y�++� � A. ■1, -1 IN 7e'.t k4gi �hI`�-f'�.r�6✓-�� ' f�,,4,x ..,�tr y�; fJ fII -i nl .1�.,r`4vJx ''•�'�t L.d...tir,,c�� � �� � a "RE �, �f7tat ,r„rt,. • E ITI >s�-lip, An ,tom �z �����ti..F4(�1 4 g;�'Sr"Z���Y�"urr. i �Fy� } tiS fah. • .,�7 2�ar�l�v�� fad. N.yr y r • 1 • we Y x P • itu�,ri F • e g4g' at ',3n �aF-�'i� �d f r�, i�•4�'1� 6���r�Ytf c s Y �r _ - .r 4 �t9s ,,,r } f+uorr� d gI e'4 amx j t.; h 1. ' t 3 r it f 4 � 2 N lot milli a r_ A —TC r 8-8'Plain Panels(08-009-5) 3.4'Plain Panels(08-016-5) 2-Y Plain Panels(08-0185) E--�-r--F---��-G N 4-7 Rodas Corners(08-141) x 111umbwik Braces(OS-214) SIZE A t3 C D E F G H K 1-Steel Hardwom Kit(08-204) :N6r ti' 32' r r4' r t4'. 5'i' 4'i' 4•i' 8 4. 1-16x32 Straight Coping Set 6'Radius(10401) e+meo•aarwe , 1-2'Rodes Coping Corrmr Set(10-138) roalsloaallo. li 32' 5'6' r4' r 14' S'i' 4'6' 4'6' r YY -Daryl[bier(See options below) ■ 6'Step-Remove 1-(08-009-5)8'pone(and snreuna-E 1-(0&016-5)4'panel insert 1-(01-006)6'step, 2408-017-5)3'panels and 1-(08.214) * turnbuckle brace. PANM '4'• < 8'Ste Remove 5)8'pa„ d p-Rem a 1-(08-004- elan 1-(08-016-5)4'panel Insert 1-(01-002)8'step, PLATE 2-(08418-5)T panels and 1-(08-214) turnbudde brace Y-r�xc�rrE 0.�� � 5 "" - Replace 4-8 � Y c��,,►'t� �•._ : • K 1-$'skuoraap 108-009-5)rritb h srM (OB-011-5) k , �' :1.f Z °�5 ate' 2-8'inlet pm els(OB-010-5) a s F a�rN►.� . :._ r, w xa s K -8'light panel(08412-5) • -fi r t w 1 ` ate?, r kfl�r e ate , ".L .�n'" ; 4r; a'�`�"E^•Y, 'N" '�Sr'�i& - .; M-=1``k�``��t ?" t. ,t..: k •e QV_ a� N r � 7 NSPI TYPE its "•'g� arm: ,� .�."r rT,,l ��.�3'' `ke- � c+�s•` yhf„x��.'_ � � i, ;..a�� �.. i h�t'#`�: SS $,„�}a a1S � ..a�-� $,;',-'rF'' i. `�'£ -�% +.s- "' 'tom Fitt',c-"'.'' - - z� ta" ;,•- x s f cr: TOPAZ"- STERLING,;sM STONEiITF 103-P03=� ' 103-R03- IN NONDMNG�WlERS ,�.,� :.rw+rn+»eD�ei.ri:�°'r�pyie.rrtieiu�e•rf'P�9�vie.id�dbrFwl:ii...de���edtei. - 4 _ ,:�,� H-6(03�R40.2) I-8103-P40• 8.14(03-H40= .. �*,�•a• �<�,t- ,� g� •°" $ .. g� �� • �1C1QM1B.r�1�pRpR�tlLidlAi1V_ErL1VO5F50►11C�-��_TMw�� "�"��� FOITMATI�IOOLS®/I���g-"�` �¢zw Tim.44 rsr .b1�ldsse) xi fM�poL .isho.�daib... n CJs � � _ �f Spe� y6sli.orswnWEIDb.rd<..hiir.pada tr1 t'1�► i�A.w..�/�m agp�d...r.uwra.ie�d.'irw�drrd � s+.ar+�i.r!•� �..iiiad.e ow -.�..-.�,.�- aePri b.�s.im+r.ls iirress ad it Newad i r.S!�7+r• �`•+ p �.. roman.ss. ruwu.'�iaiw..+ardo��prsbisoiy 6e�ad► � r�cA�r�rali�� ww►.l►.cwra+.a x���".�-:��` PF - ., rW - .. ... ,,,,: "�.1. .' �` rid••on rr.poor. fvr iPramoiai� .- �•irii.w.....- alwj:wiyr swde" ;..,wTs., , a r .1.11...11 ' '.•, ;.. ..vldmdi,.wir:4loliaed Sao i Pool 4P,.!dawifrr''°9w:.ws' .aa+.�.irr....�dl •rte A+.u•.A6--Kfi e.VA 2231A 7031C31-0OS7� •.�iiedii'..".. •= ii�j�i�y�yi�.oi..p./i „'�; s� ;w; _ _ '_'.. ��y�.. •� .:., 1'+--f:ns .� ,y� ,. :,� w•�4T.�*^'•,ava+,.z� -1y�s, -. .�,N«,�se'�. _ Y ,.':: .,.�. - ,•,+ '�: ,; �-. �� ,-����i� i�w5. °moi��,'{,��� ' '�,.-�,'. - ,L,s uzi..- ..m.--yr.+sun-a3dv�+ar J3•eRrerr�e:c na. .> '�. _ y��� - •� 4. ! `�'. 4 w"..1A�`a?F.:' �y .� ,tf+ - Y' '-.. l• R � IP7E ..4 NORTH Town of Andover No. s7 o o dower, Mass. — _a7S e d/40 3 COCHICM K ADRATED PPPS S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System V 19 rJ '� r` �I e.. ..a..b BUILDING INSPECTOR THIS CERTIFIES THAT.................�.N..... 1.��. .4......"D.........a....E.1.... . . q n .. ...................... Foundation has permission to erect..t....[� .f �..... buildings on....41....CO.M.M.Y.....` ......` .................. Rough to be occupied as.....I..N.4.n0 V 0 b P1001 J N WN104 4.� ^ 0 Chimney .................................................. ............................................ . ..................... provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this officeand to the provisions of the Codes and By-Laws relating to th Inspection, Alteration and Construction of , Buildings in the Town of North Andover. 4 (0/ 418 144 y C ® PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRU ON T TS ELECTRICAL INSPECTOR g 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. DATE: SCOTT L. GILES FRANK S. GILES II RECEIVED MAY 12, 2003 -- - ---- --_ FRANK S. GILES Al! 2 4 2003 REVISIONS: r �_ JUNE 21 2003 SURV EY= E q"' ' l H NORTH ANDOVER JUNE 24, 2003 50 DEERMEADOW ROAD �3��� PLANNING DEPARTMENT SCALE: 1 INCH- 0 FEET 5 , �d � NO. ANDOVER, MA 0184.. o' a°' 40' TEL: (978) 683-2645E�A q�app° 2 l4e3 E-MAIL: FrankGilesSurvey@attbi.com M�Y ? , 2003 THE ZONING DISTRICT IS PRD (R3� PLOT PLAN OF LAND LOCATION 41 COPLEY CIRCLE NORTH ANDOVER, MA PARCEL 103 PREPARED FOR SUSAN WILLIS s 73 11,353 MAP 46 ss.07, PARCEL 98 LOT 19 AREA= 0.296 AC. MAP 46 10, icy► \ LOT 18 o. � ,�/ � • '/;' � s Ssoo PARCEL 97 OPEN SPACE AREA I Qd �'?, f ro, 000 111_1 , I / L I,r L_L Cb 20.11 LL; :11_LL _ _Ll(: J I_.I_I „ 16 . i vl bo I c17 � I I L y i L i 4.17_i / 101 -1 LI v PROIOSED. L � 2 p [ o ADDluON— q-L OLl 9 COPLEY CIRCLE l ^ 4 e i /A,y•. f N I W �G 10.02` 79.101 --- N 89°44'33`F• LEGAL REFERENCES SUBJECT PROPERTY o ' - H V' COPLEY MAP 46, PARCEL 98 CIRCLE ELGUEZABAL, DORA A& SUSAN M WILLISCol3BLE SII E 41 COPLEY CIRCLE NORTH ANDOVER, MA. 01845 G ROAD R1N SEE PLAN 12330 @ N.E.R.D. CIIlCKE BK. 4728, PG. y LOCUS NTS C:\CLIENTS\W1L.LIS SUSAN\PERMIT PLAi,.DRG Date. . .f. .�. .? . ,,ORT" OR': TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 3ACMUSE� This certifies that . . . . .. .C . . . . . . . . . . . . . . . . . . . has permission to perform . . .f .—i r. . l f .,. . .1".i'!'�. . ../. .r�.�...-.c. . . . plumbing in the buildings of . . . . . . . . . . . . . . . . . . . . . . at. . . . t./. ! . . S , North Andover, Mass. Fee.3.) . . . .Lie. No.. .7.: :. . . . . . . . . . �4_. . .L. . . .v. PLUMBING INSPEC OR Check # �juJU MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) / NORTH ANDOVER,MASSACHUSETTS Date Building Location �I GU ��� ��'r Owners Name < 4 P ��!��S Permit#----" Y �— Amount Type of Occupancy New Renovation ❑ Replacement ❑ Plans Submitted Yes ❑ No ❑ FIXTURES En CA Up. SUAHVIE R4S9VFNT 210 RDM ° 3MFIUR 4M FUM 5MFLaR 6IH RaR 7M EjaR gm HDQ2 rmYorCheck one: Certificate � ]� J C Installing Company Name ': �' ✓ / ' ` c h�R�C� ( ) ❑ Corp. fG Address ❑ Partner. c Business Teleph ne l /` / Fum/Co. Name of Licensed Plumber: �c`Gl9/� r/I� (-Opti Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above threeinsurance Signature Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massa to Code and Chapter 142 of the General Laws. By: igna o icens r T e of Plumbing License Title j City/Town tense iNumDer Master ❑ Journeyman APPROVED(OFFICE USE ONLY LJ Date....a.)..��..�.C. 3 ' HORTM 3?°; -1"°0. TOWN OF NORTH ANDOVER PERMIT FOR WIRING 41 I o SACMUSEt i This certifies that .... ..........:....I ..0................................................. has permission to perform PC-. i ........ ....... ........................................ ...... ..... wiring in the buildingf of...v���.....:..�..................�..`�..�.�e..z... .. �. ....... at.....�t4?. .1.:�..`.�.....C..'..?� ,North,Andover,Mass. Fee.. .. .... Lic.No..!. .�.� .......:7... `'r`::.!!A...:1��..:........ ELECTRICAL INSPECTOR Check # t �� '; 7 _ Official Use Only 1, i Permit No. 7' 2M C09119140ALW01F5 t",4CHVSE2TS / (Department ofrnu6Gc Safety Occupancy&Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12: APPLICATION FOR PERMIT TO PERFORM E CTRICAL WORK .All work to be performed in accordance with the Massachusetts EI 'cal Code 5527 CMR 12::00 ? (Please Print in ink or type all information) late To the Inspector of Wires: Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location(Street&Number �T�Ptl t1f Owner or Tenant..7 U SA, "c? Owner's Address Is this permit in conjunction with a building permit Yes 11� No 0 (Check Appropriate Box) Purpose of Building 'P, S //�-2A C-rG Utility Authorization No. Existing Service Amps Voits Overhead 0 Undgmd 0 No.of Meters New Service Amps Voits Overhead 0 Undgmd 0 No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work /!/!Lid P7,-� Total No.of Lighting Outlets No.of Hot fuse No.of Transformers KVA Above 0 In 0 No.of Lighting Fixtures Swimming Pool gmd 0 grnd 0 Generators KVA No.of Emergency Lighting No.of Receptacles Outlets No.of Oil Burners Battery Units No.of Switch Outlets No of Gas Bumers FIRE ALARMS No.of Zone Total No.of Detection and No.of Ran es No of Air Cond Tons Initiating Devices Heat Total Total No.of Diposal No. Pumps Tons KW No.of Sounding Devices No./of Self Contained No.of Dishwashers Spaceorea Heating KW Detection/Sounding Devices 0 Municipal 0 Other No.of Dryers Heating Devices KW Local Connection No.of No.of Low Voltage No.of Water Heaters KW Signs Bailases Wiring No.Hydro Massage Tuds No.of Motors Total HP OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES O% NO,0 have submitted valid proof of same to the Office YES C% NO 0 If you have checked YES please indicate the type of coverage by checking the appropriate box INSURANCE 0 BOND 0 OTHER 0 (Please Specify) Q _ (Expiration Date) Estimated Value f Ele rical WU� Work to Start — 9 Inspection Date Resquested"� —,2 Rough Finaly Signed undertheAenattleyof perju . FIRM NAME G/ r E' ✓ -c LIC.NO.1_?kk -Q Licensee Signature LIC.NO/� ./ � s.Tel No. c Address fc2L c/��C" 4✓� -s/ /�'i�Y1P56►•✓'C///<�0�� Alt Tel.No. "��✓� 45�� OWNER'S INSURANCE WAIVER: 1 am aware that the Licelfses does not have the insurance coverage or its substantial equivalent as required by Massachusetts � General Laws.And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) Telephone No. PERMIT FEE $ (Signature of Owner or Agent) Date.. .. . . ... . ... . . .... . NORTH TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION �9 h gs,SSAC HUSESA This certifies that . . . . . .l. . .e . . . .'.. . . . . . .:. . ... . . . . .. . . . . . has permission for gas installation . . . . . . . . . . . . . . . . . in the buildings of . . . . . .i. . . . .a. .. .? . . .. . . . . . . . . . . . . . . . . . . . . at . . . l. . . . . . ... . . : . . . . . . . . . . .. North Andover, Mass. Fee.":.. . . . . . Lic. No.. . . . . . . . . . . . . . . . . . . . GAS INS9EM6R Check# c. . a -" u MASSACHUSETTS UNIMRM APPUCATON FOR PERMIT TO DO GAS FITTING (Type orprint) Date NORTH ANDOVER,MASSACHUSETTS BuildingLocations 1_ ` C t�� Permit# _ kV,Vd j��� Amount$ ��_- Owner's Name (6, New❑/ Renovation ❑ Replacement ❑ Plans Submitted ❑ Z a CL F E' z0 x W o o � F C GE. z d x N o c 0 W 3 c a SUB-BA SEM ENT BASEMENT ]ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH . FLOOR 5TH. FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . FLOOR Name or�) /-�..- %/[G/, .9�'1.� C�one: Certificate Installing Company C/��S Corp. Add r s ❑ Partner. 3 Business Telephone 0--Fnm/C0. Name of Licensed Plumber or Gas Fitterc +/ m e ;--- IN COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes � No❑ Ifyou have checked yes,please in tate the type coverage by checking the appropriate box- Liability ox Liability insurance policy Other type of indemnity 0 gond D 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 ❑ Agent ❑ I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under permit Issued for this application will be in compliance with all pertinent provisions of the Mass ach a ode an ha ter 142 of the General Laws. By: ❑ Signature of Licensed Plumber Orfitter Title Plumber -,/> �4 City/Town ❑ Gas Fitter Liceifse Number ❑ �M!aster APPROVED(OFFICE USE ONLY) ' �j/JOumeyman Date.... ............... :�........ t ,%ORT", 3?°•�e "�,� TOWN OF NORTH ANDOVER PERMIT FOR WIRING �SSACMUS� w r This certifies that ....:..................:.::....... r ................................................... has permission to perform : :.. .." 1. .................................................................. wiring in the building of......................,........ ?................................................ at... ......................:6n:.................. ................... ,North Andover,Mass. Fee A, ................` Lic.No............1.'.............:........................... ::..,:�............. ELECTRICAL INSPECYOR Check # 1., 6 J Lommonwea(1A of h1'/adgachude/t9 Official Use Only Permit No. (P 2epartmenl'I��]f Seire ruicej Occupancy BOARD OF FIRE PREVENTION REGULATIONS p Y and Fee Clte ke _ [Rev. 11/99] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC).527 ChiR 12.00 (PLEASE- PRIN"TININK OR TYPE-ALL ilY ORMATION) Date: 3 City or"Town of: To the Inspector of 1Fjres: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) �• � �C it Owner or Tenant S(l� '� /' Telephone No. ' Owner's Address Is this permit in conjunction with n building permit? Yes ® No ❑ (Check Appropriate Box) Purpose of Building le 1 we tliIn Utility Authorizalion No. Existing Service Amps 1 Polis Overhead ❑ Undbrd ❑ No.of rlfeters New Service Amps ! Polls Overhead ❑ Undgrd ❑ No.of;Meters: Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work:Won �. Completion of the olloni,rc table may be n-aive(/by the h4cctor or Wires. No.of Recessed Fixtures ' No.of Ceil.-Susp.(Paddle)Falls No.of Total Transformers KVA No. of Lighting Outlets No.or ilot"rubs Generators KVA No.of Lighting Fixtures Swimming Pool Above ❑ iii- ❑ o. o mergeuc} tg ttmg b und. rnd. Batte Units No.of Receptacle Outlets. No.of Oil Burners FIRE ALARIIIS No. of Zoites No.of Switclies •L� No.of Gas Burners No.of Detection and • Initiating DeviTotaces No.of Ranges No.of Air Cond. Tons! No.of Alerting Devices No. of Waste Disposers Heat pump Number. PonsK1V No.of Self-Contained Totals: DetectioidAlertino Devices No.of Disltit•ashers Space/Area Heating Kti\' Local ❑ 1v1unicipal ❑ Other Connection No.of Dryers Ileating,Appliances K\V Security Svstelns: No.of Devices or Equivalent No. of!Vater «, No.of No.of Heaters ■{ Dat.^.1\'irittg ir Sins Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total IIP Ielecommunications Wiring: OTHER: No.of Devices or E uivalent ` . Attach additional detail if desired,or as required by the Inspector of;vires. INSUPL NCE COVEIUIGE: Unless waived by the otivner,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 sucli coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INS RANCE U1 BOND ❑ OTHER ❑ (Specify:) .S;e: 'TY S s-Eln ic61 SSI - Estimated Value of Electrical Work: (When required by municipal police.) (Expiration Datc) Work to Start: Inspections to be requested in accordance with IvIEC Rule 10, and upon completion. i certify, under the pains acrd penalties of petjur)•,that the information oil this applicatiolr is true azul complete. F110I NAME: LIC.NO.: Licensee: fl;t,K r, Signature LIC.\0.:3 ,0 - (if applicable, enter "ereurpt'•in rhe license number lime.) Bus.Tel.No.: 0 ' 7S Address: ILl Gky Ston A.fl $G(/�Sf/S �j9 �� r\]t.Tel.\o. 4l` Q- OWNER'S INSURANCE \VAIVER: I am aware that the Licensee does not have the liability insurance covera�e normally required by la��. By my signature below,I hereby waive this requirement. I am the(check onc) ❑owner ❑ Owner's agertt. Owner/Agent ` Signature _ '1•elephone No. FPj--Rj111TF-E-E: S A .,; Date..S...Z.. 0.�.. NORT►, TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,SSACMUSE� This certifies that .......W.:. has permission to perform .......!�..A .... ........?.I r� j:........................... wiring in the building of 1)c> rrk. 'E l G U z I A A I t `i I C d Q , C �................. .North Andover,Mass. Fee... .-3.�... Lic.No. r �J ELECTRiCALINSPECTOR Check # + a7 THEC0A M0Ar9 I -LTHOFA1ASSACHUSE7TS Office Use only DEPARTNffATOFPUBLICWMY permit No. BOARDOFFIREPREVEIVHONREGUT4HIONS527CAM]2:Gb.f Occupancy&Fees Checked APPLICATIONFOR PERMIT TO PERFORMELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL40DE,527 CMR 12:00 �y L (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date C/ Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described bel W. y Location(Street&Number) �"/ cop/� y f�r r ` I Owner or Tenant ��rQ I L UeZ C', fbc.l 50&—,V\ L 11;C Owner's Address 1") coN-Y C- r Is this permit in conjunction with a building permit: Yes© No (Check Appropriate Box) Purpose of Building ��� yv�,�-� �Wp.\�w�C Utility Authorization No. Existing Service Amps / Volts Overhead Underground = No. of Meters New Service Amps / Volts Overhead Underground r--J No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work 0Ux,VN ihom No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total KVA No.of Lighting Fixtures Swimming Pool Above BelowGenerators KVA round round 4 No.of Receptacle Outlets ` No.of Oil Burners No.of Emergency Lighting Battery Units No.of Switch Outlets ^ No.of Gas Bumers No.of Ranges No_of Air Cond. Total FIRE ALARMS No.of Zones Tons No.of Disposals No.of Heat Total Total No.of Detection and Pumps Tons KW Initiating Devices No.of Dishwashers Space Area Heating KW N9.,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 )THER- s WMFCoverage.PtuanritmthetequffrentsofMassachuscmcvr)CdLaws iawaammLmbihtykwrmxPOhqinckxhngGDMP]eteOP=hcnsCovaaWOrZ&IstanUapvakit YES NO iavesubmmdvandptoofofsametothe0ffia-- YES r7p IfyouhavechededYES,pleawindicato the typeofooverageby erla<lg the box. tSURANCEBOND OITIER (Please Spey) Expiation Date EsWroled Value ofEbcftical Work$ odctosw InspactionDaleRape ted Rough Final 7ledundertr Rn*esofpajtny: ZMNAME LiceiseNo. ensee I� `'� CCy Sigr>am Li�No I a BushmTel.No. "7g/ g t/t-/ Xp0 dress li �G V S 1.2 Q �9U 6 Alt.Tel.No. 782 — � _'3 i1NM'S INSURANCE WAIVER;I am aw&e that dr Lim does nothave the lns2uarxe coverage orits sural Nuivalent as reWted by Massachusetts C>emal Laws that my signAm on this pcimit application waives this reg�t ease check one) Owner ® Agent Telephone No. PERNJIT FEE$ rgna ure o wner or gen U The Commonwealth of Massachusetts d Department of Industrial Accidents Office of Investigations .� Boston, Mass. 02111 Workers'Compensation insurance Aff1davit 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. Company name: Address City: Phone#: Insurance Co. Policv# 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..penattiesinfheformnfa..STOP WORK_ORDER.and_ofiine_of.(.$1D0.00)._adayagainst me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature Date , Print name Phone# Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing Building Dept ❑Check if immediate response is required p Licensing Board ❑ Selectman's Office Contact person: Phone#: F-1 Health Department r Other 1 Location + No. ' i Date NORTH TOWN OF NORTH ANDOVER 0 •. 1 • pw A ` Certificate of Occupancy $ yea••^•''<�' Building/Frame Permit Fee $ f a,+ca,se -, Foundation Permit Fee $ Other Permit Fee $ + TOTAL Check # Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING W1$Seetwo ft►1-UAI Use UII BUILDING PERMIT NUMBER: n Q DATE ISSUED: - _j Q© 3 X ic SIGNATURE: Building Commissioner/inspedor of Buildings Date Z SECTION i-SITE INFORMATION O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: r Map Number Parcel Number (', 1.3 Zoning Information: 1.4 Property Dimensions: V Zoning District Proposed Use 3 T~ Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided R aired J Provided l ZQ 1 2U 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Se erage Disposal System: Public Private 0 Zone Outside Flood Zone Municipal On Site Disposal System ❑ SECT N 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT rn 2.1 Owner of Record [� Name( nt) Address for Service—: 7 -. 1 Q SigiTtIfte Telephone Q 2.2 Owner of Record: Name t Address for Service: O Z rn Signature Telephone 90 SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervis : License Number ddress bl/v Expiration Date Sig ature ci Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ 0 Company Name rn Registration Number r ddress I I I -to In ` bLA. r Expiration Date Z Si na re Telephone v/ 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 thebuilding permit. Signed affidavit Attached Yes......"A 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: pt SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant 1. Building (a) Building Permit 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 l/ 1/ a Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Here authorizS k,e A, to act on My Vhalf,ii all Matt' elative to work autho zed y this building permit application o� ) i Mature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, ,<"V 4�'J (Q 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 Pri e U ' Si nature of Owner/Agent Date Elm NO. OF STORIES SIZE _ ,Q BASEMENT OR SLAB RD Sf/_.E OF FLOOR TIMBERS —LK—LID 3 SPAN c DIMENSIONS OF SILLS yL DDAENSIONS OF POSTS DIMENSIONS OF GIRDERS IIFIG[IT OF FOUNDATION `► THICKNESS SI/.E OF FOOTING X MATERIAL OF CIMVINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION APPLICANT ��,v.,, � l PHONEf5,�J - �3 LOCATION: Assessor's Map Number 0 PARCEL-6 —0 D9 8 SUBDIVISION LOT(S) STREET M CJ ST. NUMBER_ *********************************AA*OFFICIAL USE ONLY ** ******** ******************** RECO MIENDATIONS O TO N AGENTS: CON ERVATION ADMINISTRAT DATE APPROVED 1 DATE REJECTED We, COMMENTS 1 A w /OD / it !l1 ! TOWN PLANNER DATE APPROVED_ DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED EPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE__ Revised 9197 jm 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 51 S - !T'ag-n3 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 Facility Signature of Applicant L „ Ivy Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through.the Office of the Building Inspector U The Commonwealth of Massachusetts M d Department of Industrial Accidents Office of investigations Boston, Mass. 02111 Workers'Compensation Insurance Affidavit Name Please Print ff , Name: t..e, ! -►,..,P Location: Ci tv 1-/t_ h.�..� —E �--r� Phone # 1 am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity TNI am an employer providing nworkers'compensation for rry employees working on this job. pany name: ComI�w �� ���t AV Address -J U Phone# Insurance.Co. Poli # l.,-, 3Z Company name: , Address Ci .. Phone*- Insurance Co. Policv# Failure to secure coverage as required under Section 25A or MGL 152 can lead to the i -/� imposition of criminalP ()(,a fine up to$1,500.00 and/or one years' mprisorwnent_as_welLas_cbM altiesjnsheSmn-fa-STSP.Y OM-OftDFRandafxie-cfA$lDO-oo)aAay.agaiostme I understand that a copy of this statement may be forwarded to the office of Investigations of the DIA for coverage verification. /do here certify u e and penalties of perjury that the iirforrnation provided above is true and correct. Signatu Date_'S-�( b Print name t� w �-v. Phone. i{,- S"3T) Official use only do not write in this area to be completed by city or town official' City or Town Pern*Ajcensi El Building Dept []Check if immediate response is required 0 Licensing Board p Selectman's Office Contact person_ Phone A El Health Department Other NvR ' ►-1 own of fAndover No. 4,Wfa78 i o 1W CA � over, Mass., S_al 6 A-61 00 3 COCMIC � AORATED P'?0� C7 S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR Will S....*..,SORA.... '/. . vs..z.A...b...8..1..................... THIS CERTIFIES THAT................................. •••..•••. Foundation MG has permission to erect... . ... ........ '.... buildings on.....V/ �� ............. Rough AO *PJ 00rO P� �✓� a�V P AW OO 0094/e Chimney to be occupied as.... ..... �....... I.... ................................. 7............................................................ . . . .. ............. 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-Ljws relating to the Ins ection, Alteration and Construction of Buildings in the Town of North Andover. y` Iva PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION ST TS ELECTRICAL INSPECTOR C e 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. GENERAL BUILDING NOTES/CHECKLIST- NOT LIMITED TO ITEMS BELOW POST ALL LOT NUMBERS, ADDRESS, AND PERMIT(COPY OK)..or no inspections INSPECTIONS: (Minimum) Excavation , Footing, Foundation, Frame, Insulation, Final. FOOTINGS: Continuous Full 2x4 Keyway Continuous strip footings for interior columns FOUNDATION: Rebar as required Anchor bolts or straps Damproofing Foundation drain-pipe/stone/fabric filter/cover and outlet connection. FRAME:Fireblock-over girts/plates between floor joist Penetrations for plumbing, heat, elec, etc. Walls at stair stringers. Windbrace corners and center bearing partitions. Size ridge to provide full bearing at rafter cuts. Hip and Valley rafters-watch bearing at walls. Ridge&Hip-Provide proper connections. Cathedral roof rafters provide proper connections and use"Hurricane Clips"tie to plate. Stair stringers-watch cuts and heal support. Joist hangers-fully nailed w/hanger nails. Sill plates 2-2X6(1 PT)w/sill seal. Girls-solid brick or steel plate bearing at foundations '%"air space at sides in foundation pockets. Lateral bracing at ends. Certified calculations. required for Beams/LVL's Trusses. Solid.bearing support for Headers/Beams etc. Check headroom clearances-stairways, under beams Attic Access. (min. 22x30 w/3' headroom above). Crawl space access. (min. 18x24). Bath exhaust fans to have metal duct to exterior(not in soffit). Firecode S/R wood frame of"0"clearance fireplaces&stoves Window Schedule or Every Habitable Room Must Have: Natural light equal to 8%of floor area. %of required glazing shall be openable. Bedrooms required min. 20x24 egress window or door. Vent attic spaces-"proper vent", soffit and required ridge vents. Firecode under stairs if used for storage FIREPLACES: Separate permit required. Inspections at Footing-Smoke Chamber- Finish Smooth parging, clean joints, 8"solid @ combust. Surf. DECKS: Separate permit required: Lag to house, provide flashing. Rails min. 36" high, Baluster max space 5"on center. Over 8'above grade, use 6x6 posts w/lateral bracing. Lag all posts and rails. Pier footings down 48", Conc. pad at stair base. FINISH: Handrails returned to wall/newall post. Guardrails required alongside open cellar stairs. Exterior grading complete. Certificate or occupancy required prior to occupying structure. Temporary Stairs required for inspection. Re-inspection fee-$25.00(Be Ready). Certificate of occupancy required prior to occupying structure. i DATE: FRANK S. GILES R MAY 12, 2003 SCOTT L. GILES j REVISIONS: FRANK S. GILESjHOF SURVEYING 50 DEERMEADOW ROAD a II ND' SCALE: 1 INCH= 20 FEET NO. ANDOVER, MA 01845 o' 20' 40' TEL: (978) 683-2645 ND su FEss% E-MAIL: FrankGilesSurvey@attbi.com 12 2003 THE ZONING DISTRICT IS PRD (R3) PLOT PLAN OF LAND LOCATION 41 COPLEY CIRCLE NORTH ANDOVER, MA 3 PARCEL 103 PREPARED FOR ' SUSAN WILLIS C 730 l S 3533°F i 5.07, { 2 _ 1 MAP 46 Lc MAP 46 PARCEL 98 LOT 18 { LOT 19 PARCEL 97 { AREA= 0.296 AC. ss 00 { r f -"� f l \6 r �4�, ,y f ' I 1100. i i rim r r Z� F 1 r \ . 5 F ti a ��. PROPOSE-0 ADDI7'1,ON 0.S' F F J 23.s' s. COPLEY CIRCLE '{ iN S, { O { { 4 79.10' N 89044'33"E LC LC LEGAL. REFERENCES SUBJECT PROPERTY z c jf OCOPLEY MAP 46, PARCEL 98 /CIRCLE ELGUEZABAL, DORA A& \ SUSAN M WILLIS COBBLE SITE 41 COPLEY CIRCLE NORTH ANDOVER, MA. 01845 ROAD SEE PLAN 12330 @ N.E.R.D. CKERG BK. 4728,PG. 154 c LOCUS C:\CLIENTS\WILLIS SUSAN\PERMIT PLAN.DRG TITS