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Miscellaneous - 46 CHADWICK STREET 4/30/2018
� 46 CHADWICK STREET ��Yl� 210�066�0000.0 b Commonwealth of Massachusetts FHEALTH 214Asbestos Notification Form ANFDecal Number 2014fH ANDOVER ARTMENT Important: When filling out A. Asbestos Abatement Description forms on the computer,use 1. a. Is this facility fee exempt-city,town, district, municipal housing authority, owner-occupied only the tab key residence of four units or less?❑✓ Yes ❑No to move your cursor-do not b. Provide blanket decal number if applicable: use the return Blanket Decal Number key. 2. Facility Location: VQ OWNER 46 CHADWICK STREET a.Name of Facility b.Street Address , NORTH ANDOVER 101845 c.CityFrown d.State e.Zip Code f.Telephone Number INSTRUCTIONS 3. Worksite Location: 1.All sections of this ATTIC form must be a.Building Name/Building Location b.Building# c.Wing d.Floor e.Room completed in order to comply with 4. Is the facility occupied? ❑✓ Yes ❑No DEP notification requirements of 310 CMR 7.15 5. Asbestos Contractor: and the Division of Occupational DUDLEY SERVICES INC 43 DUDLEY STREET PO BOX 132 Safety(DOS) a.Name b.Address notification ARLINGTON 02176 7816434328 requirements of 453 CMR 6.12 c.Ci /Town d.Zip Code e.Telephone Number AC000112 f.DOS License Number g. Contract Type: [DWritten El Verbal h.Facilitv Contact Person i.Contact Person's Title 6 SAMUEL J NIGRO III I JAS032802 a.Name of On-Site Supervisor/Foreman b.Supervisor/Foreman DOS Certification Number ENVIRO-SAFE ENGINEERING JAM060297 7' a.Name of Project Monitor b.Project Monitor DOS Certification Number ENVIRO-SAFE ENGINEERING IAA000131 8' a.Name of Asbestos Analytical Lab b.Asbestos Analytical Lab DOS Certification Number 05/01/2014 05/02/2014 9' a.Project Start Date mm/dd/ b.End Date mm/dd/ �0 8AM-5PM �N c.Work hours Mon-Fri. d.Work hours Sat-Sun. 10 10. a. What type of project is this? -0 ❑ Demolition ❑✓ Renovation ❑ Repair ❑ Other, please specify: b.Describe 11. a. Check abatement procedures: 0 ❑Glove bag ❑ Encapsulation �o ❑ Enclosure ❑ Disposal only amu- ❑✓ Cleanup ❑ Other, specify: ❑✓ Full containment b.Describe -z -Q 12. Is the job being conducted: ❑✓ Indoors? ❑Outdoors? .. ■ anf001 ap.doc-10/02 Asbestos Notification Form-Page 1 of 3■ A Commonwealth of Massachusetts " 100196214 Asbestos Notification Form ANF-001 Decal Number A. Asbestos Abatement Description (cont.) 13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed, or encapsulated: 10 - 400 a.Total pipes or ducts(i—f`near ) 6. 1 otal other surfaces square c.Boiler,breaching,duct,tank d.Insulating cement surface coatings Lin.ft. Sq.ft. Lin.ft. Sq.ft. e.Corrugated or layered paper f.Trowel/Sprayer coatings -J II t� pipe insulation Lin.ft. Sq.ft. Lin.ft. Sq.ft. g.Spray-on fireproofing h.Transite board,wall board Lin.ft. Sq.ft. Lin.ft. i.Cloths,woven fabrics � j.Other,please specify: � 400 Lin.ft. S .ft. Lin.ft. S .ft. k.Thermal,solid core pipe IVERMICULITE insulation Lin.ft. Sq.ft. 1.Specify 14. Describe the decontamination system(s)to be used: CONTAINMENT BARRIER WITH CLEAN ROOM USING NEGATIVE AIR SYSTEM AND HEPA 15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2) (g): WET ASBESTOS PROPERLY SEALED IN SIX MIL POLY BAGS PLACARDED FOR ASBESTOS 16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency: a.Name of DEP Official b.Title c.Date(mm/dd/yyyy)of Authorization d.DEP Waiver# e.Name of DOS Official f.DOS Official Title N g.Date(mm/dd/yyyy)of Authorization h.DOS Waiver# � 0 17. Do prevailing wage rates as per M.G.L. c. 149, §26, 27 or 27A—F apply to this project? ❑Yes❑✓ No B. Facility Description 9-N =0 1. Current or prior use of facility: RESIDENTIAL DWELLING �o 2. Is the facility owner-occupied residential with 4 units or less? ❑✓ Yes ❑No SAME 3' a.Facility Owner Name b.Address o c.Ci /Town d.Zip Code J e.Telephone Number area code and extension �LL 4' a.Name of Facility Owner's On-Site Manager b.On-Site Manager Address —Z I D �Q c.City/Town d.Zip Code e.Telephone Number(area code and extension) anf001ap.doc•10/02 Asbestos Notification Form•Pa e 2 of 3 Commonwealth of Massachusetts ! 100196214 Asbestos Notification Form ANF-001 Decal Number B. Facility Description (cont.) 5' aa'.Name of General Contractor b.Address c.Ci /Town d.Zip Code e.Telephone Number area code and extension) f.Contractor's Worker's Comp.Insurer .P p _olic Number — h.Exp.Date mm/dd/y 6. What is the size of this facility? F a.Square Feet b.Number of floors C. Asbestos Transportation and Disposal 1. Transporter of asbestos-containing material from site to temporary storage site(if necessary): Note:Transfer a•Name of Transporter � Q b.Address Stations must comply with the c.City/Town d.Zip Code e.Telephone Number Solid Waste Division 2. Transporter of asbestos-containing waste material from removal/temporary site to final disposal site: Regulations 310 CMR 19.000 J.O.B. ROLOFF a.Name of Transporter --� r Cb.Address� c.Ci /Town d.Zip Code e.Telephone Number 3. a.Refuse Transfer Station and Owner b.Address I I c.Ci /Town d.Zip Code e.Telephone Number 4. IWASTE MANAGEMENT OF MAINE a.Final Disposal Site Location Name b.Final Disposal Site Location Owner's Name AIRPORT ROAD I INORRIDGEWOCK c.Final Dis osal Site Addressd.City/Town ME co e.State f.Zip Code g.Telephone Number �o D. Certification �N The undersigned hereby states, under the ISAM NIGRO penalties of perjury,that he/she has read the a.Name b.Authorized Signature �o Commonwealth of Massachusetts regulations 1PRESIDENT 1 14/2/2014 — 1 for the Removal, Containment or Encapsulation of Asbestos,453 CMR 6.00 and c.Position/Title __— d.Date mm/dd� _ 310 CMR 7.15, and that the information IDUDLEY SERVICES INC. contained in this notification is true and correct e.Telephone Number f.Representing o to the best of his/her knowledge and belief. o q.Address �Z h.City/Town i.Zip Code anf001 ap.doc•10/02 Asbestos Notification Form•Page 3 of 3 ,17 Location "/ (4�' C .4 w IC l` No /63 Date /c/ U NOR7N TOWN OF NORTH ANDOVER 3?0�,•`•o ,•,h0 0. - 9 Certificate of Occupancy $ �'�s''^•''<�' Building/Frame/Frame Permit Fee $ 60 sACKWU 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 0 Check # �a r J L V i Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING - - f4toase O it rn BUILDING PERMIT NUMBER. / / DATE ISSUED: SIGNATURE: Building Commissioner/InTwtor of Buildings Date Z SECTION 1-SITE INFORMATION O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 146 QJ/9-ow eck s 1 6 ,� J fjN60U„_,�7'C n Map Number Parcel Number � 1.3 Zoning Information: 1.4 Property Dimensions: (� V" Zoning DiArict Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS 00 Front Yard Side Yard Rear Yard Required Provide red Provided ReqWred Provided 0 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal 0 On Site Disposal System 0 SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of Record Name(Print) Address for Service: Signature J Telephone \i 2.2 Owner of Record: Name Print Address for Service: z M Signature Telephone 90 SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ of.9 12 L-> -G69 �Z o Lidensed Construction Supervisor: Q O e��e�2 S o^) S T License Number 11 Address ` '/I 9/7j 97� �S3I Expiration Date / ic Signature Telephone,�4 r c.J S::2L 3.2 Regist Home Improvement Contractor Not Applicable ❑ ALL U,70(---tz Coe wo,:4� /J Company Name / / rr T��3 M AJA Registration Number r Address 9//?- / 7S 3 Expiration Date Z Sina r Telephone SECTION 4-WORKERS COMPENSATION(M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......❑ No.......❑ SECTION 5 Description of Proposed Work check au applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ J Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant I. Building l( (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a) x (n) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGE OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owne uthorized Agent of bject property Her-b 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 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/Agenter Date ,; .•aY f � ,-ri.ry _ w. - Vit _`+.— ?, NO. OF STORIES SIZE BASEMFNT OR SLAB SI/.E OF FLOOR TIMBERS 1 2WD3RD SPAN DIMENSIONS OF SILLS DMENSIONS OF POSTS DIMENSIONS OF GIRDERS 1II?[GIIT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY 1S BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE ' J �� I J`1n�us�rialArciaeszza 54 .. 600 y(JQsirirt�ioti,$'treet ..�asrotz, � Q2Y11 Wof=,Campcnsaoon Insurance Affidavit �pPLICANT I7�FOP lATION Please PRINT Lembly Name: dh� �.� c�(�+J�zf�G/-1,r►� Location: cliv A,1.0 0,3 C e Teiephone '9 18- 9 2 - "IS-3/ D i am a homeowner,perigrm m;aE work myself, D 1 am sole proprietor and have no one wormnP in my capacity D I am an ernpioyer pro hum.-worker' compensation for my employees won=,-on this job Company Na=c /q LL l)✓1 Q Ohl 0- Rocjj ' Addres,: r)o FFC-i2ScvO ST Grp 8✓)10boe m-n/-}SS ' CitY: 2 Insurance Compaa5}: r1UGYZ5 / Policy D I am(circle one) sole proprietor,general contractor or homeowner,and have hired the contactors listed below who have the following. worker' campensauon policies: Company Name: Addre6s' City:Taicghone�: insw-anoe Company: Policy r: Company Name: Address: City: Te)�phone T: Insuznce Co=-o Poll'y': Atmel,addinoaa)sheetii necessa�' raiiuse to secure coverage as required uncle.'Section^5A of MGL'.5B can lead M the imposition o minipenalties of a fine up to 5'!,50 U•OD and/or one years' imprisonment as well as civil penalties in the form of a STOP WORIL OP -and a Erne of 5100.00 a day against M. I vnder6tand that.a Corry of this srziement may be IorvJardeo to the Dfnce of iavestieauens of the DI P.for coverage verincatlon. 1 do hereby certzft under the Gains and penalties of penury that the information above is mue and coerce Si�ature: LD Date; g /q A,Z it!t Nam t: Oinual'Dse ONLY-Do not write in tttis arez 0 5uildino Denanm ent Ciiy or 7 cmnz PermltJUrenss r: n Licensino board 0 selectmen's Ofnes m Health Deoarrmerni D Check 11 Immediate response is required o Other t+oriviAmm, &msmucrrio s Musachusetts General Laws chapter 152 section25 regtures all employers to provide worl=s' compensation for their employees. As quoted from the "lave" 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, con.�ucuon 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 section 25 also-states that ever' state or local licensing a ency 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, neither the commonwealth nor any of its political subdivisions shall enter into an_y contract for the perrormanee of'public work until acceptable evidence of compliance vrith-the insurance requirements of this chapter have beeripresented io.the contracting authority. .4ppiacants Please nll in the workers' compensation affidavit completely,by checlting the.box that applies to your sit9:1uation and supplying company names, address and phone numbers as all P-15 davits may be submitted to the. Dcpart o= of Industrial Accidents for.conEa=tion of insurance coverage. Also'be sur a io sign.and.date the affidavit. The affidavit should.be returned to the city ortawn that the application for the permit or license is being requested, not the De_parimeut of3ndustrial Accidents. Should you have any questions regarding the "law" or if you are required to.obtain a workers' compensauon policy,please call�the Deparnnent at the number Listed below. City or Towns please be sure that the affidavit is complete and printed lei bly. The Departnent has provided a space at the bottom of the affidavit for you to nil out in the event the Once of Invesugations has TO contact you-regarding the anplicant. .Please.be sure to till in the permit/license number which wit be used as a reference numb. The afndavits may be returned to the Department by mail or FAX-unless other arrangements have been made. The Ofri ce 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 Depa?-tn-ken`, address, telephone and cr_ number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of investigations 600 W ashis,-_ton.Street . Boston, YL4. aZ111 (017) 727-7749 Telephone- (617) 727-1900 ea. 406,409, or "75 td , AWLL UNDER Residential & Commercial Roofing All Types Of Chimneys CHIMNEYS POINTED-REBUILT-CAPPEDpert Masonry Work Siding �-Roof Leaks Experts Licensed&Insured Mass Toll Free Locally p,,,ned 4&Operated Since 1976 License#034200 1-800-WAIT-4-us m We Work Year Round (924-8487) IKO G�aP,� �esn Oe °olrn }-e�—s Phone Dam Proposal Submitted To Job Name Street ,.... Job Phone City,State&Zip Code lob Location We Propose hereby to furnish and labor in accordance with specifications below,for the sum of: o,tm .41, Dollars All material is guaranteed to be as specified.All work to be completed in a workmanlike Authorized manner according to standard practices.Any alteration or deviation from specifications be- Signature: r low 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 NOTE:This proposal may be or delays beyond our control,Owner to carry fire,tornado and other necessary insurance. withdrawn by us if not accepted within days. Our workers are fully covered by Worlanen's Compensation Insurance. We hereby submit Specifications and estimates for: S-7 x,10 ❑ Install 3 feet of special "Eave Seal" ice and water barrier protection along all bottom edges of roof and top to bottom in each valley. If roof is stripped, we will apply conventional ice and water shield ( 6 )ft. high in the same locations previously described and tar paper will cover the remaining bare wood. Any rotted or damaged boards will be replaced at( ) per linear ft. or ( (,'a ) per sheet of plywood. Install heavy gauge aluminum drip edges along every edge surface of each roofline 8` ld Cover entire roof(s)with IKO 25 year all asphalt, non-fiberglass, premium grade shingles (Color of choice). U'Replace all pipe boots where possible. 6d Seal all flashings with clear Geo-Cel sealant. No black tar unless previously applied. IdRemove all work-related debris. LdContractor warrants roof against all leaks due to defects in his workmanship for 12 years under normal circumstances. 91-ocal current references and proof of workman's compensation insurance gladly given. 0 Remarks: .-, �- _'j /r,c.� r ►� llc�t`T R �C.a.a��� `f=-c Lft4 / Acceptance of Proposal-The above prices, specifications i and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment Signature: will be made as outlined above. 1 Signature: Date of Acceptance: r NOKTfy Town of EAndover No. 143 O� CoCHIC LA � dover, Mass., ADRATED S BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT.....��.'�.......OF ,ao 4 to r ZBUILDING INSPECTOR ................................................. .. �A .. ............ ..... Foundation . has permission to erect.... -10".. 0".. buildings on ..... ......Ckj.004.w�, .. ....... ` Rough '...R't S �. � Q Chimney to be occupied as.... ....................... ........... ............................................................................................ 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- ws relating to the In ection, Alteration and Construction of G ` Buildings in the Town of North Andover. PLUMBING INSPECTOR y '� 6 O V. VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTIO STAR ELECTRICAL INSPECTOR Rough ............. .............. ......... ........................................................ Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. 3 CHAD-ICK STREET 210/O66�OC)00.0 ` Date f ...................l....... NORT1� TOWN OF NORTH ANDOVER PERMIT FOR WIRING �,SSACMUSES This certifies that .. !. ...... ............................ has permission to perform A :.... wiringinthe building of.` .. h�I� ...... ......................... ......................... &,? ................. orth Andover M S. Fee. J..r... Lic.No.... .. .. ............. . ELEdr &R Check # �vU �-• �,vrrrrrecyervd��rraer are a�r�n��sndeaa.a��ac�� Permit No. Department of Fire Services - Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (lmveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASEPRTNT.ININKOR=EALLINFOMWTION) Date: City or Town of: I`7®JEZTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or h intention to perform the electrical work described below. Location(Street&Number) 5 11 (A_J/C'k Cd Owner or Tenant Re(`ha r YI (I Telephone No. 9`Jp 400 Owner's Address s U PM G Is this permit in conjunction with a b 'lding permit? es ❑ No (Check Appropriate Box) Purpose of Building /e? Utility Authorization No. Existing Service 00,Amps }O o Volts Overhead� Undgrd❑ No.of Meters New Service AF Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work:' qC� lrG / I III Completion of the fallowing table may be waived by the Inspector of Wires. No.of Total No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans Transformers KVA � No.of Luminaire Outlets No,of Hot Tubs Generators KVA Above In- o.o Emergency Lighting No.of Luminaires Swimming Pool rnd. ❑ rnd. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Tons TotNo.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: ...""...... Detection/Alerting Devices Municipal Other No. of Dishwashers Space/Area Heating KW Local❑ ElConnection No.of Dryers Heating Appliances KW Security Systems: No.of Devices or Equivalent No.of WaterKW No.of No.of Data Wiring: Heaters Sim Ballasts No.of Devices or E uivalent Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent OTHER: -Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: 0 %3 (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 cove e is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:) X certify,under the pains and pena17)lties of perjur ,that the information on this application is true mttl cor�iplete. FIRM NAME: Q M G LTC.NO.:��F Licensee: l_aM S u Signature LIC.NO.: (If applicable,enter "e�enjpt in the license lan line. Bus.Tel.No.:- Gd�S Address: < t//'►9Q�' O G //109 �n ,+ D �� Alt.Tel.No.. 98,E y76� *Per M.G.L c.147,s.57-61,security work requires Departme 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 PERMIT FEE: $ Signature Telephone No. The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 �,„ s�• www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lel;ibly Name(Business/Organization/Individual): <+ / /ut 7 Address: vt 3i '� I m a ron oe k City/State/Zip: h U 9,FPhone#: �/7 7 9 F 0D;2 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction loyees(full and/or part-time).* have hired the sub-contractors 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. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10. 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.❑Roof repairs insurance required.]t employees. [No workers' 1311 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. 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: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: 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 do hereby cetify under the ains andpe aloes ofperjury that the information p ro vided above is true and correct. Si ature: c Date: Phone#: 0 9 av 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#: Location C Date MORTq TOWN. OF NORTH ANDOVER O? • , OLS" F p Certificate of Occupancy $ �, Building/Framelo rmit Fs $ / ' SSA�MUs t Foundation Permit Feb0*" Other PerVi, Fee _ $ Q9 Sewer Cappedion Feee $ Water Connection ?ee 199 TOTAL Building Inspector L'/�;l� n n �' Div. Public Works Location No. Date NORTH TOWN OF NORTH ANDOVER „ Certificate of OccupAhcy $ Building/Frame Permlif Fee ,$ Foundation Permit Fee $ s�c►+us e Other Permit Feg✓jJ� $ Sewer ConnectionV& $ Water Connection"Pee 1>$4t*3 TOTAL $� �' Building Inspector Div. Public Works PERMIT NO. YgZ/. APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. v PAGE 1 MAP 4,40. LOT NO. 2 RECORD OF OWNERSHIP IDATE BOOK "PAGE ZONE SUB DIV. LOT NO. rI LOCATION \_�A\ \' �+7y�_•�-T" PURPOSE OF BUILDING OWNER'S NAME SL±u, `�K IICGC NO. OF STORIES SIZE OWNER'S ADDRESS t+� CWrr��V:�(I C+T-y��_-�� BASEMENT OR SLAB ARCHITECT'S NAME DI K7�aG SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME SPAN -- DISTANCE TO NEAREST BUILDING 1, iltoLL2lC 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 LAND COST SEE BOTH SIDES 'delEST. BLDG. COST 1679- / 7 own 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT. PAGE 2 FILL OUT SECTIONS i - 12 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR /] DATE FILED l J BOARD OF HEALTH SIGN URE OF OWNER OR AUTHORIZED AGENT F E E OWNER TEL.��4� PLANNING BOARD PERMIT GRANTED CONTR.TEL.#_42!9L4A63(�_ 7t9 CONTR.LIC.#-Lott y BOARD OF SELECTMEN BUI INC INSPECTOR BUILDING RECORD a 1 OCCUPANCY 12 SINGLE FAMILY S_ RIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES _ LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE a 1 2 13 CONCRETE BL K. ---III PINE BRICK OR STONE HARDw D — PIERS PIASTER _ DRY VJAIL _ UNFIN. 3 EASEMENT 11 AREA FULL FIN. B'M'T' AREA _ '/. 1/1 '/. FIN. ATTIC AREA _ N_O B M T FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I g FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE �_ WOOD SHINGLES EARTH ASPHALT SIDING HARDW'D ASBESTOS SIDING _ COMtACN VERT. SIDING ASPH.TILE _ STUCCO ON MASONRY _ STUCCO ON FRAME BRICK N MASONRY ATTIC STRS. 6 FLOOR I_ BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME SUPERIOR I� POOR _ ADEQUATE NONE S ROOF 10 PLUMBING GABLE HIP BATH (3 FIX.) _ GAMBREL] MANSARD TOILET RM. (2 FIX.) LAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY _ WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING _ TAR 3 GRAVEL STALL SHOWER _ ROLL ROOFING I 11-MODERN FIXTURES _ 11 TILE FLOOR TILE DADO i 6 FRAMING 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. 6 COLS. STEAM STEEL BMS. d COLS. HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ ELECTRIC 1st 13rd NO HEATING gAORTH Town of �� > > over ,, NoZ '_ri s r �` �� T 3 7 19 S3 o� �o�H;� Q dover, Mass., AERATED ,9S H BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT �!!� .........Tii�... 'bl"1 ................................... ................................ Foundation qt LO has permission to �t..... 4 ...... buildings on .... .... �. � ....... Rough to be occupied as.........Re!!.. it ���. ZLII Chimney ................... provided that the person accepting this per shall in every respect onform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating 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 QELECTRICAL INSPECTOR Rough • Service ................... ... ................ ..................................... .......... BUILDING INSPECTOR Final Occ-upancy Permit Required to Occ-ujpy Buildirig GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough P 7 p Final No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner PLANNING FINAL CONSERVATION FINAL Street No. Smoke Det. CFIA/FR /IA/ATFR FINAI DRIVEWAY ENTRY PERMIT Suggested Affidavit for Home Improvement Contractor Permit Application For Office Use Only NAME OF CITY/TOWN Permit No, N D 2'[1.4 1►s(�b✓��� Date — 3 AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application MGL c.142A requires that the"reconstruction,alteration,renovation,repair,modernization,conversion,inprovement,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 exceptions,along with other requirements. Type of Work: �E--(�,vo�' l�w*—Z.L/1uC:f Est. Cost Address of Work %T Owner Name: ©oc S Date of Permit Application: V► L 4 7, S 3 I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law _Job under $1,000 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 FUND UNDER 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: IrU wQ c w 1 t Date Owner Name C, � y �d ,�),s -2 RAYMOND E. DAMPSOUSSE, JR. AND SONS ROOFING COs, INC. BOX 431 LAWRENCE P.O. MA. CONSTRUCTION LAWRENCE, MA 01842 SUPERVISOR LIC,. It 046606 TEL: 683-4588 HOME {MPRUVEMEN'i' REG. # 101862 ROOFING — SIDING — INSULATION Date From:4 'l7 f (Name) (Address) To: RAYMOND E. DAWRODSSE, JB. IUCD SONS HOOFDIG CO., INC., BOX 431 LAWRENCE P.O., LAWRENCE, MASSACHUSETTS 01842 I (we) hereby authorize the Contractor to furnish all materials and labor necessary to install, construct and place the Improvements described below In-on building located at No. �`3 Gi� I� W c/e Street, City IAIJ ,/��/������ State �7�rf in accordance with the following specifications: C�� /��G G /'��1'�✓aGG .4 i,%cul C.c//-�%•T� �L v.�ii+�/r✓�� 14 A _ --T /� I� _17r1iL�J :J L o 6T�i� ? 6Z L All of the above work to be done in a good and workman-like manner. All men and equipment insured. Premises to be left clean upon completion of work. For the total sum of S� %/���/1'/ —1�U /1// ���/7 S LGl/�/✓Ly �/ //� dollars. Entire Sum to be paid immediately upon completion in accordance with plan as shown below. TOTAL CASH SELLING PRICE . . .. . . . .. . S DOWN PAYMENT IN CASH . . . . . . . .. . .. . DEFERRED BALANCE UPON COMPLETION . . . . . ... .. . . . . . . . . The undersigned agrees to keep property mentioned in this agreement properly Insured against loss by fire including the Contractor's interest therein. This agreement shall become binding only upon the written acceptance hereof by said Contractor, and upon such acceptance this shall constitute the entire contract and be binding upon the parties hereto, there being no covenants, promises or agreements, written or oral except as herein set forth. It is the Intention of the parties hereto that this contract shall be binding upon their respective heirs, executors, administrators, successors and assigns. Customer agrees to pay a reasonable sum as attorney's fees and Court Costs if placed in hands of attorney for collection. The owner further agrees that in event of cancellation of this contract after acceptance by the contractor and before the work is commenced the OWNER agrees to pay 20% of the total consideration herein named as liquidated damages for breach of contract. Said contractor shall not be responsible for damage o delay due to strikes, fires, accidents, or other causes beyond his reasonable control. We, the undersigned, certify that we are the sole owners of the property herein described on which said work or repairs are to be performed. IN WITNESS WHEREOF, the undersigned has (have) hereunto set his (their) hand(s) and seal(s) the day and year written above. Accepted By Husband RAY NbiE •DAMPHOUSSE, JR. AND SONS 'life R06FING CO.,INC. '/ Mail Ac{�re s / — (if different from above) // (Sig re Ad Title of Official)