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Miscellaneous - 41 HOLBROOK ROAD 4/30/2018
41 HOLBROOK ROAD t - 210/021.0-0018-0000.0 Date...............i.1.q........................ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ....................................—....................................... This certifies that C-0 rv,t�exc-,f-1 o"`. ..... ............ has permission for gas installation ci45 vvA A... ........................................... % in the buildings of CLk tj e. ......at ................q...................................... ...................................................... North Andover, Mass. Fee( Lic. No. v . � 7- (.11 ............... .....i3n.*.... H.0.............................. GASINSPECTOR Check# 9200 t�, •' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY North Andover MA DATE 3/24/2014 � J PERMIT# JOBSITE ADDRESS 41 Holbrook St OWNER'S NAME GOWNER ADDRESS Same TE FAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL® RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:0. REPLACEMENT: PLANS SUBMITTED: YES[j NO[] APPLIANCES Z FLOORS, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER � [ FIREPLACE FRYOLATOR FURNACE GENERATOR —� GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN PQOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER i OTHER Re lace Gas Meter ( x and Pipinq as Needed INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ® BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will bein pliance with all Pertinent provisio the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Joseph Marino LICENSE# 8736 SIGNATURE MP MGF JP JGF LPGI CORPORATION Ej# 3285C PART SHIP # LLC El#= COMPANY NAME: RH White Construction Co ADDRESS 141 Central St CITY I Auburn STATE=ZIPI 01501 TEL (508 832 3295 FAX 508-926-4347 1 CELL 508-832-4614 1EMAILI JMarino@RHWhite.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ Cz� G FEE: $ PERMIT# PLAN REVIEW NOTES UIII► I'm gem BERS ;AND GAS F1T'E.fZS s_E-p AS'.A..Ma TER P;LUNf k s _ -15SUE8THE`ABQUE"LICENSE MAR I N.0 W(7`RCESTEGTON ST R MA 0io .5`#:-3I<p<j s 05/01/14 GQiti7MNWEALTHOFMASSA,C`!#US:E'IiS: •. .Iml oil :..•, . :.. `i P11U1ti%(BERS AND GASFITTERS: L6'CENSEE7 AS A J4U.RNEY111I 1N L11ItIE .,•air' •__ -ISSUES THE ABOVE"LICENSE TO-•`-+'�`< __ _ :-•.•' " i462RI=NGTQN ST <KiA G�_STt R MA it 1 6_ :45 05/01/14 fog °. t i 04/03/2014 14:04 5088326751 RH WHITE CONSTRUCT PAGE 02/02 CERTIFICATE FDATE(MMIDDINY"OF LIABILITY INSURANCEpage 1 oP 18/29/2013 THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(jos)must be endorsed. If SUI3ROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s), PRODUCER CONTACT NAM 9villi4 of Massaehueetts, Inc. PHONE FAx C/o 26 Cyy QxltU Blvd. NO_FXTr. 877-945-7378 Nod, 888-46_7-2378 P. 0. Box 305191E-MAIL Nnobville, TH 37230-5191 -ADD RF,&SL Cexti f iia a t%s..willia.com INSURER(8 AFFOROINGCOVERAGE NAICrf INSURED INSURERA: The Charter Oak Fire insurana* Company 25615-001 R. X. White Conatruction Company, Inc. INSURERS:Trnvol,gXs Property Casualty Cotgpany of Am 25674-003 41 Cmntraa Street INSURER C:Natiolgal Union Fir* Ineuraneo Company of 7.9445-001 P. 0. Box 257 Anburn, MA 01501 INSURERD:TravOlers Indamnity Company Z5658-DO1 INSURER F,; INSURER F; COVERAGES CERTIFICATE NUMBER:20267680 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER OOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIM17S SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE DD SUB POLICY NUMBER POLICY EFF POLICY EXP vvvn LIMITS A GENERAL LIABILITY VTC2000 977X9948-13 9/1/2013 9/1/2014 EACH OCCURRENCE s 2,000,OOQ X COMMERCIAL GENERAL LIABILITY PRE �%B�Ee Deco ancr.) .S 3 00, 9 0 CLAIMS-MADET OCCUR MJEDEXP(Anyone arson 1 10 000 PERSONAL&ADV INJURY $ 2 OOQ,000 GENERALAGGREGATE $ 4, 00,000 GEN'LAGGREGATFLIMITAPPLIESPER: PRODUCTS-COMPIOPAGG Is 00O 000 POLICY PRO LOO $ 13 AUTOMOBILE LIABILITY VTJCAP 977K955A-13 9/1/2013 9/1/2014 OMBI EDSINGLFIJMIT $ 2,000,000 ALLOWNED SCHEDULED X ALIYAUTO BODILY INJURY(Perpemon) $ AUTOS AUTOS BODILY INJURY(Peraccldent) X HIREDAUTOS X HOWOWNED AUTOS eraccldent $ X Co Dad X Coll Ded !tr ordo C UMBRELLALIAD R- OCCUR BEB766140 9/1/2013 9/1/2014 EACHOCCURRENCF $ $�GOO,O00 BXCESB LIAR CLAIMS-MADE AGGREGATE $ $,000,000 DED I X RETENTIONS 7,0,000 $ D WORKERS COMPENSATION '�►7�tRUB 8205A185-13 9/1/Z0�3 9/1/2014 X 0 - AND EMPLOYER8'LIABILITY y N TARP LJ D ANY PROPRIETORIPARTNFRIFXECUTIVE� NIA VTC2XUB 9208A71A-13 9/1/2013 9/1/2014 E.L.EACH ACCIDENT s 1,000,000 OFFICERrMEMSER EXCLUDED? 11 fre.deof(YYbaunE E.L.DI8EASE-EAEMPLOYCE $ 1,000 000 9e,tleoaIn M) , U�v KII+IIUNUfONFRATIONSbeI6w F.,L,DISEASE•POLICY LIMIT S 1,000,000 DESc RIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach Acord 101,Additonel Remarks Schodula,If more ep sea Is acquired) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF TWE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Evidence of InlpuXance AUTHORIZED REPRESENTATIVE Collt4197604 Tpl:1694012 Cert:20287680 ®1988-2010ACORD CORPORATION.All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Date......... Y � a aORTOI TOWN OF NORTH ANDOVER PERMIT FOR WIRING SsACMU`�� i- � This certifies that ................................... .....�,�.� .�... has permission to perform ....... ... cl ........................................ wiring in the building of.....5 :.�?.faJ .................... at......:�70—.....f�'� 4.,u4 9 *A............ . .North Andover,Mass. Fee....3?7���" Lic.No.3..'4 ..... .. LECTRICALINS PECIbR s Check # ------ 10532 Commonwealth of Massachusetts Official Use 4 ' Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK t 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: 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) Ao L k tiza if PJ Owner or Tenant L<S pr r(,vwltN Q-, Telephone No. (p(7- 2.`VTC/0 C Owner's Address 1� Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building tip �.�j {idt ?, Utility Authorization No. Existing Service Amps 'IJ/7 440 Volts Overhead Undgrd ❑ No.of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity -_ Location an Nature of Pro osed Electrical Work: r f 1OSe- A �<t+F�F �crz9 rpt ��C� � OtJl7e-1s Com letion o the ollowing table may be waived by the Inspector o Wires. I% No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- No—.of Emergency Lighting No.of Luminaires Swimming Pool rnd. [:] rnd. ❑ Battery 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. TotalTons No.of Alerting Devices No.of Waste Disposers Heat Pump NumbeK r Tons W No.of Self-Contained Totals: Detection/Alerting Devices 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 Kms, No. of No.of Data Wiring: Heaters Si ns BallastsNo.of Devices or Equivalent Telecommunications Wiring: ;No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Equi valent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of lec ical Work: &0'C/o (When required by municipal policy.) Work to Start:42 I ( Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE CO E GE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 054OND ❑ OTHER ❑ (Specify:) I certify,under the p and penaltiesiof perjury,that the information on this appli tion is tr and complete. FIRM NAME: 1 vole edl LIC.NO.: O Licensee: e.S G Signature LIC.NO.: 376 7,0 (If applicable, ter "exe pt"in the license umber li e.) Bus.Tel.No.' 3 y Address: A 0 Alt.Tel.No.: ie 17 ryD *Per M.G.L . 147,s.-57-6 1,security work requires partm t of Pu lic Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance covers malty required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑ owner ❑ owner's Owner/Agent Signature Telephone No. PERMIT FEE. $ F �'''+ ]D/vim//' • 'n v/V sj I Y E , 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 Le ibl Name(Business/Organization/Individual): V Address: )6 (d Q City/State/Zip: S v U Phone #: t—/2,7 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction loyees(full and/or part-time).* have hired the sub-contractors E] Remodeling 2. I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp.insurance. 9. ❑ Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their ME] Electrical repairs or additions 3.❑ I am a homeowner doing all work g P per MGL 11.[:] Plumbing repairs or additions right of exemption myself.. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]fi employees. [No workers' comp. insurance required.] 13.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp:policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic. #: /� i Expiration Date: Job Site Address: 4� �l6ee-C t ' �Cl City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of e D ft for insurance co rage V_ on. I do hereby cer f u r the pains a pe ti of perjury that the information provided abov is tr a and correct. Si nature: Date: z <� Phone#: Official use Vitly. 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#: Location 4 \A C,,Dk� i7 No. Date 'so-� &ORTN TOWN OF NORTH ANDOVER _ O .. 9 + : , Certificate of Occupancy $ CHUS Building/Frame Permit Fee $ ' Foundation Permit Fee $ Other Permit Fee $ /2� TOTAL $ / Check # "7 1583 © `` Building-In pector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPA15 RENOVAT& OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER. /2 DATE ISSUED.'� ¢ �© q SIGNATURE: ici Building Commissioner/Ingwor of Building Da z SECTION 1-SITE INFORMATION I o1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number two• lam.e��oyt7�Z 1.3 Zoning Information: 1.4 Property Dimensions: Cp—Z1s�)ry Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide R red Provided Rapired Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public Private ❑ Zone Outside Flood Zone Municipal 11� On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record !!k/ A4 01-)3RzAa << 1Z 1p, Name(Print) Address for Service: Signature Telephone �,L3 r"i}3 7 2.2 Owner of Record: //Ge:v� ti tJe�r L/l L Name Print Address for Service: z M Signature Tele hone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: , Not Applicable ❑ 7-z 7 cn C-_P)�- F 131 .0 � a19,5- Licensed Construction Supervisor: O License Number d�— - 0.<5�71 94 Expiration Date S nature Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name ,` ��� Registration NumberIq r A dress �T CYC/ 7� Expi on Dat Siature 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 rmit. —Signed affidavit Attached Yes.......0 No.......❑ SECTION 5 DesciA tion of Proposed Work(check all appficcable New Construction 0 Existing Building ❑ Repair(s) Alterations(s) ❑ Addition ❑ Accessory Bldg. 0 Demolition 0 Other ❑ Specify Brief Description of Proposed Work: Ll tae V L cs ) I-,? i SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be {11FCIAL USE OIdL�t kx � Completed b permit applicant 1 1. Building ,,v (a) Building Permit Fee rS'—U Z Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X (b) / - 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number I►Z�j'�''�''ERZ SECTION 7a OWNER AUTHORIZATfODLJO BE COMPLETED WHEN S AGFAT OR CONTRACT PLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby authorize to act on e ,in a ma s relative to authorized by this building permit application. _Vgfr tore of Owner Date /StCTION 7b OWNER/AUTH01MED AGENT DECLARATION as Owner/Authorized Agent of subject Po rty ereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name Si ature of Owner/A ent Date J NO.OF STORIES SIZE f BASEMENT OR SLAB SIZE OF FLOOR TIMBERS iST 2 ND 3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DINIENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHPgNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Page Of Office (603) 893-4599 Residence (603) 382-1868 JOE BRADISH Vinyl and Aluminum Siding and Roofing 7 Moulton Drive P.O. Box 448 East Hampstead, NH 03826-2416 PROPOSAL SUBMITTED TO PHONE DATE tj r G' 2) ,3 STREET JOB NAME oor ` / f-f-1) c.--PjYZvc� CITY,STATE and ZIP CODE JOB LOCATION A47 1TA_1 ARCHITECT DATE OF PLANS JOB PHONE We hereby submit estimates for: 7"Lf✓� d cJ�s�'t tz a.c% C� ria 4" ? di T � �� `tet We Propose hereby to furnish material and labor— complete in accordance with above specifications,for the sum of: /J/ dollars(S Payment to be made as follows: All material is guaranteed to be as spectfled.All work to be completed in a workmanlike manner according.to standard practices. Any alteration or Authorized deviation from above specifications involving extra costs will be executed Signature only upon written orders,and will become an extra charge over and above the estimate.All agreements contingent upon strikes,accidents or delays beyond our control. Owner to carry fire, tornado and other necessary insurance. NOTE:T s proposal may be Our workers are fully covered by Workmen's Compensation Insurance. withdr n by us If not accepted within days. A000UmC@ of PMpl" — The above prices, - specifics ions and conditions are satisfactory and are hereby ' accepted.You are authorized to do the work as specified. Payment Signature will be made as outlined above. Date of Acceptance: Signature 3. BOARD OF'BUILDING REGULATIONS } 4 1 �" License CONSTRUCTION SUPERVISOR 4•f Number CS 021298 els a B�rthd"ater05/21f�r9g5 ExWet: 05/2i/2004j } 9 Tr.no: 24063 r } Restnc 00 i JOSEPH P BRADISH PO BOX' rygOULTON DR"'' ` E HAMPSTEAD, NH 03826 L'�"'y I Administrator t O fie �arvnwii..iealltY o���?�,!`�oe�ta , Board of Building Regulations and Standards License or registration valid for indireturn use only t before the expiration date. If found return to: IjVHOME IMPROVEMENT CONTRACTOR Board of Building Regulations and Standards Registration=402097 One Ashburton Place Rm 1301 I Expiration 6/3072004 Boston,Ma.02108 ^"Type.; Individual JOSEPH P.BRADISH JR Joseph Bradish, --- 7 Moulton Drivel Box 448 Not valid without signature E.Hampstead,NH 03826 Administrator O tj®RTHTown of - a i `/ s.... Andover0 . 12.1 0 �OCHI dover, Mass.,500f ADRATED PPC low BOARD OF HEALTH ERMIT D Food/Kitchen Septic System �` • • SO BUILDING INSPECTOR THIS CERTIFIES THAT.....!/t /1J .3&41.�44 ...4�i ,. .�.1 .... .1�!� • ""' """""" ' Foundation has permission to-ereet............� .�.IZ...... buildin s on .....�.A....�0,�(���{.....� �..... Rough • . Ma to be occupied as ................V.t.l.i.. .. .....gt. l...10.0 �7070 .....S.T� 4..1...�...44wr Chimney provided that the person accepting tris permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION START ELECTRICAL INSPECTOR 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 C •S• �O d aW���� ����� Street No. SEE REVERSE SIDE Smoke Det. � -\rwASSAC:HUSETTS�UNIFORM- APPLICAT N (Print or Type) FOR PERMIT T060 GASFITTING NORTH ANDOVER . Maas. Dated Building //// Permit # 66 Z �2� Location ?� :- U T Per •• Owner'LLe--,, Name 7' ct N D New ❑ Renovation ❑ Replacement EKY plans Submitted: Yes ❑ No [y— h a v x a: 0 r°. u a N s to de 4 a ~ O p tl 0 79 W M tl tl v r X = M h QJS K tl h = F i qtr+ tl ; J I O !! 1'i. O It, O 0 ��yy W 3 V �' O b h O p sue-9sMT. BASEMENT 1sT FLOOR lNO,FLOOR I • !AO FLOOA 4TH FLOOR STH FLOOR I � STH FLOOR a 7TH FLOOR , STH FLOOR Installing Company Name_ w Check one: Certificate �.�_ J��.r.�•q.J 7Q�-f� �1 corp. Address__ 55 Al KO �z s a-u 14,, /h+O Ci Partnership Business Telephone_ -`UCS- V-•73 3 W-Flrm/Co. Name of Ucensed plumber or Gas Fitter INSURANCE COVERAGE: one have a current liability Insurance policy or its substantial equivalent. YescEl' No ❑ It you have checked yea, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy Other type of Indemnity O Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General taws, and that my slgnature on this permit application waives this requirement. Check one: Signature o Owner or Owner a Agent Owner ❑ Agent ❑ 1 hereby certify that all of the details and Information I have submitted(or entered)M above application are true and accurate to the best of my knowledge and that ail plumbing work and Installations performed under the permit Issued for this application will be In compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 112 of the Gerrer Laws � TFG I License: � Title umber gna ure o nae um er or aser sflltet p Cth,/Town alter License Number C?,loumeyman Arf' "VED(OFFICE USE ONLY) r a Date. . . . . . .. I. .�. . . . 40RTI, SOF NORTH ANDOVER - OE t c o a 94, PERMIT CAS INSTALLATION 414R - 'b 9SSAcHusES - e This certifies that . . . `.. .`. . . . . . . . . has permission for gas installation . . . . ., �� c:' a!� `'`� / �'--' in the buildings of , . . . f Irl!'! r! . . . . . . . . ... . . . . . . . . . at . . . . . .5 z+!. . '. . .�' . . '. , North Andover, Mass. Fee. t. . . . ,tic. No. ! ?� . . . . . . . . . . . GAS INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer GOLD: File LocatiCIA G�l L Zi("- Z<, No /Z_ / Date MORTh TOWN OF NORTH ANDOVEN Certificate of Occupancy $ Building/Frame Permit Fee $ �ss�cNuSEt Foundation Permit Fee $ O�P--ermit Fee $ �, r. Sewer Connection Fee $ i' Water Connection Fee $ V s; � E TOTAL $ Building Inspector '.` -9710 Div. Public Works . PF,RAX T • APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1 w MAP K,$.E � LOT NO. L,>-3j0 2 RECORD OF OWNERSHIP (DATE BOOK '.PAGE - I ZONE I SUB DIV. LOT NO. F I LOCATION / � � PURPOSE OF BUILDING OWNER'S NAME ��L �J/'���' G'i rwNO. OF STORIES SIZE OWNER'S ADDRESS ' 1 BASEMENT OR SLAB ARCHITECT'S NAME Y' SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME / p SPAN _-- DISTANCE TO NEAREST BUILDING •�3_ DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES-SIDES REAR GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION Y'(�C�e- �7� MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 04-t 6 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES EST. BLDG. COST/(!5'©-o PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT. y 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER ROOM 'itAGE SEPTIC PERMIT NO. I ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY I ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED BUILDING INSP[CTOR SIGNATURE �O $Rp AUTHORIZED AGENT o F E E ��- " OWNERTEL.# PERMIT GRANTED CONTR.TEL.# 19 CONTR.LIC.# H.I.C.# BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY SiOR1ES THIS SECTION MUST SHOW EXACT DIMENSION50F.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 d 1 2 13 �. CONCRETE EL K. PINE - - BRICK OR STONE H ASTERRDW —_ PIERS PLASTER _ DRY WALL _ UNFIN. 3 BASEMENT 11 AREA FULL FIN. B M AREA _ y, 1/2 / FIN. ATTIC AREA _ N_O B M T FIRE PLACES _ HEAD ROOM MODERN KITCHEN _ I 4 WALLS I 9 FLOORS - CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE �_ + WOOD SHINGLES EARTH 1 ASPHALT SIDING -HARDW'D _ ASBESTOS SIDING COMMCN VERT. SIDING ASPH. TILE „r STUCCO ON MASONRY _ STUCCO ON FRAME BRIC ON MASONRY ATTIC STRS. 8 FIOOR I_ BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME SUPERIOR POC AD QUAATE I-i ONE 5 ROOF 10 PLUMBING GABLE HIP BATH (3 FIX.) _ GAMBREL MANSARD TOILET RM. 12 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 g FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. &COLS. STEAM STEEL BMS. 8 COLS. HOT W'T'R OR VAPOR t+ WOOD RAFTERS _ AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ ELECTRIC tft 13rd I NO HEATING Town of oz JLC over No "® idover, Mass., 7 196e . 1 BOARD OF HEALTH �JU PERMIT TO . BFood/Kitchen Septic System t BUILDING INSPECTOR THIS CERTIFIES THAT.......................... ............P.4T/7*.v.................................. Foundation has permission to erect........ -t 7........ buildings on ...........el...........G � l2� .......................... Rough to be occupied as Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final ` this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. g PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough EP. r x T �1 V��T Final _ .`�' ± L - _ ,;-s ,. T n -t.A -T ELECTRICAL INSPECTOR Rough .......................... ........................ ............. . ..... . . .............................................. Service LDING INSPECTOR Final C. f�Qi'.. '}t` ,; ±tr l �i t�_;_1' i.:u, `- Builc �7;? GAS INSPECTOR ~Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner Street No. ;x Smoke Det. .h Location `l1 14OLMOOK I/O 1 / No. S,13 Date f TOWN OF NORTH ANDOVER p Certificate of Occupancy $ i Building/Frame Permit Fee $ SSACmUSEt Foundation Permit Fee $ p� i,, /Other Permit Fee $ 7- ewer Connection Fee $ OfO v1 40*, nnection Fee $ NQ 03 TOTAL 47' ,� $ q7a �`�CC Building`Inspector %`p L_ ' I q01- Div. Public Works PERMIT NO. APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1 M14P 4-40. LOT NO. 2 RECORD OF OWNERSHIP (DATE BOOK .'PAGE ZONE I SUB DIV. LOT NO. I r _ LOCATION PURPOSE OF BUILDING OWNER'S NAME NO. OF STORIES / SIZE OWNER'S ADDRESS �'Z/1� BASEMENT OR SLAB ARCHITECT'S NAME- - SIZE OF FLOOR TIMBERS 1ST,2,(r)® 2ND 3RD BUILDER'S NAME rn y �I�/_/��6 SPAN -- DISTANCE TO NEAREST BUILDING w DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES-SIDES /:� REAR GIRDERS AREA OF LOT 1(1oo J(� FRONTAGE HEIGHT OF FOUNDATION C! THICKNESS IS BUILDING NEW SIZE OF FOOTING / X IS BUILDING ADDITION N .1r'i i d.1,{I _ / „5-�r/t/ MATERIAL OF CHIMNEY IS BUILDING ALTERATION 4/ IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE 7Q+ IS BUILDING CONNECTED TO TOWN W E BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWfd� E IS BUILDING CONNECTED TO NATURAL GAS LINE V INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES EST. BLDG. COST FT COST PER SQ BLDG. . . PAGE I FILL OUT SECTIONS t - 3 EST. PAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST FI ED AND APPROVED BY BUILDING INSPECTOR DATE NFE BOARD OF HEALTH SIG T TiE OF OWNE R AUTHORIZED AGENT F E E OWNER TEL.# -2332- CONTR.TEL.# Z 6IF PLANNING BOARD PERMIT GRANTED CONTR.LIC. BOARD OF SELECTMEN ILDINQ 1 BUILDING RECORD 1 OCCUPANCY 12 , SINGLE FAMILY I STORIES 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 8 INTERIOR FINISH CONCRETE _ B 1 2 13 CONCRETE 81.K. PINE BRICK OR STONEHARDW'D PIERS PLASTER - n9 DRY WALL UNFIN. 3 BASEMENT r' l AREA FULL 11 IVIl FIN. B'M'TAREA _ '/, 1/1 3/, FIN. ATTIC AREA _ N_O 8-M'T FIRE PLACES _ HEAD ROOM MODERN KITCHEN I — — I Zq iN 4 WALLS I 9 FLOORS 3yry� CLAPBOARDS B _ 2 3 5 x►y 1 Auno+U DROP SIDING CONCRETE �— - -_ - -- 7v r- gI Mtf'S"j WOOD SHINGLES EARTH �I 1 ASPHALT SIDING HARDY✓'D V I - ASBESTOS SIDING COMMON _ VERT. SIDING ASPH. TILE STUCCO ON MASONRY �_ t STUCCO ON FRAME BRICK ON MASONRY ATTIC STIRS. & FLOORapr BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIORI� POOR AATE DEQUNONE 5 ROOF 10 PLUMBING GABLE HIP BATH )3 FIX.) GAMBQEL MANSARD TOILET RM. )2 FIX.) r FLAT SHED WATER CLOSET ASPHALT SHINGLES V LAVATORY - 24 WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO _ 6 FRAMING 11 HEATING VaLWGO/L sl— WOOD TWOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. &COLS. STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ ELECTRIC lsf 13rd NO HEATING 111111 MINE■■■■ ■■ ■M■ ME i ■■■■ INN ■■ ■ ■:■ ll MEN ■■I O. ' 101 I ■E ■■MME■MEMO ■■ ■MM■ ■ ■ E■■■M■■ 1 ■■■■� ■■■■ ■ E■■EEM■■■■ M■No=M�—_ _■■■ ■ ■MME■MME■M■■SEEM i ■■EMMmm M■■■M■ g'+' 5"i"fire'v r`tt+,+',,r s'K#r''r ,{ irfi "`P� �.,f.. �., A�P , �t �' 3�•t t� 'rte'_.; 1 , .y_: ter n t ^,�', i7 7 r. 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F - , - T. • r;i t r t 1 .9 L k }r a COMMONWEALTH DEPARTMENT OF `f y PUBLIC SAFETY - OF 1010 COMMON L MA r WEALTH AVE. r r SSACHUSETTS BOSTON,MASS.02215 t EXPIRATION DATE L I E N S ' .11 i —I at CONST ' S � 0��92 • ..sup€ iso #EFFECTIVE DATE i - ` 1-1 . . . . LIC NO: . NONE ° - f12/{�1/19H�9 C� .257 � ; HERBERT A CLCUGH �� mi ;� SS AI OZ9-6p-6994 246A �CE�IOZ!1 yg ' Hd1VEAHILL MR 0 z , � , r 18.,Q t PHOTO(BLASTING OPq ONLY) FEE: T r f { t - .. ` : { 0.00 i HEIGHT: . NOT VALID UNTIL SIGNED BY LICENSEE AND OFFICIALLY 1 - >•'STAMPED.OR DOB. SIG OF THE COMMISSIONER 9/27/196 : .' I THIS DOCUMENT MUST�BE ( II CARRIED ON THE PERSON OF • ` `� - 1 �+'I - OTHERS -RIGHT THUMB PRINT THE HOLDER WHEN ENGAO• SI F LICENSEE- 1. I ED IN THIS OCCUPATpN, f ' 20OM-2.87-81429 - COMMISSIONER ' ft J :F 111- -. x to '+Pr;t ;,r—" 4 -:t - .:xar i f 14y y 4R11 ---- _ T. f t rlt lY t , M .* §pt 3�1f71,:e4,��x � . L +� t, t ' a e4 k ;-' '.N„S ;��t• af4r,1 0y. { r 1 { 13.,1 I� 1 � s4 IIw n ."1Z " gra$ '+ t -f� i' �- i .ff $ a .1, may-y . r .— >kf11 > 1 Y�t `i �' 4 +Ftp Cr �71tA 6, #I 1; �kr d; . . II li x + +t ry,�+t , t Jd, e+T Cp` ° T jtt.. . t"t I -1— —I I kk k r4 i 1 ! r' 1/ 't' t j I ]tt I ft t d41 1,,r .1,1 t ? + , a ' r t,6. '"l t I,: r It 75n a' 1 - , . r I - .. . t - •+ -f • o . - f. I FORM U TOWN OF NORTH ANDOVER tir LOT RELEASE FOIUI SUBDIVISION F 'x ASSESSORS MAP �.:. SUBDIVISION LOT(S) PERMANENT ADDRESS (ASSIGNED BY D.P.W. STREET OG/S,000/L �T APPLICAN �Ar�1 ZeZ7 n,�j PHONE DATE OF APPLICATION 1.2 TOWN USE BELOW THIS LINE PLANNING BOARD DATE APPROVED TOWN PLANNER DATE REJECTED CONSERVATION COriHISSION DATE APPROVED ( qj CONSERVATION ADMIN. DATE REJECTED BOARD OF HEALTH DATE APPROVED HEALTH SANITARIAN DATE REJEC'T'ED DEPARTMENT OF PUBLIC WORKS DRIVEWAY PERMIT SEWER/WATER CONNECTIONS TIRE DEPT. RECEIVED BY BUILDING INSPECTION DATE This form shall be signed by the agents of the Planning and Health Boards, the Conservation Commission prior to the issuance of any building permits for the subject lot. This form shall not releive the applicant from the compliance of any applicable Town requirement or Bylaw. Ato "tri i'Q9%;eN� 3 iIIilkI. bLVYk: t1V � ATF �lii� � AL Town ® _ 6 0over Px � :.wF . . E�s � - �K er, Mass 19g �" -- -- - C H HEWICK A �v oR pR SS PERMIT 0 BOARD OF HEALTH THIS CERTIFIES THAT.` .�Y.• .��. ...................................... BUILDING INSPECTOR has permission to er Moauildings on Rough t0 be occupied as?C *rAVAJ*77-WJ. Chimney Final provided that the person accepting this permitshall in every respect conform to the terms of the application on file in PLUMBING INSPECTOR this office,and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Rough Buildings in the Town of North Andover. Final VIOLATION of the Zoning or Building Regulations Voids this it. PERMIT EXPIRES 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONS URoughC STA S Service Final .• BUIL NG • PECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Final Display in a Conspicuous Place on the Premises FIRE DEPT. Do Not Remove Burner No Lathingp to Be Done. Until Inspected and Approved Y Smookeke DetN..roved b ID . Building Inspector Location No. -' Date �ORTM TOWN OF NORTH ANDOVER O • OL 9 s i ' Certificate of Occupancy $ sACMUs Building/Frame Permit Fee $ 6 F� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ s Check # �v Building I �m&or i TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: r c SIGNATURE: Building Commissioner for of Buildings Date SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: i Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft I Front Yard Side Yard Rear Yard Required Provide Require Provided Required Provided 1.7 Water Supply M.G L.C.40.§54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSIUP/AUTHORIZED AGENT n 2.1 Owner of Record Name nt) Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone n SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Constr on Su rvisor:: Not Applicable ❑ a Licensed Constructs Superyor: a License Number f �� � Address prExpiration bate Si nature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ C Company Name Registration Number r Address r W Expiration Date Signature Telephone i ` SECTION 4-WORKERS COMPENSATION(M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result•, in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......❑ No.......❑ SECTION 5 Description of Proposed Work check applicable) New Construction ❑ Existing Building Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify f ' Brief Description of Proposed Work: �. 9 SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost Dollar to be ( ) � {}FFICIAVUSE 4DNLY ;s Completed b permit a licant v • ,_ :,:•:, 1. Building (a) Building Permit Fee �7 cl Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a) x (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, 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 /0 Q 1,I C'7 G.0 k Ep, Print Name Signature of Owner/A ent Date r NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 ST 2ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 2Fie Commomveafth of�l'lassac&usetts ► (Department of Ind ustriafAxidents Off=of Investations 600 Washington Street Boston, a(X 02111 Workers'Compensation Insurance Affidavit APPLICANT LKFO ON Please PRINT Legibly Name: l� Location: City: 0441&0 Telephone#: 0 t9 ❑I am a homeowner performing all work myself. ❑ I am sole proprietor and have no one working in my capacity ❑I am an empl er providing workers' co pensation for my employees working on this job Company Name: Address: City: Telephone#: Insurance Company: Policy#: W C _') I Q� �lf f 4, Q � P ❑I am(circle one) sole proprietor,general contractor or homeowner and have hired the contractors listed below who have the following workers' compensation policies: Company Name: Address: City: Telephone#: Insurance Company: . Policy#: Company Name: Address: City: Telephone#: Insurance Company: Policy#: Attach additional sheet if necessary Failure to secure coverage as required under Section 25A of MGL 15B can lead to the imposition of criminal penalties of a mine up to$1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I ' understand that.a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. 1 do hereby certify under the and penalties of perjury that the information above is true and c rrect. 4' Signature: Date: Print Name: Phone# �i 0 Ofucial Use ONLY-Do not write in this area o Building Department City or Town: Permit/License#: ❑Licensing Board o Selectmen's Office o Health Department 0 Check if immediate response is required 0 Other :" , ✓rie -F'aninaarecuea.�i..a�/�aac�ucaeCt' BOARIS OF�BUlLDING.REGULA71bNS 1 ..` License ;:CONSTRUCTION SUPERVISOR Number•/CS 034049 a�. Birthdate; 12!08/1"923 hx Expires: 12/08%2U01 Tr.no: 10391 Restricted To: 00 4ARIO T CAS'TRICONE 3T COURT ST N ANDOVER, 'MA 01845 AdmihhWgtor 07 NONE IMPROVEMENT CONTRACTOR mpg- Registration: 103317 Expiration: 07/07/2002 Type: DBA CASTRICONE ROOFING & SIDIN Natio Gastricone '?I Court St. ADMINISTRATOR N. Andover IIA OlU4� r� NORT►y E Town of dover o C, " 0� coc ��' y lover, Mass., ADRATED P`? 5 BOARD OF HEALTH PER T . T Food/Kitchen Septic System • BUILDING INSPECTOR THISCERTIFIES THAT..............:..... :................................................... ................................... ........ ......................... Foundation has permission to er ..... dins on ... p ................ g /.................................................................................. Rough to be occupied as ... .... .. Chimney .................................................. provided that t person accept' g this permit shall in every respect,conform to the terms of the application on file in Final this office, and to the provisio of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION START3 ELECTRICAL INSPECTOR Rough Service ...................... ................................... $ rBU =INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final I No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved- by the Building Inspector. Burner Street No. IFSEE REVERSE SIDE Smoke Det.