Loading...
HomeMy WebLinkAboutMiscellaneous - 453 WAVERLY ROAD 4/30/2018LibeMutual, INSURANCE November 13, 2015 Town of North Andover Attn: Building Inspector 120 Main Street North Andover, MA 01845 Liberty Mutual Insurance New England Region Central Property Unit 75 Sylvan Street Danvers, MA 01923 Tel: (800)566-0323 Re: Property Address: 453 Waverley Rd, North Andover, Ma 01845 Policy Number: H3521829521540 Underwriting Company: LM Insurance Corporation Claim Number: 032764022-0001 Date of Loss: 2/19/2015 Attn: Town/City Official Pursuant to M.G.L. c. 139, § 3B, please be aware that a homeowners insurance claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or causes the condition of a building or other structure to render Mass. General Laws, Ch. 143, 5 6 applicable. You are required to notify Liberty Mutual by certified mail in accordance with Mass. General Laws Ch. 175, 599, if you intend to initiate proceedings designed to perfect alien pursuant to Mass. General Laws, Ch. 139, 5 3A & B, or Mass. General Laws, Ch. 143, 5 9, or Mass. General Laws, Ch. 111, 5 127B. This letter should not be construed as a waiver or estoppel of any of the terms, conditions or defenses afforded by the policy or applicable law. Please direct your notice to the attention of the undersigned and include a reference to the above captioned property address, policy number, claim number, and date of loss. Sincerely, Liberty Mutual Support Liberty Mutual Insurance New England Region Central Property Unit 1-800-566-0323 . 9571 Date... '6 6 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .......... .......... . I .............................. has permission to p erform A -'Luc --c /& . aw- &M'tr'("6 04M�- ...................... . .................................................... wiring in the building of ........... e<91R. �yp--V. ............................... at ... ............................. , North Andover, Mass. �S�E�TO Fee. ............ . ..... .... 'L �"r- - - ' E4RICA�L INSPECTO Check# t.u►r►►nul"MOIt►, v► ria��ac,►�u�c��� --- - -- - ' Department of Fire Services Permit No. JqJ— 7 ° Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leave blank) f APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code ( C), 527 CMR 12.00 (PLEASE PRINT I7V INK OR TYPE ALL INFORMATION) Date: �- City or Town of. NORTH ANDOVER To the Insp ctor 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 Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ® (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: F Comoletion of the following, table may he waived by the In.cnertnr nfWiroc 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 No. of Luminaires Swimming Pool Above [i In- ❑ rnd. rnd. o*o Emergency Lighting Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump Totals: Number ............................................................. Tons KW No. of Self -Contained 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 WaterKW Heaters No. of No. of Si ns Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: .���d��� g� Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: 1 /s—zlai (When required by municipal policy.) Work to Start: 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, under the pains and penalties of per'ury, that the information on this application is true and complete. FIRM NAME: _ , `cy r LIC. NO.: rj 3 0 �liC Licensee: $ �4v Signature LIC. NO.: (If applicable, enter"exempt" 'n the licen number line.) Bus. Tel. No too3 �6�'9�3 Address: ` i +P�f� 5���.� D3o� Alt. Tel. No.fo3 6Vo oq,S'6 *Per M.G. 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 Owner/Agent Signature Telephone No. PERMIT FEE: $ t�. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 ay www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: V, City/State/Zip:<e��� 0303 Phone #: Are you an employer? Check the appropriate box: 1.0 I am a emplo er with / 4. ❑ I am a general contractor and I employees klull nd/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions ILEI Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *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. tContractors 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: Q Policy # or Self -ins. Lic. #: �o��c� Expiration Date: o Job Site Address 1!� r �, / jL�/l i(/. t,E f� 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 the DIA for insurance coverage verification. I dd hereby certify nder the pains and penalties of perjury that the information provided abov is tr a and correct. Signature: Date: "Y- 1, Phone #: gl5e-13 c CSD ©yS d 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 #: lw-,*�► ORM U -LOT RELEASE FORM INSTRUCTIONS: This form's used to verify that all nec.:ssary 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. 'AFFLICANT FILLS OUT THIS SECC TIC N�"t****"***�t"`:t"``* aPPLlCA�`dT 6tT Inc r, ST(OA)2 PHONE C a.V� LOCATION: Assessors Map dumberPARCEL SUBDIVISION LOT (S) STREET ` J V @ T �� �S T . NUMEER 5 > USE RECOMMENDATIONS OF TOWN AGENTS�CQ i D'Aac,",4 far CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS { WIS �"'�r Q T� �S Alin C rr -�-�.0 TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR -HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS - SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVE, EY EUILDING iNSPECTC R Revised 91.97 im DATE � .x M ` .'i:. F TTTJJJ J/ J 1 I , �92 • . TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING ". v✓9Lk k 4�'4 fS-r,¢- '�v ....: .^r� 4�5 BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioner/Inspector of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: Y Q 1.2 Assessors Map and Parcel Number: wa, Map Number Parcel Number 1.3 Zoning Information: Zoning Diaiic—t Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS R Front Yard Side Yard Rear Yard Required Provide Required Provided ReqWred Provided 30 /-5— 3 0 1.7 Water Supply M.GL.C.40. 54) 1.5. Flood Zone Information: Public ❑ . Private 0 Zone Outside Flood Zone 0 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record ►2o b-e'r�r Name (Print) Address for Service: Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Construction Supervisor: / % �;' C,V r r t er ft -A ?4,1— "tui /Ij } Address 0 -CD N v O nature Telephone Not Applicable ❑ �Licensed C3 5 35 3 License Number Expiration Dat 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Tele hone M M Z O f X SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 & 2506) 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 .......❑ No ....... 0 SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: a SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost Dollar ) to be ( Completed by permit applicant �` OFFICIAL USE tONLY .; k 1. Building (a) Building Permit Fee Multiplier 2 Electrical S�Q (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 I, , as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, as Owner/Authorized Agent of subject pr erty Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief L -%/-s Lvvy Print a SVhature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS iST2 ND3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIlvWEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE BUILDING DEPARTIN/i T DEBRIS DISPOSAL FORM la accordance with the provisions of MGL c 40 S 54, a condition of Building Permit Number rs that the debris resulting form this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150A - The debris will be disposed of in: r` dv S "7- 0 nl Location of Facility Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector . Y 1 r 1 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print Name: V f f� �� r� �,t%s Z n% Location: , VA S �— City /-) C: f (UT Y_3— Phone A-3 am a homeowner performing all work myself. �m a sole proprietor and have no one working in any capacity 0 I am an employer providing workers' compensation for my employees working on this job. Company name: Address City: Phone #: Insurance Co. Policy # Company name: Address City: Phone* Insurance Co. Policv # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as 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. I do herby certify under the pains and penalties of perjury that the information provided above is true and correct. Print name KCL)iP-J Pd s s2rvy Phone # &<F3 L )L� } Official use only do not write in this area to be completed by city or town official' ❑ Building Dept r_1 Check if immediate response is required Building Dept ❑ Licensing Board ❑ Selectman's Office Contact person: Phone #: ❑ Health Department ❑ Other FORM WORKMAN'S COMPENSATION Hip roof trusses -16" oc, 5/8" cdx plywood, 25 yr fiberglas shingles. .SLAB wilt IR U 'Mo, I I A good choice for coldychmte the steep pitch of thisroof'de~ sign will stop snow build up cold I A The solid brick construction° ' topped with decorative shingles. offers enough space to get two cars j in out of the weather. Natural light enters through a double -hung window in the side wall, and side entry is provided by a pre -hung door near the front ... just a short dash to the house. Design by Larry W. Garnett and Associates, Inc. 26 GREAT GARAGES Width 24' Depth 23' C� a ` u ` C u a C2-7 -ti,- CkI Location N o. Date 0Y -- TOWN OF NORTH ANDOVER Certificate of Occupancy $ �71- tit Building/Frame Permit Fee $ CHU Foundation Permit Fee $ Other Permit Fee $ TOTAL s �S Check # '2 � �, �,4 1513 3 Building Insp2or r rt TOWN OF N RTIT-i-AN ®VER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY. DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioner/I ctor of Buildings Date CT ltmT�» I � xxwrq 1- allr. ll'4VVM1V1A11Vn 1 1.1 Property Address: 1.2 Assessors Map and Parcel �- 0? Map Number Number: Parcel Number 1, L�i ,f `--Y-- ` d A-6 2.1 Owner of Record Name Print) Address for Service (v 2 �. 1.3 Zoning Information: Lonmg District Proposed Use Signature Telephone 1.4 Property Dimmsions: Lot Areas Frontage ft 1.6. WELDING SETBACKS ft Signature Telephone Front Yard Side Yard 3.1 Licensed Construction Supervisor: M[censed Constructi Supervisor: Address Signature,. Telephone Rear Yard Required Provide Required Provided R red Provided Not Applicable ❑ Company Name Registration Number Address 1.7 Water Supply M.G.L.C.40. 54) Public ❑ Private ❑ 1.5. Flood Zone Information: Zone Outside Flood Zone ❑ 1.8 Municipal Sewerage Disposal System: ❑ On Site Disposal System 0 ���-■��.. � - r>nvrr,l�1 = vwi�i!,i(�nil-/AU 1riVK1GL+1) A(i�N'I' 2.1 Owner of Record Name Print) Address for Service (v 2 �. Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES i 3.1 Licensed Construction Supervisor: M[censed Constructi Supervisor: Address Signature,. Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Si nature Tele hone . 4 SECTION 4 - WORKERS COMPENSATION (NLG.L. C 152 § 25c(6) 1 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 .......0 No ...... ..Q SECTION 5 Descrintioa of Pronosed Work (check all aonlicable ) New Construction ❑ 1 Existing Building ❑ 1 Repair(s) ❑ 1 Alterations(s) ❑ 1 Addition ❑ Accessory Bldg. ❑ j Demolition ❑ 1 Other ❑ Specify Brief Description of Proposed Work: I SF.( TION 6 - F.STTMATRD CONSTRITrTION rOSTS I Item Estimated Cost (Dollar) to be Completed b permit a lican x ISI+3�Y . , 1. Building(a) C! no d Building Permit Fee Multiplier* �° e6 2 Electrical -(b) Estimated Total Cost of Construction q(0 / 3 Plumbing.Building Permit fee (a) X (b) J)')� ((/ 4 Mechanical. HVAC 5 Fire Protection 6 Total 1+2+3+4+5 p p Check'Numbet ISECTION 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 ; in all matte relative�tk�authorized by this building permit application. l �© 61 Signature oPbwner Date I SECTION`%b OWNER/AUTHORIZED'AGENT DECLARATION I I 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 of Owner/. Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TRABERS 1 ST 2 ND 3 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 D. Robert Nicetta Building Commissioner (978) 688-9545 .,..:(978) 688-9542 Fax Please print DATE . Town of North Andover Building Department 27 Charles Street e If North Andover, MA. 01845 HOMEOWNER LICENSE EXEMPTION JOB LOCATION 'r 3 W keku Number "HOMEOWNER Name PRESENT MAILING ADDRESS Street Address Home Phone Lt)#✓LZl K fp- Map / lot Work P . M . t� City Town State lip Code The current exemption for "homeowners" was extended to include owner-0ccupied dwellings of two units or less and to allow such homeowners to engage an individual for hire who does. not possess a license, provided that the owner acts as supervisor. (State Building Code Section 108.3.5.1) DEFINITION OF HOMEWOWNER: Persons)"who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures ac- cessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned "homeowner' certifies that he/she understands the Town of No. Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNER'S SIGNATURE 1U, ` , APPROVAL OF BUILDING OFFICIAL FORM U - LOT RELEASE FORM ~ INSTRUCTIONS: This form is used to verify that all necessary 1 � ry approvals/permits from r 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 f .y yn . �"Q,I/y157CLUNG PHONE LOCATION: Assessor's Map Number �O� PARCEL SUBDIVISION LOT (S) �..STREET ST. NUMBER *****************************************OFFICIAL USE ONLY*********************************** AGENTS: 'CON TVATION ADMINISTRATOR DATE APPROV9D _.DATE REJECTED_�fh COMMENTS IITI As �.,� I1.... 1W i , - I,.rml __ 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 9\97 jm North Andover Building Department r 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 o (Location of F ity) L Signature of Per Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector 0 0 cd 0z �a wo w�a I Ell A-� I CD 0 a) Z 0 0 CO) CD CO) co co O v M CL CO2 O O CO) O C.) s 0 CD co 0 o 0. Q. C Q O O O Z w CD CO) c • 0 U) W W w U) L x W pG a w O y p '� c O w w O cn E. v, 0z �a wo w�a I Ell A-� I CD 0 a) Z 0 0 CO) CD CO) co co O v M CL CO2 O O CO) O C.) s 0 CD co 0 o 0. Q. C Q O O O Z w CD CO) c • 0 U) W W w U) O y c O V c ;Z O ►' O �:msa0 O O CD �• m c oLA m (�• ^� 3� ca r6 M5 m o cmc y m ; 'S Cc'sa C_ •a (uti C=a ' at 0 � m IS :y = o Q0 a C W rL�+ oc_ C +• .� .a = 4'IS .0 0; • 93 a cm O L3 h 4D 0 '� m � c F- z �a�m 0z �a wo w�a I Ell A-� I CD 0 a) Z 0 0 CO) CD CO) co co O v M CL CO2 O O CO) O C.) s 0 CD co 0 o 0. Q. C Q O O O Z w CD CO) c • 0 U) W W w U)