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HomeMy WebLinkAboutMiscellaneous - 44 PLEASANT STREET 4/30/2018 / -44 PLEASANT STREET l 210/055.0-0038-0000.0 Cunningham Lindsey U.S.,Inc. ACA P.O.Box 703689 Cunnin ham sw Dallas, 75370-3689 Lindsey Telephonene(888)738-8714 Facsimile(214)488-6766 CLCAT@CL-NA.COM Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS Ch. 139, Sec 3B Building Commissioner or Inspector of Buildings 1600 Osgood Street, Building 20, Suite 2035 North Andover,MA 01845 Claim Number: 2626728 Policy Number: 2626728 Company Name: MERRIMACK MUTUAL FIRE INSURANCE CO Date of Loss: 03/10/2015 Insured: MICHAEL SUFFOLETTO Property Location: 44 PLEASANT ST, NO ANDOVER, MA 01845 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 3B 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. Section 3B. No insurer shall pay any claims (1) covering the loss, damage, or destructions to a building or other structure, amounting to the one thousand dollars or more, or (2) covering any loss, damage or destruction of any amount, which causes the condition of a building or other structure to render section six of chapter one hundred and forty-three applicable, without having at least ten days previously given written notice to the building commissioner or inspector of buildings appointed pursuant to the state building code, to the fire department or arson squad of the city or town and to the board of health or board of selectmen of the city or town in which the same is located. If at any time prior to the payment the said city or town notifies the insurer by certified mail of its intent to initiate proceedings designed to perfect a lien pursuant to section three A, or to section nine of chapter one hundred and forty-three, or section one hundred and twenty-seven B of chapter one hundred and eleven, the said payment shall not be made while the said proceedings are pending; provided, however, that said proceedings are initiated within thirty days of receipt of such notification. Any lien perfected pursuant to section three A, or to section nine of chapter one hundred and forty-three or section one hundred and twenty-seven B of chapter one hundred and eleven, shall extend to and may be enforced by the city or town against any casualty insurance policy or policies covering any loss, damage, or destruction pursuant to which the proceedings to perfect the lien were initiated. No insurer shall be liable to any insured owner, mortgagee, assignee, city or town, or other interested party for amounts disbursed to a city or town under the provisions of this section, or for amounts not disbursed to a city or town under the provisions of this section. On this date, I caused copies of this Notice to be sent to the persons named above at the addresses indicated above by First Class Mail. Cunningham Lindsey Catastrophe Department cicat@cl-na.com 800-867-3885 t, Date." ..........� ................... � of NogTti�ti fir; co TOWN OF NORTH ANDOVER PERMIT FOR WIRING * z . L This certifies that ..... .1.J....... - .............................................. has permission to perform .........:...... wiring in the building of...... .: � ���' 40 ......................................................................................... at ..............'.!.:..1.......... ............................ North Andover,Mass Fee......1Q..`...............Lic.Not.1ao..... ."!Pr............. J } ELECTRICAL INSPECTOR ` Check4t j2ol - i 11501 is r= � <Ll\ Commonwealth of Massachusetts Official Use Only Permit No. 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(NEC),527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: � A// 3 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) Y--6 I��ec.sr c57� Owner or Tenant _ /7,-,kc- Telephone No. 7/6 465' 023'� Owner's Address y6 1-/• 4Q 7 RU 4,J©©�� rn� Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) . Purpose of Building Utility Authorization No. [ 377 Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service 200 Amps t00 / Z'tCJ Volts Overhead p Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: I Completion of the following table maybe waived by the Ins ector of Wires. No.of No.of Recessed Luminaires No.of Ceil:Susp:(Paddle)Fans Trans Total Trsformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- o.o mergency ig ting No.of Luminaires Swimming Pool rnd. ❑ rnd. ❑ BatteEy Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches 2 No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Tons TotNo.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained P Z Totals: W Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal [J Other Z I? g Connection Heating Appliances KW Security Systems:* No.of Dryers No.of Devices or Equivalent No.of WaterKW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent Bathtubs No.of Motors Total HP Telecommunications Wiring: No.Hydromassage No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: 6300 (When required by municipal policy.) Work to Start: YLL& 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 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 ❑ BOND ❑ OTHER ❑ (Specify:) I"certify,sander the pains and penalties ofperjury,that the inform tion on this application is true and complete. FIRM NAME: � S w4e1 f 'cst, LIC.NO.: Licensee: 1 ,1_ ��&s.o-7 Signature NO.: (If applicable,enter "exempt"in the license number line.) Bus.Tel.No.: Address: 26 ioi PJ F/Ls-knvJ A) 63r s-E 6 Alt.Tel.No.: *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 a ent. Owner/Agent FPn?mITFEE.- $ D Cianafirra Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the AW permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass EN Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: r. Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: ( Inspectors Signature: Date: ROUGH INSPECTION: Pass F?1 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments• Inspectors Signature: Date: nmo lnlr1n111-1n —r 1 � The Commonwealth of Massachusetts -' Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/individual): 1�5CU� —�v//fpm �'! /e C To'rCl� Address: City/State/Zip: rm.`s-� , 0>%66 Phone#: 979 Zq6 T Are you an employer?Check the appropriate box: Type of project(required): L❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction __/employees(full and/or part-time).* have hired the sub-contractors Remodeling 2. I am a sole proprietor or partner- listed on the attached sheet. ship and'have no employees These sub-contractors have S. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.F1 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no: 12.❑Roofrepairs insurance required.]t employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I 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. lam an employer that is providing workers'compensation insurance for my employees Below is thepolicy and job site information. Insurance Company Name:. Policy#or Self-ins.LiFc.9: Expiration Dater 9 ) D Job Site Address: 7� f`IP,G S�-✓1 City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP.WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certio under the pains anddpeennalties ofperjury that the information provided above is tru and correct. Simature: ��� G✓���`— Date: Phone#: / 0' Z7 t-)^7 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 7 - - Contact Person: Phone#: I 09795 Date . .,,.:.. . . ►. . . . . I TOWN OF NORTH ANDOVER C PERMIT FOR PLUMBING i This certifies that . . . . . . . . .�• . . _ . . . . . .. . . . . . . r has permission to perform .(.&G �r!r . . . . . . . . . . . . . . plumbing in the buildings of. S . . . . . . . . . . . . . . . . . at . . . . . . . , , North And jve Mass. Feed: ,1-/7.,,O. Lic. No. ✓(./. . . . . ... . PLUMBING INSPECTOR` Check# p MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY ._.Q _ MA DATE )PERMIT# JOBSITE ADDRESS OWNER'S NAME &IRZ . - _ POWNER ADDRESS _ TEL _8 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW: �k RENOVATION: REPLACEMENT: PM PLANS SUBMITTED: YES N0�1 FIXTURES'l FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB ( } I .._.___ _( i k _ I _--_-_ CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM I __-_ _( ._-____,►. ..._ __f ._ ..,I _( --_,-_ -,_.._ ._._._.._k _.._ I .-___J k _. i I DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN _ _l .---.__-.J l __._.___I ___...__k I __._.--! --.__-_( --_-_- .___....._ __._._1 ._—.-.( FOOPADISPOSER FLOOR/AREA DRAIN I _1 ._._.__ __-.-_- ( ___ l I .__..._-_.( _,_---.__1 .._....-._! --._-_ .---,_-_-_ -..._._.._( ..___.._J INTEFCEPTOR(INTERIOR) _. kk. ._ (k _-._ KTC EN SINK J LAVATORY ROOF DRAIN — I __ _____J1 SHOWER STALL __J .___ SERVICE MOP SINK -_.-----_ __j TOILET ( ` ..__J _E _1 __.__.. . __.__1 . _._.J - 1 URINAL _ 1 .._...___ � k _..._.__J .........___! WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING - OTHER _-_._____ ._ ! f INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES r_�l NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY�f OTHER TYPE OF INDEMNITY Ej BOND El 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 E- AGENT 10 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 be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME "L?# LLICENSE# �Q SIGNATURE MP o! JP Q CORPORATION[:]# PARTNERSHIP _.f# I LLC COMPANY NAME I ALI /� '/1/�C' `, /k /V ADDRESS CITY hf _._._.._........._.-.....-_i STATE i%-I ZIP _ Q/ �"— TEL �-_ � FAX j CELL�]EMAIL 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 Vmh-g .J r l- S .rs .w f The Commonwealth of Massachusetts - Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 kvi www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): fQ 10 1-h-146 a A0 Address: aC—Ba-cd &r beq&J R. Z> City/State/Zip: A/01nj,,//X 9<_ 1414 A- Phone#: I 74 9' X62 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 employees(full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet. �• Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g, ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.El Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.[]Roof repairs insurance required.]f 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 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. lam an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: rA A 4/4 PA`" / 1 � Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: y V tt y hT 6/¢ 44) S)L— City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I-do hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct - Signature: �l�iret.ff — 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#: { A Informati®n 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 ofhire,. 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 aJoint enterprise,and including the legal representatives ntatives 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 rp ore 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 withholdthe issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used.as.a reference number,_-In addition,an,applicant that must submit multiple permit/license applications in any 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 CorumonweaXth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 TeX,#617-727-4900 ext 406 or 1-877,7MASSAX?B Revised 5-26-05 Fax#617-727-7749 www.mass,govldia xt Location No. /7Z2 Date leg- 6v NORTq TOWN OF NORTH ANDOVER 41 Certificate of Occupancy $ Building/Frame Permit Fee $ MU Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 12d Check # 17624 —6-i-Iding inspe(gr TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY"gjq1ii 0* BUILDING PERMIT NUMBER: / DATE ISSUED: Q i SIGNATURE: Building Commissioner/1or of Buildings Date SECTION 1-SITE INFORMATION 1.1 Property � 1.2 Assessors Map and Parcel Number: Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: v Zoning District Proposed Use Lot Area Franca ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide ReqWred Provided Required Provided 1.7 Water Supply M.G.L.C.40.§54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal S ystm Public ❑ Private ❑ zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of-Record IV _( Name(Print) Address for Service i '% Signature Telephone 2.2 Owner of Record: Name Print Address for Service: 2 Signature Telephone SECTION 3-CONSTRUCTION SERVICES ' 3.1 Licensed Construction Supervisor: Not Applicable Licensed Construction Supervisor: License Number Address Expiration Date Signature Telephone NONE r 3.2 Registered Home Improvement Contractor Not Applicable ❑ v Company Name Registration Number M r Address r o 000010 Expiration Date ^Z Signature Tel hone YI 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 it. Signed affidavit Attached Yes.......❑ No.......0 SECTION 5 Description of Proposed Work(check an applicable) New Construction ❑ Existing Building 0 Repair(s) 0 Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition 0 Other 0 Specify Brief Description of Proposed Work: ,�l 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 no Construction 3 Plumbing Building Permit fee(a) x (b) 4 Mechanical(HVAC) J�'^ 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 1, Y UZ as Owner/Authorized Agent of subject property Hereby authorize � to act on yj+ My half,i all t rs r ative tow authorized by this building permit application. SMgAture of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, as Owner/Authorized Agent of subject property Herebv 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/Agent Date h NO. OF STORIES SIZE . i BASEMENT OR SLAB i SIZE OF FLOOR TIMBERS 1ST2ND3RD 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 FORM U - LOT RELEASE FORM Rp D <<w� ' b' 3� H j 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 �� C 'HONE LOCATION: Assessor's Map Number �v ` PARCEL SUBDIVISION � ' LOT (S) STREET �� �� ST. NUMBER *********OFFICIAL USE ONLY*************** REG MMENDATIONS TOWN AGENTS: N NSERVATION ADM I TRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED - DATE REJECTED - COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm f TOWN OF NORTH ANDOVER AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application MGL c. 142 A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units...or to structures which are adjacent to such residence or building" be done by registered contractors, with certain exception, along with other requirements. r_ 1 , Type of Work: &e-lovtl �k �S' l,z Est. Cost Y-6 Sb Address of Work Owner Name: Qcu) � IJIJ�SU?J Date of Permit Application: hereby certify that: Registration is not required for the following reason(s): For office Use Only Work excluded by law Pemit No. Job under $1,000 Date Building not owner-occupied Owner pulling own permit Other (specify) Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FIND UNER MGL c. 142A. Signed under penalties of perjury: I hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No.. OR: Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property: Date Owner Name e 1 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: /Vv. lWbvt - Location f . ( o F ility) Signatu e P plicant Date I NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector �� �� ,�, 3'� �� ���-'� ,. r .9�+ •-.�'.�' 0 _ t� - . � - ..7G �x.h w+..f trv°w+_Y y � �•z; � P t� ro 52 lb /A6 � tnntNA°avii* e .. � ' { jL 4" S .. c9y s� 9 l� ros cs V 4 '.. .. .. �:. { -' JI�� a y:• .,,s a � /Wr:3� r fir,„3►i9 t i -iF� y+A01�' � JAW i, � � RDOG ,� tqp • � �/�4f� �; � r � � � '. ;00 �c dA F 90 �:' i „ dQd r i.--��i t~ ,� O ri Rk,`4 •N� f5 It `�i" 1 R.•.�tkgMyyf5 .l ...E��} `JNa �'t .�.,, 7 r x• • :•� a�"Y�` rP �. ry'p �� ��:.r.t� �:�: -{:: � �, 't •r."Lt' .L , Co4 b•a• /✓I }"t- �� z�` r' �x ys 'a' - �".'C'^ ,}s„ ..?zy+•.�"•^ �,,. t _ .. ,'.,.xW�f;r "� .t .•�� t. .F:� ¢J:;�. � Iyt"ytir V,I` l. ' +' �' ;i;i �'-a., � •�'ii ��'�" '�. 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V'ri•,'+,NF k' 1 •s -' .;� 1 rv4�•. .j x..v �''P A a�,.. ,':. �tri g ,� r��} y �.�.r} •� ,'7'�5'�` � r'�s.- � � •a. , - ��Jc' '�'V',�'. :tom _ i `.''tiq:- r� t ''r".�Y + t•'iJ. s ;�j Y,1�' a€€"� '� r. � �f`r . �,��r "' Y VIN(1) �J o ` NORTH Tomm of Andover No. /70 - A o, dover, Mass., dd COC MICKEWICK AERATED `S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THISCERTIFIES THATA.P..VY • C /f± O. ... ............................. .................... . ........................................................................ Foundation has permission to erect. /P0N►0 60* buildings on.....!0.....y......G............J..O....J....r....6)....s. .Nf........$..� Rough ... .... .... to be occupied as *# �� c. .� � e 0 � 1r Chimney le ... . 4.t. 3.....................�N.................cK 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 Inspecti n, Alteration and Construction of Buildings in the Town of North Andover. S4 0 J PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STAR 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 (Nall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Bumer Street No. SEE REVERSE SIDE Smoke Det. . , Location No. `5 c Date01 .. NpRT" TOWN OF NORTH ANDOVER 3? 0 F p Certificate of Occupancy1491 $_ Building/Frame Permit Fee $ C" SIA Foundation Permit Fee $ Eflr elsrFee'� $ Ar,0 U E COLLECTOR Sewer Connection Fee $ Water Connection Fee $ JUL ?i7 4MTAL $ ,•'t,__•� - - 777 err Building Inspector 6306 Div. Public Works PEIV41T NO. ����' APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 MAP 4-40. LOT NO. 2 RECORD OF OWNERSHIP ;DATE BOOK ;PAGE ZONE I SUB DIV. LOT NO. rI OCATION �� �`� f ,,L J I PURPOSE OF BUILDING OWNER'S NAME O NO. OF STORIES fSIZE WNER'S ADDRESS / BASEMENT OR SLAB ARCHITECT'S NAME 7 SIZE OF FLOOR TIMBERS IST 2ND 3RD ILDER'S NAME ,`�G, / � / M q /�C SPAN DISTANCE TO NEAREST BUILDING `s 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 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 3 PROPERTY INFORMATION L ND COST SEE BOTH SIDES EST. BLDG. COST ) PAGE 1 FILL OUT SECTIONS t - 3 EST. BLDG. COST PER SQ. FT. G� PAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 13 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY .{ ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR D/ATE ILE v BOARD OF HEALTH GN TURE OF OWNER OR�ryA TH IZED AGENT V FEE � ' v ^� OWNER TEL # b J�� PLANNING BOARD PERMIT GRANTED CONTR.TEL.# t9 __Z �dTR. LIC.# BOARD OF SELECTMEN /yam BUILDING INSPECTOR BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY I ISFORIEsTHIS 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 d l 2 13 :ONCRETE BL'K. ---III PINE BRICK OR STONE HARDw o — PIERS PLASTER _ DRY WALL _ UNFIN. 3 BASEMENT 11 AREA FULL FIN. B'M'T AREA _ '/, 1/2 FIN. ATTIC AREA _ J_O B M T FIRE PLACES _ READ ROOM MODERN KITCHEN 4 WAILS I 9 FLOORS -LAPBOARDS B 1 2 3 )ROP SIDING CONCRETE _ - NOOD SHINGLES EARTH _ ASPHALT SIDING HARDW'D _ ASBESTOS SIDING _ COMMGN _ VERT. SIDING ASPH.TILE _ iTUCCO ON MASONRY _ JUCCO ON FRAME 3RICK ON MASONRY ATTIC STRS. & FLOOR _ 3RICK ON FRAME :ONC. OR CINDER BLK. ,TONE ON MASONRY WIRING DONE ON FRAME SUPERIOR I I POOR _ ADEQUATE NONE - 5 ROOF 10 PLUMBING�AB , :LAT HIL— BATH (3 ;AMBREL MANSARD TOILET RM. 12 FIX.) LAT SHED WATER CLOSLOS ET _ kSPHALT SHINGLES LAVATORY _ HOOD SHINGES KITCHEN SINK iLATE NO PLUMBING _ CAR & GRAVEL STALL SHOWER _ tOLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING 11 HEATING VOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. •IMBER BMS. &COLS. STEAM JEEL BMS. &COLS. HOT W'T'R OR VAPOR VOOD RAFTERS _ AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL 3'M'T 2nd ELECTRIC cst 13rd NO HEATING \ *4 a TOWN O 120 Main Street OFFICES OF: �" North Andover. APPEALS ;i; .y NORTH ANDOVER Massachusetts o 1845 BUILDING (617)685.4775 CONSERVATION DIVISION OF- HEALTH PLANNINGPLANNING & COMMUNITY DEVELOPMENT ` KAREN H.P. NELSON, DIRECTOR In accordance with the provisions 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 c 111, S 150A. The debris will be disposed of in: (Location of. acility) Z' C-rq-600 lyl t Signature of Permit Applicant l� Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. ' � <`•� ✓lee f ammwa,uirallfi y�✓1�,auc/r*:wits �. -\ HOME IMPROVEMENT CONTRACTOR Registration 101752 3 Type - DBA Expiration 06/29/94 Andover Chimneys David A. Hawkins 640 South Union St ADMINISTRATOR Lawrence MA 01843 - � ".i ANDOVER CHIMNEYS 640 South Union Street LAWRENCE, MASSACHUSETTS 01843 July 22, 1993 Paul Lockwood 44 Pleasant Street � � Z North Andover, MA 01845 Roof Contract Strip vest section of roof Install 8" aluminum drip edge on horizontal and vertical perimeters Install felt paper Install Bird or GAF 20 year Fiberglass Shingles $1600.00 Remove debris Permit will be acquired if needed Point two (2) chimneys 300.00 Remove gutters and refasten correctly -5 - If roof requires plywood we will use CDX 3/8" 750.00 Deposit required - Half Balance upon completion Ct`� CO•.-- (t�(c _� Andover Chimneys is fully insured for Workers Compensation by Liberty Mutual Ins. Co. Agency: Howe Agency Andover Limited Warranty Enclosed Notice of Cancellation vi_d A. Hawkins Home Improvement Contractor Registration No. 101752 Expiration -- 6/29/94 k (508) 683-5139 • NORT► Town of o 0 .� : . : INA=�oC�,� dower, Mass., 19 a 0RATEO BOARD OF HEALTH Food/Kitchen PE RMIT T Septic System ��� � ����Q a� BUILDING INSPECTOR THIS CERTIFIES THAT.....>� ..................................................................... Foundation has permission to erect.*.1.J*# ...... buildings on...yfAX..X001 tOA17P........................ Rough to be occupied asf..R.100..jr.1.Jr.&&f...0.4'.s.Act 09..l1**qd,Q.rf� Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application ifn 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 STARTS ELECTRICAL INSPECTOR Rough o ................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Finalh No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner PLANNING FINAL 1"12 CONSERVATION FINAL Street No. v Smoke Det. nr1�rrn i1nrnTrn CIKIAI �n npi3i�3ninv �nlTRv PFRn�iT _