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HomeMy WebLinkAboutMiscellaneous - 44 APPLETON STREET 4/30/2018 44 APPLETON STREET 2101037.B-0041-0000.0 March 29,2015 Inspector of Buildings Town of North Andover 1600 Osgood Street North Andover MA 1845 Clain Number: 033546112 Policy Number: 15927400002 Company Name: Arbella Mutual Insurance Company Date of Loss: 2/18/2015 Insured: Brucato,David Property Location: 44 Appleton Street No Andover,MAO 1845 To Whom It May Concern: Claim has been made involving loss, damage, or destruction of the above captioned property, which may either exceed$1,000 or cause Massachusetts General Laws, Chapter 143, Section 6, to be applicable. If any notice under Massachusetts General Law, Chapter 139, Section 313 is appropriate,please direct it to the attention of the writer. Kindly include a reference to the captioned insured, location, date of loss and claim number. Very truly yours, Chris Bennett Crawford&Company 204 Second Ave Waltham, MA 02451 CC: North Andover Fire Department North Andover Heath Department Arbella Mutual Insurance Company I'i Location L No. laf-2 Date y 6, NORTH TOWN OF NORTH ANDOVER 0 • OR 9 i • Certificate of Occupancy $ <.44, �'�s "°''•t� Building/Frame/Frame Permit Fee $ s�CHust 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 2267 22 � �) 8 Buil ing Inspector ., 62U2 ' Date....//— /a,17:.ea Ott,Gao7 e�ti0 TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,SSACMUS� This certifies that .51,,,vw 6.........&Fz :C-7...... a` has permission to perform wiring in the building of.. .........!0 ....�4./ /... ................................. at..... TO1/......5.T............. .North Andover,Mass. o® Fee. ._"".... Lic.No1173--5...............�` 'F: ............ ELECTRICAL INSPEc+oR { Check # 3 39 V L.O.MonwaaaA of /Iladd Aud—w For OfficeUseonly e-� (Rev.11/99) /9 Permit Number._ Occupancy&Fw �A P HOARD OF FIRE PREVENTION REGULATIONS APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK (ALL WMTO RRE PF.RFO1tMBD IORM MM MASSACHUSfT7S=CMICAL CODE 527 CMR IM PLEASE PRINT IN INK OR TYPE ALL INFORMATION Date: —City or Town of: e�L- ;:�J 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) Owner or Tenant Owner's Address: Is this permit in conjunction with a Building Permit? Yes 0/No a (Check Appropriate Box) Purpose of Building:,, -c �/Lm Utility Authorization Existing Service: Volts Overhead Underground.❑ n of Meters New Service: 7-vv Amps /zG f 'z y c Votfs Overhead a""-- Underground.❑ #of Meters:/ Number of Feeders and Ampacity: Location and Nature of Proposed Electrical Work: ✓ "" /�G ��? �a� � No.of Recessed Fixtures No.of Cell.-Susp.(Paddle)Fans No. of Transformers Total KVA No.Of Lighting Outlets No. of lint Tubs Gertaratom KVA No. of Ughting Fbduras Swimming Pool: Above ground n In Ground a #of Emergency lighting Battery Urttts No.of Receptacle Ouliats No. of OB Bumers Fire Alarms #of Zones #of Detection&Initiating Devices No.of SwitchesL/ No.of Gas Bumem #of ff Soundi�tt Devices dam: SelfDetecdon/Soundmg Devices No.of Ranges No. of Air CatditIoners TOTAL TONS: Local c Municipal Connection c Diner No. of Waste Disposals Heat Pump Totals: Sectatty Systems: Number TONS: KW.— No.of Devices.or Equivalent a No.of Dishwashers Space fArea Heafing KW Data wiring.No.of Devices or Equivalent No.of Dryers .__ Heatbtg Appliances KW Taiecommunications Wiring:No of Devices or y Equivalent rr No. of Water Heaters KW No. of Signs: #of Ballasts. OTHER; #of Hydro Massage Tubs No. of Motors Tata)HP INSURANCE COVERAGE:Unless waived by the owner,no permit tar the performance of electrical work may issue unless the licensee provides proof of liability i stLar including'completed operation'coverage or Its substantial eq The undersigned car tlries that such coverage is in fame,and has exhibited proof of same to the r issuing office. CHECK ONE INSURANCE t BOND D OTHER a Please specify: Estimated Value of Electrical Work 5 (When required by municipal policy) Work M Start /G — G 5 . lmpecffons to be requested in accordance with MEC Rule 10,and upon=mal 1 certify,under the pains and penuries of perjury,that the information on this application is true and complete[.! Finn Name: 5i1 Licensee: -5'1' . L/v / � /111, w G i:-, / S19naWre- _ UC.#�F„�� 3� fff applicable,ant a z N`in rhe license nfikfier line) 1 i 1 'o y��/ —7-- Address:J 7 a� d c T 1 Bus. /G�Alt Tel.w A OWNER'S INSURANCE WAIVBrt I am aware that the license doer not have the liability insurance coverage nwrrtalty required by jaw. By my signature below,i nt } waive this mituimmord, i am the(check one) owner o OR Agent a 'Q "r4It-UHM APPLICATION F-- PERMIT TO DO GASFITTING (Print of Type) NORTH ANDOVERnn ` Mass. Date_�� 19=�0 Z 31 — Building Location Permit #_ 3 } V 1 Owner Name New C] Renovation ❑ Replacement Plans Submitted:. Yea ❑ No k X ' R - w w r0 2 N= � d -j 0 i n Za p h t r Y s 0 �. a 14 b K C 0 x w a A s u S = M 1X Mt A h t ( s < w = F� fir. d 0`7 11 a�I J 1 = O O x O .1 0 0 SU!!—dSMT. • SASEMENT IST FLOOR 2ND.FLOOR 3ROFLOOR 4TH FLOOR STH FLOOR STH FLOOR 7TH FLOOR I STH FLOOR 1 Installing C0mpan,Name / Check one: Certificate Address C? �7 Corp. d, Partnership 1I/ Business Telephone Firm/Co. Name of Lkensed Plumber or Gas Fitter ' INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent. ! Yesc ne No O IN you have checked yea, please indicate the type coverage by checkingthe appropriate box. -t ftabillty Insurance policy d • Other type of indemnity O Bond O OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required b Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. y q irement. Check one: %nature o Owner or Owners ens Owner ❑ Agent ❑ Ler11h that eh of the deln(Is end (nlormatlon i have aubmftted(a enter )Ina vs eppllcatlon are true end ecru to the best of me and lhet aN pplumbiny work end Installations performed under the rm#i Iss for thioprovlslona of the Massachusetts State obs Uode erid piepter 112 ;the Plkatlon velli co pllance with°IIyai Laws. T f License: Plumber G slitter 9na ure o n u er or as er aster License Numbe Joumeyman D(OFFICE USE ONLY) ,_�.�...;��°�+µ7 oLc.�..�►,�.uQ..��-'r'\..s':�r.v^M.�..i�-.....i s-sr�''' '-��..vr -_.,,,= "n„�..--`�:.-.'+y,...^.�-...'. 233 Date t 40RTH TOWN OF NORTH ANDOVER pFt�,,co 3? '� PERMIT FOR GAS INSTALLATION t i • s o �• �9SSAGMUSEt�y - x This certifies that . . . f l e . . . �� . . . . . . . . . . . . . . . . has permission for gas installation J. . . .1.3V.'.�'P. `. . . . . . . . . . . . . . . in the buildings of . .1�1a U. 4,q.I.G. . . . . . . . . . . . . . . . . . . . . .. . at .4t4f.. 4/r.4{�aV .f Y". . . . . . . . th Andover, Mass. . . Fee 10/2��1gG' 0/24116"f:44 25-00 No.h25.00: . . . -��1^. . . . . . . . . PAID GASINSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer GOLD:File Date.,�. �;.N�°T•�tic TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 41 SSACMUS� This certifies that/ . . / y . . . pP.c :. . . . . . . . . . . . . . . . . . . . has permission to perform . . . .�� . 9' `` �'.`" plumbing in the buildings of . . .1�.�.�.4 �.{.� . . . . . . . . . . . . . . . . . . at . . F�/a�Z,!-� . -.. . . . . . . . . . . . . . .. North Andover, Mass. Fee. .Z. ... . .Lic. No..1 6 ?`:j. . . . . . . PLUMBING INSPECTOR Check # �y 6638 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Date 0 Ove Building Location Owners Name Permit#/ 3 Amount 6 Z. Type of Occupancy , New ©'' Renovation Replacement Plans Submitted Yes No FIXTURES W. SUB-o A1C 1S1C)1•ID[R 3�D]HI M 3i1)i!ID R 4M Fl" 5M H fm 6M HDM 7M 1H " MH ft" (Print or type) Check one: Certificate Installing Company Name'/7 iIl�� •//� � � Corp. Address �j �� Partner. Buusin�ss a ep one 1PY-1 ;7..V - 9l ©" Firm/Co. Name of Licensed Plumber. •��/.�.�j/fl � f� Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy El Other type of indemnity 1:1 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 and Permit sued for this application will be in compliance with all pertinent provisions of the Massachus to PI "bin de and apter 142 of the General Laws. L BY: Signature 01 LiCensea Type of Plumbing License Title City/TownLicense NumuerMaster ❑ Journeyman APPROVED(OFFICE USE ONLY Location No. Date MOR7h TOWN OF NORTH ANDOVER ' Certificate of Occupancy $ ��s'•^°tt�' Building/Frame Permit Fee $ ACMus Foundation Permit Fee $ t► Other Permit Fee $ 7� TOTAL $ Check # :t. 18524 R Building Insp(Or TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REP RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING ,., BUILDING PERMIT NUMBER. DATE ISSUED: —�l / W go A SIGNATURE: - Building Commissioner/I or of Buildings Date — Z SECTION 1-SITE INFORMATION 1 O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 31s `1 \ Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use LA Area Fronts ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Reqffed Provided ReqjUred Provided v 1.7 Water Supply M.GLLC.40.§54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public 0 Private 0 zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System 0 J SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT IS OTIC IS CIC : Yes . O rn 2.1 Owner of Record �.. l � M \ Qr k c O yy (1�1�� 1 csr ``1 •�neltly+Y Name(Print) Address for SRice Signature ... hone 2.2 O�j'yner ecord: _A 4 Name Print Address for Service: Z rn Signature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable Licensed Construction Supervisor: O License Number on 'Address a ic Expiration Date a one h Signature Telephone r. 3.2 Registered Home Improvement Contractor Not Applicable ❑ v Company Name rn Registration Number r r Address Expiration Date Z^ Signature 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 rill result in the denial of the issuance of the building permit. Signed affidavit Attached Yes•......`' No.......❑ SECTION 5 Description of Proposed Work check all applicable) New Construction 0 Existing Building 0 Repair(s) 0 Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: MSA—\\ ko X VA S�Mr SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be QF ICIAL USE ONLY Completed by permit applicant 1. Building (a) Building Perntt Fee ?re_F°'V sve-A. * ag3q Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbin Building Permit fee N) x (b) 4 Mechanical HVAC 5 Fire Protection 26 d" 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 r 1, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this buildnig permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, as Owner/Authorized Agent of subject ` property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name Signature of Owner/=t Date NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS iST 2' ;RD SPAN DIMENSIONS OF SILLS DTTW..NSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDA'17ION THICKNESS SIZE OF FOOTING X MATERIAL OF CFEMNEY IS BUILDING ON SOLID OR FILLED LAND 1S BUILDING CONNECTED TO NATURAL GAS LINE NORTH TONM Of ItAndover L.. ..... No. Af C . dover, Mass., 0'r COCHICAMEWICK "ATED Pk? 5 BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR ......................................................... .............. THIS CERTIFIES THAT....4004).0........ .. ......... ....................... <!Pu Foundation has permission to erect...... buildings on .Amt.. - .............. Rough .. ........ M -.n a Chimney to be occupied as..., -rl*—"—",*"""**""*"*'*""**.....­­***­­*...'....*"*"*...**"*.....***""*...."*"**"***"*"**'*""*"*"**....* 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. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES N 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS 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. Ito �cI4 FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments havin9jurisdiction have been obtained. This does not relieve p the applicant and/or landowner from compliance with any applicable or requirements. ************* ******APPLICANT FILLS OUT THIS SECTION APPLICANT Q,3� c T��� PHONE `11 C 8 6- 4 S LOCATION: Assessor's Map Number 31 '3 PARCEL SUBDIVISION LOT(S) STREETykyars ST. NUMBER LN OFFICIAL USE ONLY AF TOW ENTS: (� CONSERVATIO AD NISTRATOR DATE APPROVED ('l DATE REJECTED COMMENTSAW V`rW d<,( (.cu it& �nT 4w�( u)(I I GC'd 00- 61 ve, y V-( ,� OAll i Q f ��'Is A(M r as 5(` &0� ..� -cafes �- 9`�/IV p tWN PLANNER DATE APPROVED / � DATE REJECTED COMMENTS (�( R` .�y. Qihol.l E��✓Cts i .I�„ .� Pte_. _ I IV FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS -SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm •O O t O • • 1 C • I MODEL FLOOR PLANS ALL THREE BASIC STYLES ARE AVAILABLE WITH ANY OF THESE MODEL FLOOR PLANS. MODEL FLOOR PLAN 1 MODEL FLOOR PLAN 2 MODEL FLOOR PLAN 3 SIZES RANGE SIZES RANGE SIZES RANGE STYLE FROM TO STYLE FROM TO STYLE FROM TO CLASSIC 6 x 8 12X20 CLASSIC 6 x 8 12x20 CLASSIC 8x 10 12x20 CARRIAGE 6 x 8 10 X 20 CARRIAGE 6 X 8 10 X 20 CARRIAGE 8 x 10 10 x 20 GAMBREL 8 X 8 12 x 20 GAMBREL 8 x 8 12 x 20 GAMBREL 8 X 10 12 x 20 1 WINDOW, 3' DOOR 5' DOOR 1 WINDOW, 5 DOOR MODEL FLOOR PLAN 4 MODEL FLOOR PLAN 5 MODEL FLOOR PLAN 6 SIZES RANGE SIZES RANGE SIZES RANGE STYLE FROM TO STYLE FROM TO STYLE FROM TO CLASSIC 8 x 12 12 x 20 CLASSIC 8 x 16 12 x 20 CLASSIC 8 x 16 12 x 20 CARRIAGE 8 x 12 10 x 20 CARRIAGE 8 x 16 10 x 20 CARRIAGE 8 x 16 10 x 20 GAMBREL 8 x 12 12 x 20 GAMBREL 8 x 16 12 x 20 GAMBREL 8 x 16 12 x 20 2 WINDOWS, 5' DOOR 2 WINDOWS, 3' DOOR, 5' DOOR 1 WINDOW, 3' DOOR, 5' DOOR *MODEL #4 IS NOT AVAILABLE ON 12' VINYL FRONT. 3 Industrial Drive 2005 PRICE LIST Hudson, NH 03051 ° Toll free (800) 697-5471 xsT' Jr� (603) 883-1362 Fax (603) 882-9566 - www.reedsferry.com ■Nc_ AMERICAN COUNTRY TRADITIONAL CLASSIC CARRIAGE GAMBREL SIZES AVAILABLE IN THESE MODELS SIZE #1 #2 #3 #4 #5 #6 PINE VINYL CEDAR PINE VINYL CEDAR PINE I VINYL I CEDAR ` ," 6X8 * * 1,249.00 1 ,449.00 1 ,619.00 1,379.00 1 ,499.00 1 ,789.00 � � P: 6X10 1 ,549.00 1 ,659.00 1 ,969.00 1 ,699.00 1 ,799.00 2,159.00 „ 8X8 * 1 ,469.00 1 ,709.00 1 ,909.00 1,619.00 1 ,769.00 2,099.00 1 ,619.00 .1,769.00 2,099.00 8X10 * * * 1,819.00 1,969.00 2,309.00 1,999.00 2,119.00 2,539.00 1,999.00 2,119.00 2,539.00 8X12§ * * * * 2,099.00 2,279.00 2,629.00 2,309.00 2,429.00 2,899.00 2,309.00 2,429.00 2,899.00 8X14 12,329.00 2,539.00 2,909.00 2,559.00 2,689.00 3,199.00 2,559.00 2,689.00 3,199.00 8X16 * * * * * * 2,729.00 2,889.00 3,359.00 2,999.00 3,149.00 3,699.00 2,999.00 3,149.00 3,699.00 10X10 * * * 2,099.00 2,319.00 2,649.00 2,309.00 2,449.00 2,919.00 2,309.00 2,449.00 2,919.00 10X12§ * * * * 2,409.00 2,629.00 3,009.00 2,659.00 2,809.00 3,309.00 2,659.00 2,809.00 3,309.00 QT OX * * * * 2,669.00 2,989.00 3,319.001 2,939.00 3,119.00 3,649.00 2,939.00 3,119.00 3,649.00 10X16 * * * * * * 3,109.00 3,359.00 3,809.00 0 3,589.00 4,189.00 3,419.00 3,589.00 4,189.00 10X18 * * * * * * 3,369.00 3,609.00 4,119.00 3,709.00 3,899.00 4,529.00 3,709.00 3,899.00 4,529.00 10X20 * * * * * * 3,629.00 3,979.00 4,429.00 3,989.00 4,159.00 4,869.00 3,989.00 4,159.00 4,869.00 12X12§ * * * * 2,719.00 3,049.00 3,379.00 �� � f Kir' " ": f � 2,989.00 3,179.00 3,719.00 12X14 * * * * 3,009.00 3,389.00 3,729.00 3,309.00 3,539.00 4,099.00 * * * * * � f _° R "' 12X16 3,479.00 3,779.00 4,249.00 3829.00 4,039.00 4,669.00� �.,,�.��� ..�^,..� �. ., , * * * * * * ., 12X18 3,779.00- 4,119.00 4,599.00 � � �f, � ,. � �, r � � -� 4,159.00 4,409.00 5,049.00 * * * * * 4 109.00 4,589.00 4,929.00 � � �rhYf 4,479.00 4,779.00 5,429.00 12X20 - �z §Model#4 is not available on 12' Vinyl Front. Prices include installation in New Hampshire and Massachusetts. Tax NOT included. Prices subject to change without notice. ,Permits are the customer's responsibility where required.- Tan Prices Effective 1/1/05 E STATE ® 1 CL�.12L Q. MtLLC2 A,V 2& i# t !p-7 t . o 0 0 1 LU LL AC(ZE-S± w 1 . � ♦3 ��j a hMP ' r �k . 00 ca, cs D.O cs.rte d=. Co. .00.4a+a-+.r...► s Or ..t_+s. .. .0►',.w ..r..ar 65TATE f .�.rr.- �' wr•�? 1^Y�A f3►G.�1.�.�.• i +fir Gi �" �. �Ii1r w. �.ate►�F �r.�r�� r• �► ` � . 21 I OP CARL U. M I LLEle N DOV E re MASS SCALA y � moo` &L)G, 2, 15s-7 2nLvu g �2a!ss�v2 ,C.E . 1.1 t��rE2 aLL. /A &SS . Location No. / _ Date MORT1y TOWN OF NORTH ANDOVER a � + ; # Certificate of Occupancy $ �'�s'•^�•;.�' Building/Frame Permit Fee $ �cHus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 418666 Building Ins `c�tbr t TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCTREP RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: / DATE ISSUED: ! O X z SIGNATURE: BTIF Co-mmiss-10ner/I_ of Bw1dings Date Z 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: Zonin District Proposed Use Lot Area Fronts ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard ReqWred Provide ReqWred Provided ReqWred Provided v 1.7 Water Supply M.GL.C.40. 34) 1.5. blood Zone Information: 1.8 S;w W Disposal System: Public ❑ Private ❑ Zone Onside Flood Zone ❑ Municipal ET On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes Nd rn 2.1 Owner of Record adv ►d, �`�U G�� o �'r�c �'Q�'��"��'�l ��. Name(Print) Address for Service tgnaturet /> Telephone 2.2 Owner of Record: it Name Print Address for Service: O Z rn Signature Tele one M SECTION 3-CONSTRUCTION SERVICES i0 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor. License Number q an Address (/ v 7 4 11 �-1- ( 7 Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ v !R6 A(Ae�, 0 Company Name 5965rn Registration Number r '7ja11"� z Address 6 7a�' Expiration Date Signature Tel hone G) r SECTION 4-WORKERS COMPENSATION(KG.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 all applicable) New Construction ❑ Existing Building $O Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: G�� e n!RL ���!Zl an6. __:L1 SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to beQI 'ICIAL USE Q , Completed bV permit a licant 1. Building Q (a) Building Permit Fee Multi lien 2 Electrical ` (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X(b) 4 Mechanical HVAC 5 Fire Protection 500 MCI. b Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZ TION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I> \>S1 L L `lam -V as Owner/Authorized Agent of subject property Hereby authorize to act on r M half,in X11 matters relative to work authorize by s buildin,g permit application. SP ature of Owner o Date } SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION h 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 -nke��\ Print Name Si ature of Ownekgent`-��- Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR MMERS iST2ND 3RD SPAN DEV ENSIGNS OF SILLS M ENSIONS 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 NORTH Town of RAndover 0 No. *71 _ dover Mass. "0 T O CA 1• 1 I� COCMICKEWICK V 7 ADRATED I"? '4S BOARD OF HEALTH Food/Kitchen PERMIT T Septic System BUILDING INSPECTOR flA THIS CERTIFIES THAT.—A.......... Foundation has permission to erect........................................ buildings on ...Y ...... .. ........ ........ 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. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION T S 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. �N The Commonwealth of Massachusetts c Department of Industrial Accidents Office of Investigations 600 Washington Street Boston MA 02111 www.mass.g ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/individual): Address: City/State/Zip: 1Vjj�� Phone #: Are y u an employer?Check the appropriate box: Type of project(required): I.Z1 am a employer with a- 4. ❑ I 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. + 7• �etnodeling 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 officers have exercised their 10.❑ Electrical repairs or additions required.] 3.❑ 1 am a homeowner doing all work right of exemption per MGL I i.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#I must also till 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: Am(' `f;kaq I vOn` ' & ' Policy#or Self-ins. Lic. so C_ 1119` 13& � Expiration Date: t t a C9 Job Site Address: ")li* ,�,P�G�✓L �a . City/State/Zip: . at,�,a�� 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 tine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of investigations of the DIA for insurance coverage verification. I do hereby certify under the p ins penalties of perjury that the information provided above is true and correct. Si nature: Date: 16 Ila OS Phone#: 1 7 7 g Official use only. Do not write in this area,to be completed by city or town gfficial. 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 w 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 carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any 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 tilled 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: 1 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 vvww.mass.gov/dia SENT BY: NORTH ANDOVER & FOSTER INSURANCE;9785865410; DC7-12-05 2:23PM; PAGE 111 M.00. CERTIFICATE OF LIABILITY INSURANCE �O G IE Pltoouc�RTHIS CER11FINN 3 1RUED AS A MATTER OF INF TION NORTH ANDOVER SN9ttAANCE Al:IENC1' iZtC ONLY AND CONFERS NO RIGFIT$ Upas) THE C IFICATE HOLDER, TNIB .CERTIFICATE DOES NOT AMEND, LEND OR 9 NAVERLX Rm ALTER THE V GE AFFORDEDBY THE POLICIES LOW. INSURERS AFFORDING COVERAGE NORTH ANDOVBR MA 01845-2415 LNSURSIC •PATI QpAk;m MUTUAL W ahael Redden INsuRER a AMUCAN 1MRNATIONAL 47 Prescott Street IMauReRc: North Andover MA 01645mwim E; - C THE POLICIES OF INSUMNCE LISTED BELOW HAVE BEEN ISSUED I'0 THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWfTHS ANDIN(i ANY AFOUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT NTH RESPECT TO?WHICH THIS CER11FICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 16 SUBJECT TO ALL THE TERMS, EXCLUMON6 AND CONDITIONS OF SUGM POLICIES. A00AWATE LIMITS SHOIMV MAY HAVE BEEN REDUCED BY PAID CLANS. MSR 11?E or PMRANCE POLICY N mul. p"CTIYR mmuTIONRa man LMHiS A 211INIM1.L / / ! ! EACH=URASKI I 000,000 X ERCLALt3E iTY FIRfDAMAGE ar>VsI SO01000 cLmsvme cK;(;LR MPP37305 02/01/3005 02/OS/2006 MEbDiI' I 10,000 PERSONAL&AOV IMILMY a 11,000,000 12,000,000 3ENLADOAEOATE LIMIT APPLIES PER: PRODUCTS-COMPJOP Am a 1:2,000,000 POLICT LOG A AutarorrlQ !!7747777 07/26/2005 07/16/2006 COMWfNED Smu MIT ANY AUTO ALL OWNED AUTOS / / ! BODLY Rdmy X SCHeDWDAUTOS ow P-60 100,000 WIM AUTOS BODILY R6WRY NON-04M ,AUTOS (Pwaaawkno : 300,000 PROPERTY OAMAOE 100,000 MRAo!LM00.IT1' AUTOONLY-EAACCEIENT I ANY AUTO ! I I OTMIR TK%N FAA I A.....A AUTO ONLY: AO>3 I LJAEiL11Y, MHE t OCCUR CLAIMS MADE qO S M W l / _ DEDLICTIILE ! ! ! 1 1 NIRIIi�UAWTY'I1nNAH° �/ ! x ,uyllfa E.L.EAC"AM"NT I 100,000 e ssC6929366 01/01/2005 01/01/2006 r, ,DISEASE•sAEL I 100,000 S00,000 OTNen MGRIPTN9N OP OP21RA110NC1 OCA"OfthIMMLIL"GLUEIONp ADM SY I PRWIIOMII 7`1 0 970-697-0293 TIF rn ENOULO ANY OF 7W AEON! OElORI® EOLICKS W CAMMAL®I��ORi THE E74M111ATION DAT§,:Tim. TM ISRU N0 NSUIR WLLL SNCEAYpR Td Wll. 1;0 DAYS YMf 4TM: Wr=TO rig!CS7M MATS HOLDER NAMED To t 12 Lwr,on Tw OF NORTH mom FA LURI To N saftm TIO NO GIMTIM OR LIANUTr c1 IW UPON THE MUFAL ITS 011 REPRO/ERTArTl L AW"WR1>MM REIM�ENTATWE NORTH ANDMR H& 01645- 'u' ACORD 26.5(711M 40 ACORD COmdRATION 1888 INS0198(9810!.01 ELECTRONIC LAOFA FORMS,INC.•(IOOfaV-aw Pape t of 2 i 4 I NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: &� . is that the debris resulting from this work shall be disposed of in properly licensed solid waste disposal facility as defined by MGL 11, S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 10A. The debris will be disposed of in: Geo (Location of Faci ity) Signature of Permit pplicant Fire Department Sign off: Dumpster Permit Date New Basement Plan-44 Appleton Street ` i Laundry Room Bathroom = (Existing) (New) �r Stairs Workroom Family Room (New) I (Exisitng e a — t v` _ —