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HomeMy WebLinkAboutMiscellaneous - 454 MASSACHUSETTS AVENUE 4/30/2018 (2) 454 MASSACHUSETTS AVENUE 210/033.0-0026-0000.0 1, MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFiTT1NG (Print or Type) Mass. Date-12—Jt7 19 5_ Permit — Building Location __Owner's Name 0A✓ 0Lla_'_ Type of Occupancy.. ccs �T New ❑ Renovation ❑ Replacement Plans Submitted: Yes❑ No (y N NW W• Y z tL N N U W W rt N K O O W = !- J W UJ O V m }' S 41 x or- .< z 0' .o t- w -cc cc U3 ILI 0 d tt O W z W yr d LC }O- d W _ _. _ W •.• C. , 1� .. x tt C7 � :sr W f• y a C7 }� Z J I-' Z F. W W O > U. H J W Y d W 4. C 1- >. W m z O o Z d W > W 7 2. < Cr d t O O t; E O F- *S O 0 X LL 7 O O J U C > O a O SUB-BSMT: ` BASEMENT , ISTFLOOR 2ND FLOOR 3RD FLOOR _ I 4TH FLOOR STH FLOOR 6TH_FLO.OR,_ ._ I 7TH FLOOR >: STH FLOOR r Installing Company Name /' ' Check� h ck one: D. I/+��S � Certificate � Address_ Cc—1 bU e." a ❑ Corporation ❑ Partnership Business Telephone Y3 5-4 Firm/Co. Name of Licensed Plumber or Gas Fitter _ � auP7 ws;�cS I IINSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements o Yes CL— No ❑ q f MGL Ch. 142. If you have checked vees, please Indicate the type coverage by checking the appropriate box. A liability insurance policy 111/ Other type of Indemnity❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: 5rgnature of Owner or owners Agent I hereby certify that:all ofthe details and iniormalion I have submitted(or entered)in above appli a true and rate to$the best of m knowledge and that all plumbing work and installations performed under the permit issued s app tlo In compliance with all pertinent provisloris'oi'{he,Massachusetts State Gas Code and Chapter 142 of the Gen w T e of Ucense: `...._' umbIter Ucense Nu er Ugnatur cense mer or Gas rtter JAN Title sti aster mber /�l—//Z1C�� City/Town Journeyman Mf'tit7Vf:�7'F'fC • O . I Tt� 2035 Date.!✓.� 9'�• . H KiF HaRTM TOWN OF NORTH ANDOVER F1: ?Oy.T�Eo ra,ti O Y tio PERMIT FOR GAS INSTALLATION= p 41 FU 9SSACHUSE� This certifies that . . .D. .tA, , , . , , .�d has permission for gas installation . . L ?. . rl-5- in the buildings of I C. . . . . . . . . . . . . . . . . . . . . .0�. 1 at : .4!s�/ . G! ./`4 . . v.e. . . . . , North Andover, Mass. j Fee!2.1?,. . Lic. No.1./..i a e. GAS INSPECTOR 4 WHITE:Applicant CANARY: Building Dept. PINK:Treasurer GOLD: File p Location No. � Zq Date &ORTN TOWN OF NORTH ANDOVER Of � u : 1ti f - 9 ♦ i Certificate of Occupancy $ cMust` Building/Frame Permit Fee $ Foundation Permit Fee $ *, Other Permit Fee $ TOTAL $ Check # 1 Q G 6 7 Building Insperet�r' — TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR.RENOVATE. OR DEMOLISH A ONE OR TWO FAMILY DWELLING �. .. rn BUILDING PERMIT NUMBER. 11 DATE ISSUED. SIGNATURE: 11'64W ...� Building Commissioner/Ingwor of Buildings Date SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number. O A-33 �n Map Number Parcel Number / 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area Frontage 11 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Repired Provided v 1.7 Water Supply M.G.L.C.40.§34) 1.3. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zose Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ _J SECTION 2-PROPERTY OWNERSE"JAUTHORIZED AGENT rn1 12.1 Owne of Record )lame(Print) Address for Service: Signature Telephone 2.2 Owner of Record: Name Print Address for Service: z Z M Signature Tele hone SECTION 3-CONSTRUCTION SERVICES 90 3.1'Licensed Construction Supervisor. Not Applicable ❑ C L 676 C� ,--% Licensed Constructs Supervisor: �/ fJ t� % 0 License Number Address f �` q G �Q O ���G — �� ExpirationDae V Signature Telephone r 3.2 Regi tered Home Improverneift Con or Not Applicable ❑ Company Name 11117(f M Registration Number r Address1101o,6 Expiration Date r Signature Telephone ti/ • t SECTION 4-WORKERS COMPENSATION(KG.L C 152 f 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.......0 SECTION 5 Description of Pro workcheck aH applicable New Construction¢gQ, , ., , VDgstin f Building ❑ Repair(s) 0 Alterk .'y+ Addition ❑ 6 vt �` '� ,•YaRx` 'C � i`r Accessory Bldg. 0 Demolition 0 Other ❑ specify Brief Description of Proposed Work: rb SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(+)x(b) 4 Mechanical HVAC _..... 5 Fire Protection 6 Total 1+2+3+4+5 o Check Number SECTION 7a OWN] IRIZIATfON 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 7bb OWNEERIAUTTHHORIZED AGENT DECLARATION 71 v ems/` /5 as Owner/Authorized Agent of subject property r 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 NameSte— Si cure of Owfiqf/Agent Date NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1Yr24D 3KD SPAN DDAENSIONS OF SILLS DN ENSIONS OF POSTS DMIENSIONS OF GlI DERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY 1S BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE NORTH ver To'lvm o g o 0 --�-A--- 0 Ao over, Mass., A� COCHICHEWICK N, * 0 RATED BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System ........................... ........To I........dwoo............. . ............................... ...................... BUILDING INSPECTOR CERTIFIES THAT.... . .. ......... Foundation 00 has permission to erect........................................ buildings on.....7?7!!!!.... ........................................... ......... Rough to be occupied a ............... Chimney 4 provided that thisperson ac Ing iiii"p*'e'*r**m*"R*"'s"h"a*ll"l*n"'e"v'*e**r*y"*r"e"s"p**e**c't"*c*'o"n"f*O"r"m***t"o'**t'h*"e*'t**e*'r"m**s"*o"f**t**h*'e'**a*'p"p**Ii*c"a*'ti*o'"n"*'o'**n*'*fl'l*e**I*n' *i"i * Final this office, and to the pprovis ons 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 S E" CAL INSPWrOR ST ................................................................................................................. 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_jl Smoke Det. GEORGOUL,IS ROOFING & CONSTATCTION INC, y p, 96 ARLINGTON AVE DRACUT MA 01826 Ma.(978)-453-4242 Nh.(603)-898-5857 Toll free(800)-340-ROOF PROPOSAL, 10/18/04 TONI OREFICE JOB LOCATION; 454 MASSACHUSETTS AVENUE SAME N.ANDOVER,MA.01845 978-686-1470 REMOVE ROO ING DOWN TO WOOD DECK ON ENTIRE ROOF. INSTALL 12-4"X 16"SOFFIT VENTS ON MAIN SOFFITS. INSTALL 6'OF GAF ICE/WATERSHIELD UNDERLAYMENT ON ALL ROOF EAVES. INSTALL GAF SHINGLEMATE FELT PAPER OVER EXPOSED BOARDS. _JN&TAi i g" l AV-Y-DU Py RIP FDCU O1A ENTI.RF-ROOF�F12�fr1� R� — INSTALL GAF TIMBERLINE 30-YEAR ARCHITECTUAL SHINGLES AND TIMBERTEX CAPS ON ROOF. INSTALL NEW FLASHING ON PLUMBING PIPE. REBUILD CHIMNEY FROM ROOF LINE UP WITH NEW LEAD FLASHING AND CRICKET. INSTALL CORAVENT RIDGEVENT ON ENTIRE MAIN RIDGE. REMOVE ALL DEBRIS FROM PROPERTY. FIVE(5)YEAR WARRANTY ON WORKMANSHIP. GAF SMART CHOICE SYSTEMS PLUS 10-YEAR NON-PRORATED MANUFACTURERS WARRANTY. $3.00 PER SQUARE FOOT TO REPLACE ANY DAMAGED ROOF BOARDS. $60.00 PER SHEET TO REPLACE ANY DAMAGED PLYWOOD ON ROOF. WE PROPOSE hereby to furnish material and labor-complete in accordance with above specifications, for the sum of.. SEVEN THOUSAND SIX HUNDRED DOLLARS $7600.00 PAYMENT TO BE MADE AS FOLLOWS; $2600.00 PAID IN FULL WHEN MATERIALS ARRIVE ON SITE.$5000.00 PAID IN FULL WHEN JOB IS COMPLETELY FINISHED ACCORDING TO THE ABOVE LISTED PROPOSAL. All material is guaranteed to be as specified.All work to be completed in a substantial workman like manor according to specifications submitted per standard practices.Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate. All agreements contingent upon strikes,accidents or delays beyond our eontr .Owner to carry fire,tornado and other necessary insurance.Our workers are fully covered by workers compensa i, _ _cc- Authorized Sign This proposal may be withdrawn by us if not accepted within 30 days. Acceptance of Proposal-The above prices,specifications are satisfactory and are hereby accepted. You are authori#to do the work as specified.Paym 11 be made as outlined above. Signature Signature ate of acceptance �� FROM ALBERTDAIGLE (MON)MAR 7 2005 12:24/ST. 12:24/0. 6338932249 P 2 - i a ACORLL CERTIFICATE OF LIABILITY INSURANCE �°"3;05""'' mccucaR (D78)469-2101 Eat. THIS CERTIFICATE Is ISSUED AS A MATTER OF INFORMATION ' Delgle "any, Albert A. ONLY ANO CONFERS NO RI©NTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 313 MI 1 lard Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Dracut, MA 01826-6098 INSURERS AFFORDING COVERAGE NAIL 4 msumm GEORGOULIS CONSTRUCTION INC INSURER A:LIoyd's London 96 ARLINGTON AVE INSURERIT.CIuatt Commercial IRS. DRACUT, NA 01626 INSURER C, INSURER 0: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REOUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR i MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERM$.EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCFD BY PAID CLAIMS. POLICYNUMBER POLICY EFFECTIVE POLICV EYPIRATION LIMITS I GENERAL LIASR.ITY EACH OGGUHHtNIit s 1 00_0,000.00 X COMMERCIAL SENa+AL LIABILITY 161034388 02/15/2005 02/1512008 pR MISF¢,(Ec o„orrano.l i CLAMS MADE F—XI OCCUR MEO EXP IA^V c%Ive Mme+ S 5,000.00 A PEasowl►L s aDv INnmr i 1,000,000.00 OEHERALAOOREOATE i 1,000,000.00 GENT.AGGREGATE LIMIT APPLIES PER' PRODUCTS•COMPIOP AGG S 1.00 000.00 POLICY P LOC AU79MOWLE IJACiL//TY COMBINED SINGLE LIMIT i ANY AUTO (Ee aooideM) ALL OWNED AUTOS eoDlLr fwuRY s SCHEDULED AUTOS (Pn put—) HIRED AUTOS BODILY INJURY NOKOWNEO AUTDS (Per egg** i PROPERTY DAMAOE i (Por eoad+et) GARAGE LLABSITY AUTO ONLY-EA ACCIDENT S ANY AUTO OTHER THAN OL Aac S AUTO ONLY: AGO i E)XCESSIUMM ELLA UAa1L I Y EACH OCCURRENCE i OCCUR CLAIMS MADE AOGREGATE S i DEDUCTIBLE RETENTION i i WORRERB COMPENSATION AND WC'STATU EMYPR RS LIMP C782-80-24 08/25/2004 09/25/2006 E.L.EACH ACCIDENT s 100 000.00 B ANrFROPgIETOR+PARTNER/Ef(ECItTNE OFFICERAAEMBER EXCLUDED? E.L.DISEASE-FA EMPLOYEE t 10O 000.00 If Igo dombe UrAof SPECIAL PROVISIONS Esbw E.L.019EASE-POLICY LIMIT i $0.000.00 ovum DESCRIPTION OF OVERATiONs I LOCATIONS I VEM CM I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION Toni Orel I Co SHOULD ANY OF 71141E ABOVE DESCRIBED PDXES BS CANCELLED BEFORE TIE MU MT10N 454 Massachusetts Ave. DATETHOREOP,"M ISSUING INSURER W LL ENDEAVOR TO MAIL 10 DAYS WRITTEN N0710E TO THE CERTIFICATE MOLDER NAMED TO THE LEFT.BUT FAILURE TO DO SO SHALL N, Andover KA 01845 IMPOSE NO OBLf BAT10N oR OF AMI KIND UPON THE INSURER.ITS AGENTS OR RE AUT ACORD 25(2001/08) ORPORATION 1909 ( � --—� The Commonwealth-of Massachuseus Department of ZndzishnialAccidents office OfANP.Sl1Q00fis 600 Washington Stree4 74.Floor Boston,Mass. 02111 �Wo kers'Compensation Insurance Affidavit:Building/Plumbing/Electrical Contractors �nn3c;�n`f�tl'orrna �b h � �:,;-r<m=�'�•:� ••�._ ",,.w-�.x;_ r:,�. •_ name: address: '�J �f r '0Cj�S city state: 1Q1 a zin 0�0 7� hone# work site location(full address): ❑ I am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel. ❑ I am a sole proprietor and have no one working in any capacity, ❑Building Addition ,i..ed.• _,a3ca.�.�b ^ w.ae.+•-mss f.. �.y.F_ fr ,,,A - °�C -��'-. �am an employer providing workers'compensation for my employees working on this job. 5: company name: - ----- Georgoulis Const.Inc. address: 96 Arlington Ave. Dracut,MA 01826 city nhane# insurance co —� G' 4 79,5— 17 Aolic�# O T ❑ I am a sole proprietor,beneral contractor,or homeowner(circle one)and have hired the contractors listed below who have il3e following workers'compensation polices: company-name: address: oh6ne#: insurance co aolicv# 777 __ .. comoanv name: ,.. address: city hone#: insurance ca. ob # A'itach addhonaLh�etztfecicssar t g yfi Failure to secure coverage as required under Section 25A of JMGL Eat can lead to the imposition of criminal penalties of afine�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. Ido hereby certify ur er thepains andpenalties of perjury that the information provided above is true and correct 00-1 Signature 3 �� J-- .Date _ Print name c©�� �4�'(�z/�� Phone# >..-:-..:..:tY >..t..:•:..:.r t. t��#..v,- �r*4,.�:« :. .,., official use only do not write in this area to becompleted by ct,or town official w city or town: permitfilcense , (]Building Department ❑check it immediate response is required ❑Licensing Board - — ❑selectmen's o,fic-e contact person: ❑1fealth Department phone# (revised Sept.2003) ; - [Other La I xe� V' BOARD',' B. ILDIN REGULATIONS license: CONST CTION SURERMSOR ! - s Number. CS ' 058&498- Birthdate: 10121/1966 k .w * Expires:10112005 fr.no: 5318 Reif iced:,:00 SCOTT C GkORGOULIS. � 4 Ea A�IIUGTON 4VE :. RAC , MA 01826 Administrator Board of Building Regulations and Standards ' HOME IMPROVEMENT CONTRACTOR ' Re9lqbtion;;.117870 Exptr0ion' 12112/2006` Type i n to Corporation GEORGOULIS CONSTRUCTIdN;INC. SCOTT GEORGODUS 96 ARLINGTON AVE DRACUT,MA 01826 a 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: 4�7 (Location of Facility) , 4Sign4of Armit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector a I