Loading...
HomeMy WebLinkAboutMiscellaneous - 46 PRESCOTT STREET 4/30/2018 46 PRES-0002-0000.0COTT STREET �� 210/068.0 �i Date. ................................................ OF r►ORT/y o TOWN OF NORTH ANDOVER �n PERMIT FOR GAS INSTALLATION ,s`4ACHU5�t This certifies that ........ .. p'-' a t lti.................. .. ............................................. has permission for gas it,ZI ation .�+�..... in t� q buil gs of...........�- at.................... �..`?�' o North Andover, Mass. Fee.... ...... Lic.No. � �� .... &.. ............ .................................................... GASINSPECTOR Check# 09891 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK .CITY �-MA DATE °+-I (5 PERMIT= _ V74 JOBSITE ADDRESS b' e cow ST OWNER'S NAME GOWNERADDRESS TELF_� FAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL[ RESIDENTIAL CLEARLY NEW:Q RENOVATION:( 1 REPLACEMENT: PLANS SUBMITTED: YES NOR-" APPLIANCES 7 FLOORS-► ssni 1 2� 3 w 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER _ _ �. COOK STOVE DIRECT VENT HEATER �- DRYER FIREPLACE [— j FRYOLATOR FURNACE GENERATOR GRILLE _ .._ _ . .. �..: .,. , . ...._. . . ,. ._ .- ..... . INFRARED HEATER _ LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE'HEATER RG0F TOP UNIT TEST LIMIT HEATER URVENTED ROOM HEATER WATER HEATER OTHER eT�� uva�e a�<..ti. INSURANCE COVERAGE - I have a current flabilify nsurance policy or its substantial equivalent which.meets the requirements of MGL.Ch.142 YES [WO 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX.BELOW LIABILITY INSURANCE POLICY Eg­' OTHER TYPE INDEMNITY ® BOND F 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 AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all,of the details and information I have submitted or entered regarding this application are true and ccur t est of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co c 'th e t provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. C PLUMBER-GASATTER NAME LICENSE# I576K SIGNATURE MP'MGF 0 JP® JGF[] LPGI CORPORATION PARTN SHIP®# LLC[3#= COMPANY NAME: ee_ 8ro Sez,, c-e,� ADDRESS — CITY- �—es.(� STATE�ZIP 2 ( 2?- TEL FAXI __... 11CELL ;EMAIL �e�N� 6c� m `� o ' i i I 1 IZ � U �-j x• • •H - FMA, : FMgS �> PE�MBEBD SFfTTE ISSUES THS Fpt"LOWI r t ;sAGC�lsEq AS A TER h1AS -Jrk ENSE -- z k PLcc UMgE�R g 2f1 6Jr1"L L pw ST'a 4 L 'H'KOIf7'ON, 15,64 . {ytA Qo X16 14x1 t,. e ,226442 I COMMONWSkCHt SETT i a BQARR'QF, PLUMBERS'}A b=' G'ASF.I Ak R ISSUES_ THEj'FDLL^OWI�tQL��'Gul ENSE REEikI'STErRED A'S A ,PLUMBYfR VDAV,44P'`W GARF I ELD ( xi EY: BSRQTH)=RS 'SERVICE, 1LCC _ Z 2d WI;LLQWwT �N ORO, . . rMa 0231 21413 36.T5;y d tea ; f , a FEENBRO.01 SMORAN -- - � WRTiI~ICATE OF LIABILITY INSURANCE DATE(MhVDDIYYYY)113012015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(fes)must be endorsed. if SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT NAME: Rogers&Gray Insurance Agency,Inc. PHONE AX 434 Rte 134 CI No Ext: Arc no):(877)816-2156 South Dennis,MA 02660 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC 9 INsuRERA:Old Republic General Insurance Corp. 24139 INSURED INSURER B Feeney Brothers Services LLC INSURERC• 103 Clayton St PO BOX 220601 INSURER D: Dorchester,MA 02122 INSURERE: INSURER F: COVERAGES' CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERRA OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, ILTR TYPE OF INSURANCE DO E3 POLICY NUMBER YI' tAhhVDFDIYFY MMEXP IDD LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,00 Uff,IAGE TOREN TE CLAIMS-MADE a OCCUR A2CG07501501 0210112015 02101/2076 PREMISES Ea occurrence S 300,00 MED EXP(Anyone Person) S 10,00 PERSONAL B.ADVINJURY S 1,000,00 G E N'L AGG REGATE U M I T APPLI ES PE R.- - GENERALAGGREGATE S 2,000,00 POLICY P�]JRC M LOC PRODUCTS-COfAPlOP AGG $ 2,000,00 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea aocidenl td ANY AUTO BODILY INJURY(Per person) S ALL OV�NED SCHEDULED BODILY INJURY Per accident) $ AUTOS AUTOS ( ) NON-Ol%NEO PROPERTY DAMAGE HIREDAUTOS AUTOS Perac6de t $ i $ UMBRELLA LIAR HOCCUR EACH OCCURRENCE $ EXCESS LIAR CLAMS-)BADE AGGREGATE $ DEC) RETENTION$ $ WORKERS COMPENSATION PEROTH- f AND EMPLOYERS'LIABILITY X I STATUTE ER A ANY PROPRIETORlPARTNERIEXECUTIVE YIN 2CW07501601 02/01/2015 02/01/2016 E.L.EACH ACCIDENT S 1,000,00 OFFICERMiFLIBER EXCLUDED? F&I NIA (Mandatory In NH) E.L.DISEASE-EAEhIPLOYE $ 1,000,00 Ues,describe under SCRIPTION OF OPERATIONS bekrN E.LIISEASE-POLICY LIMIT $ 1,000,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover,MA 01845 AUTHORIZED REPRESENTATIVE+ ©1988.2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD r�, 7+.a tac.S^a�* ^ ,:•�,.. V°j'�lt�°'�YF.�r7Y�'.F"isP4•rCPr�"'r y . 4,f- iS q'Ti 1 aYP r' Ij '� i / J a•. MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT .TO DO GASFITTIN.G . jPrint or Type) * �M Permit #d 2� Mass. Date 19 ILVIO r y r Building Location AO F'MS-P PC1f !4 Owner's Name N� Type of Occupancy >°5/ d E'I?C �3.. New O Renovation O Replacement Plans Submitted: Yes O No O FIXTURES T. �ti` PEEE`t L Sl �9 c5" t y W mg o2 0 5 ( W M 1 z O � �< � e}cp = 0 � � 7 k } m to v 4� N L7 U Z 2 N O . T �6 W to Z T. N W .� `!! Q X µ�uI yeg Q1 F� Z Z W u O Z G t W r o! I O V S r0► O 3 O . S U ow SUB•BSMT. BASEMENT 1st FLOOR ' t 2nd FLOOR i. 3rd FLOOR 1 4th FLOOR Sth FLOOR 1 AP ar r 6th FLOOR j,far +ty 71h FLOOR Sth FLOOR 3 Installing Company Namei Check.one:; Certificate WHITE ROCK PttJM0iN6 , • Address P.O.BOX 728 IX Corporation . l60 C >. NORTH ANDOVER, MA. 01845 O Partnership � •= i "J Business Telephone 775 42.Q �f LL O Firm/Co. E Name of Licensed Plumber or Gas Fitter R ci Girt o E aoc h ef+ ` INSURANCE,COVERAGE: I have a Curren liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No O If you have checked yes, please indicate the type coverage by checking the appropriate box. A liabilityinsurance policY Other type indemnityO Bond d O 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: Owner O Agent O I Signature of Owner or Owner's Agent 1 j 1 hereby certify Mut all of the details and information I have submitted for em"edl In the above application are htse and accurate to M+e bed d my knov k and that all plumbing work and i lations performed under the permit issued for this application will be in compliance with all pertinent provisions d the Massachusetts Stage Gas Code and Queer 142 of the General laws. i I .: .. _.. TVP'of Li en u. - 1 BY ' Title �aafiner . .. 1rYR?aate. Signature of lkvmed fPlumber�or Gas Fitter '' ounieyman C/ `� 7 CIN/Town License Number_ APPROVED(OFFICE USE ONLY) 5 95 Date.. !,f�.',l�'.>.... .. NORTH , TOWN OF NORTH ANDOVER - 3�Oy o PERMIT FOR GAS INSTALLATION f p a • vQ s "• O +. rr 9SSACMU`�Et This certifies that . . . . . . .f .4 c . . . . . . . . . . . . . . . . M has permission for gas installation . . . . . . . . . . . . . . . . . . . . . . . in the buildings of . . :/. . . . . . . . . . . . . . . . . . . . . . . . . . . i6 �. r , c rL-�- `` at . . . . LG. . 1.P v. �? . . . . . . . . N Andover, Mass Fee. ./A . . . . Lic. No.. . ,. .2 . ;INSPECTOR WHITE:Applicant CANARY: Building Dep PINK:Treasurer ASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO 00 GRSFITTI :JiNG (Print or Type) t NORTH ANDOVER Mass. Date 7-Z7 40- 1§uilding'-Location 4& Pres ca11 S& �L Permit # / 1,ro A)n dU V Pr a Owners Name )))r- H en j2x Lr b h�l • Y - New 77 Renovation D Replacement Plans Submitted =] FIXTUP,- S y Q 0 CC .O ca S f- W 0Q 0 V m Ir- cc Cc I o US tu tt G1 2NWs �W G COt 2 h4 �yG• d4 < O II N 1j W ul N W 6z 0�tL y CC 7 c 0 Z W0 O W t4ZWsO- CN O O WO WQ y C W F7- twZL t- a Z O SUB—$SNIT. t BASEMENT 1ST FLOOR 2HOFLOOR 3130 FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR TTK FLOOR STH FLOOR (Print or Type) Check one: Certificate Installing Company Name WAlf-e 100CI— /0� �'l/ cyr/6 (.Corp. Address 130' 72- $ = Partner. "Vo Ah C a ver -7ycl Firm/Co- Business Telephone: 97 S- 112 y 9 Name of Licensed Plumber or Gas Fitter Q� Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Q Bond Insurance Waiver: I , the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. Signature of owner/agent of property Owner ❑ Agent El I hereby certify that ail of the details and information I have submitted (or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and InsaUations performed under Permit issued.for this application will_be in compliance with all patlncnt provisions of tho Massachusetts State Gas Gude and chapter 142 of tho General Laws. By TYPE LICENSE: I umber Umber Title G sf Signature of Licensed Master Plumber or Gasfitter City/Town: Journeyman APPROVED (OFFICE USE ONLY) License Num er I� Date... . 6 HpRTM TOWN OF NORTH ANDOVER pf t��ao ,a.�ti0 0 e° a pp PERMIT FOR GAS INSTALLATION r•`�y �9SSACeHU5Et This certifies that . . : . . / ( �. has permission for gas installation,. fjt�'t . . . ..1!.! l. ... . . . l in the buildings of . . at . . .. . . . .`. . .� 1/7/fW . . .J'f . : North Andover, Mass. Fee. 3? otic. No.'. 5 .?. . . '. . . . . . . . . . . . . . . . . . . . . J- /f � GAS INSPECTOR WHITE:Applicant Q}/2jF/l��lAlft5Building Dej&50 P{f@K:Treasurer GOLD: File Location /USS No. C� Date MORTM TOWN OF NORTH ANDOVER A 9 Certificate of Occupancy $ �+ �ssw«»,'E<A Building/Frame Permit Fee $ Foundation Permit Fee $ Y Other Permit Fee $ TOTAL $ t ^ Check # -- Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING 52 BUILDING PERMIT NUMBER: A DATE X ISSUED: � SIGNATURE: Building Commissioner/In§Rector of Buildings Date SECTION i-SITE INFORMATION O 1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number \V 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BURDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide R red Provided Regpired Provided 1.7 Water SupplyM.GL.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ J SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.y / 1 yO�wnner of Record 1 Name(Print) Address for Service: N Signature Telephone 2.2 Owner of Record: Name Print Address for Service: O p�pqqq 1�1 Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ i�, X/"la/,(0 0 AV-1QHr) (l Lkensed Construction Supervisor: G 7 O I��/i t h( U t �� License Number Address 7 G o T 4' � Expiration Date SiTe Telephone 3.2 RegKfered Home Improvement ntractor Not Applicable ❑ ?.1 pany Name �f Registration Number / r?U i N 25 A,4 _j ?-I Address 1 - 7 tf Expiration Date ^� Sin re Telephone !�♦ f 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 applicable) New Construction 0 Existing Building Repair(s) Alterations(s) ❑ Addition ❑ Accessory Bldg. 0 Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: O S J/ K L t 1 /?�! 1�lel �2 c3© : - U r�P•�iC t �2e�.�' T,,r,-GR y — �/� St ae�l' c,✓;i'H 7 Q S 17(-f YA L\ aaa SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USI✓QNl<.Y Completed b permit a licantWO _` . dx � , nor 1. Building (a) Building Pen-nit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction d O 3 Plumbina Building Permit fee(8)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 pennit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, as O r Authorized Agent f subject properi Hereby eclare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief r. o,<I"q Pk c J r C — Print Ne Signature caner/A ent Date NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS iST2ND 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 s I ' �J2� -V/O�IniIYtO��tlllP.2ltiL d�✓G(CJgQCtl.'1LUQP.� BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR I Number: CS 046636 Birthdate: 06/02/1948 Expires: 06/02/2001 Tr.no: 9974 Restricted To: IG RAYMOND E DAMPHOUSSE JR 75 BUTTERNUT LANE METHUEN, MA 01844 Administrator ww HOME IMPROVEMENT CONT p�TOR Registration 101862 Type - PRIVATE CORPORATION Expiration 06/29/00 RAYMOND E. DAMPHOUSSE, JR,. + _ Raymond E. Damphous G�"'�� �. �jPutternut sJr, lane ADMINISTRATOR Methuen'MA 01844 -''L.,�+a-.+,r,,,.+i.«_..,. _... ...,_,nc,,�✓.; ��1.»r.�.trl-..fi'�r,:..,,,.,�,, ...� -r,.r......«,;.f;a-��..-...,-. . RAYMOND E. DAMPHOUSSE, JR. AND SONS ROOFING CO., INC. BOX 431 LAWRENCE P.O. MA. CONSTRUCTION LAWRENCE, MA 01842 SUPERVISOR UC.'#0466% TEL: 6834588 HOME IMPROVEMENT REG. #101862 ROOFING — SIDING — INSULATION / Date From:>c�S V I' ""Yes Y/ �/ / ��,_,r C rr i/ A! (N ame) (Address) To: RATYOND L DAYPNODSSE, JR. AND SONS HOOFRIC 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. %r f Q ' Street, City State in accordance with the following specifications: C % i � /J � r� ���''l %C i) S ."�i !i J i .��l /ter �-t,/ Cw) �'/ "'.`"t' ��C:,i rr^l i'•r I .� i)f'� ,7 . NJ ?/.G ,) ,� i Q _ "4JG G7 f /..� i./ =r-r/ r� i•% // .C/j :a ,'a - rJ ,� ,cr ter' r.� •� .� � SGF '-',tel .- r''rK 9,1^ e�'O i 1 ,-17 7'Zr^ G % `( r All of the above work to be done in a good and workman-like manner. 47�- --� All men and equipment insured. Premises to be left clean upon completion of workT'2 For the total sum'of dollars. Entire Sum to be paid immediately upon completion in accordance with plan as shown below. TOTAL CASH SELLING PRICE . ... . . . . . . S i1 Z, DOWN PAYMENT IN CASH . . . . . . . . . . . - � t� 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. I 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 or 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 -RAYMOND E. DAMPHOUSSE,JR.AND SONS Wife O`OF•I�NG CO., INC. Mail Address r, If { ✓ �` (If different from above) - �TsiOrrartlur-e antl Tit'e/ot Otticiap 7 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations , Boston, Mass. 02111 Workers'Compensation Insurance Affidavit Please Print Name: 3 l Location: �'G City Al 0(3 Phone F7 am a homeowner performing all work myself. 01 am a sole proprietor and have no one working in any capacity I am a oyoviding workers' compensation for my employees working on this job. ne r Company name: /C 1 V 1n oro C �7,�`t�?K a ur(F =x r _e rA,.,r RC,v Al Address 13 ,T1" t_N City r H Phone*: VT vs- Insurance s-Insurance Co. /ter' A Policy 7 9 � Company name: Address City: Phone#: Insurance Co. Policy# 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 as well as civil penalties in the form a STOP WORK ORDER and a fine of 100.00 a da against me. I andior one years'imprisonment ca e a of $ ) Y 9 Y� P P � understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby cert' er the pains and pen aR' of perjury that the information provided above is true and correct. Signature Date — Print name �/-i�.�-� o rr �� ,?.�,�,;�r c a r r Z i Phone# 9 `t s Official use only do not write in this area to be completed by city or town official' ❑ Building Dept ❑Check if immediate response is required Building Dept ❑ licensing Board ❑ Selectman's Office Contact person: Phone A ❑ Health Department ❑ Other FORM WORKMAN'S COMPENSATION O� NOR sFl, Town of North Andover ''•"° 1°. T Building Department 27 Charles Street North Andover, MA. 01845 ��s•,�� '�{9 D. Robert Nicetta S"` j5e Building Commissioner (978) 688-9545 (978) 688-9542 Fax HOMEOWNER LICENSE EXEMPTION Please print DATE u JOB LOCATION N tuber Street Address Map 1 lot "HOMEOWNER 1),�J U i O LA 1, ,'g g y Name Home Phone Work Phone PRESENT MAILING ADDRESS g�r CC)r ✓ ,2 City Town State Zip Code The current exemption for"homeowners"was extended to include owner-occupied 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: Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is, oris 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 APPROVAL OF BUILDING OFFICIAL XAORTii Town of 0dover ® - ,; to No. a oo dower, Mass. C2 COCHICHEWICK ADRATED S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT.......... m� 44-404Y .... ................................. :: Foundation "' "" "' oun ation has permission to erect..a+IR.(.A......... buildings on ....�.�...... ......AA.�.�..0�....... ! Rough to be occupied as....%L vie........ Chimney .............................................................................................................................. provided.that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and C struction of Buildings in the Town of North Andover. M ()00 PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. S Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUC ELECTRICAL INSPECTOR S Rough ................................................................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFina, 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.