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<".0 R' 4, TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
S� Ss�cNus�
This certifies that,..,,,,.
has permission to perform''
erform '12, r�-l.�. .. .... �,..�........ .
plumbing in the buil Ings of ..' ��!.�!�!.� .....
at=-. / . ........... , North Andover, Mass.
' // . ,�/4
Feet .. Lic. No. ..............................
PLUMBING INSPECTOR
Check #
6L62
14
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
yr (Prat of Type)
ilk'' Z '- , W!/J ('Cre Mass. 2-7
Build' Location �((1 Owners Name
2, -r4 -7 p Ii Type of OxuPancY f ��
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New �( Rerwvation 13 Replacement D Plans Submitted: Yes Q No G
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Name of Licensed Plumber '--*4eLdyx -10
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RGURMCE ZOVERWS&
. 1 have a cmment liability policy or its Svbsiantial WWWalent which meets the requi of MGL Ch. 142
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ff you �e hteK�oed YM Please indicate the type coverage by checking the appropriate boot.
A liability i+rsurance policy g 000 tm of O Bond C
OWNS S INSURANCE WAraft t am aware that the licensee does not have the amrance coverage required
by Chapter 142 of the Mass. General Lanus, and that my signature on this pmt application wauvmthis stent
SigQtne of Owner or Owner's Agent Owner Check one:
ggeM Cj
I hemp ce" that M of n,e derails and intonation I have submiftW (or in above aPPdcation are tree aed accurm to
the bent of vj bwwledge and that aH Pk nbbV walk and humlationsw�derthe iswed forn„s apps tion w�l�
oe in with ad pertKkrK poris;ons of the M� g'
otthe General Laws.
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Name of Licensed Plumber '--*4eLdyx -10
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RGURMCE ZOVERWS&
. 1 have a cmment liability policy or its Svbsiantial WWWalent which meets the requi of MGL Ch. 142
Yes t
ff you �e hteK�oed YM Please indicate the type coverage by checking the appropriate boot.
A liability i+rsurance policy g 000 tm of O Bond C
OWNS S INSURANCE WAraft t am aware that the licensee does not have the amrance coverage required
by Chapter 142 of the Mass. General Lanus, and that my signature on this pmt application wauvmthis stent
SigQtne of Owner or Owner's Agent Owner Check one:
ggeM Cj
I hemp ce" that M of n,e derails and intonation I have submiftW (or in above aPPdcation are tree aed accurm to
the bent of vj bwwledge and that aH Pk nbbV walk and humlationsw�derthe iswed forn„s apps tion w�l�
oe in with ad pertKkrK poris;ons of the M� g'
otthe General Laws.
�+ Stnawre of Lioera� Pdmew
Type of L mnwx
License Nwnber
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Location
No. -)?C9--
Date .0,5-
TOWN OF NORTH ANDOVER
.. 9
Certificate of Occupancy $
�1 <r�i��. a •
CS, �� Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
r�- O -Z,
TOTAL $ ---
Check #
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18102 Building inspect Ur
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UNN2
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TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT !FARENOVATE,
OR DEMOLISH A ONE OR TWO FAMILY DWELLING
= 'ice►ow.
BUE DING PERMIT NUMBER:
�'
DATE ISSUED:4 _
aiw
SIGNATURE:
Building CommissionerfIngwor of Buildings Date
SECTION 1- SITE INFORMATION
1,1�Property Address:
1.2 Assessors Map and Parcel Number.
e
Map Number Parcel Number
1.3 Zoning Information:
1.4 Property Dimensions:
Zoning District Pr Use
Lot Area Fronts 8
1.6 BUILDING SETBACKS R
Front Yard
Side Yard
Rear Yard
ReqWred Provide
red Provided
'red Provided
1.7 Wars Supply M.G.L.C.40. 34)
1.3. Flood Zone b foruntion:
1.8 SeweaW Disposal System:
Public ❑ Private ❑
� e Ovide Flood Zane ❑
Municipal ❑ On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT '' {% . j t� !Ct: i.:3 NO
2.1 Owner of Record
r
'Ka—me (Print)
gess 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:A
Not Applicable ❑
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Lic4rifed,constructiorf Supervisor:
LicenseNumbir
dress
Expiratio at
nature
Te phone
3.2 Registered Home Improvement Contractor
Not Applicable 0
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Company Name
Registration Number
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A s
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Expiration Date
P l7
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Tele hone
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SECTION 4 - WORKERS COMPENSATION (KG.L C 152 ; 2546)
Workers Compensation Insurance affidavit must be completed and submitted with this
in the denial of the issuance of the building permit.
SECTION 5 Descriptfe
New Construction 0
Accessory Bldg. 0
Brief Description of Pro]
I"Q. ,f-) Vt
fro fed Work check a0 ■ trk
Existing B7EO op Repair(s)
0 EAIter!atio7nis(s) 0
Demolition 0 Other ❑ Specify' -w
Work:
to provide this affidavit will result
Addition ❑
SECTION 6 - ESTIMATED CONSTRUCTION COST5 OFFICIAL US)d ONLY
Item Estimated Cost (Dollar) to be
Com leted by Dernut applicant
1. Building `; A� (a) Building Permit Fee
C/ Multiplier
2 Electrical (b) Estimated Total Cost of
Construction
3 Plumb' Building Permit fee (a) x (b)
4 Mechanical HVAC
5 Fire Protection Check Number
6 Total 1+2+3+4+5
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
nwVXWVq AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner/Authorized Agent of subject property
to act on
Hereby authorize
My behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner
Date
,....0'VnI.Trrunnr7rrn A[_FNT DECLARATION
As O er/Authorized Agent of bject
I,
property
Hereby declare that the statements and information on the foregoing application are true atid accurate, to the best of my knowledge
and belief
Print
STORIES --
BASEMENT OR SLAB NO 3Ku
SIZE OF FLOOR TIMBERS 1 2
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
jaNSIONS OF GIRDERS THICKNESS
HEIGHT OF FOUNDATION X
SIZE OF F0011NG
MATERIAL, OF CHIMNEY
1S BUILDING ON SOLID OR FILLED LAND
rc ur m nING CONNECTED TO NATURAL GAS LINE
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REPAIRS CASTRICONE CONSTRUCTION LLC FREE ESTIMATES
CASTRICONE ROOFING & SIDING CO.
Telephone: (978) 682-4266 • Fax: (978) 794-0910
MARIO CASTRICONE DAVID MICAL
P.O. Box 441, North Andover, Mass. 01845
I/we, the owner(s) of the premises mentioned below, hereby contract with and authorize you as contractor, to furnish all
necessary materials, labor and workmanship, to install, construct and place the improvements according to the following
specifications, terms, and conditions, on premises below described:
Owner's Name .... 01 .......... .............. .. ...........
Job Address , , , •'.��` 1� - , .� .City .� ..State /
SPECIFICATIONS
.......'.../C :..._=fit . ... ..... .
e
00
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.........................................................................
.............
...�. b. ............ .................................
Materials and labor to cost $ ..... ..... Payable. «. �... on . . . . . . . . . , , and balance in ...... .
monthly installments of $ ........... each, payable on ....... , day of each and every month thereafter until paid
in full (. . . . . . % charge per year is to be added to above cost of labor and materials and is included in monthly payments.)
Contractor will do all of said work in a good workmanlike manner. Workmanship is warranted for one year.
Upon completion of above work, all undersigned agree to execute and deliver to contractor, their joint note in accordance with his (their) above obligation and a
• completion as requested by the contractor. Upon refusal to do so, contractor may at its option declare the entire contract price or so much as then remains unpaid
immediately due and payable. It is agreed that if permitted by law, contractor shall be paid by the owner(s), all reasonable costs, attorney fees and expenses, in
addition to the amount due and unpaid, that shall be incurred in enforcing the terms and conditions of this contract and/or any lien in connection therewith.
It is further agreed that this contract may be assigned by contractor; and also that the obligations hereof shall bind and apply to their heirs, successors or estates of
the parties.
The undersigned warrant(s) that he is (they are) the owner(s) of the above mentioned premises and that legal title thereto stands of record in his (their) name(s).
PROVISO: This contract shall be void and of no effort if credit approved of owner(s) is refused.
There are no representations, guaranties or warranties, except such as may be herein incorporated, if any, nor any agreements collateral hereto, nor is this contract
dependent upon or subject to any conditions not herein stated. Any subsequent agreement in reference hereto shall be binding only if in writing and signed by all
parties.
Cover attic storage cleaning not included. Not responsible for ice back up, Not responsible for broken plants or rip-offs.
Receipt of a copy of this contract is hereby acknowledged, and it is further acknowledged by the undersigned that the foregoing provisions have been read and the
contents thereof understood and that no representation or agreement not herein contained shall be binding upon the parties and that all of the agreements and
understandings of said parties are contained herein.
Owner or Owners are not responsible for Property Damage or Liability while job is in operation.
IN WITNESS WHEREOF, the parties have hereunto signed their names this. . , , day of , , , , , 20 , ,.j
Accepted: Signed .V�
1
Owner
• (OWNER HAS 3 DAYS IN WHICH TO CANCEL,
Per. .. . . ..... .
Representative
Signed............. .............
Owner
Signed..............................
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Reg'stratioh: 103317
License or registration valid for individul use only
before the expiration date. If found return to:
Expiration 7172006
71
Board of Building Regulations and Standards
One Ashburton Place Rm 1301
DBA
Boston, Ma. 02108
CASTRICONE ROOFING &SIDING CO.
Mario Castricone
31 Court St.
N. Andover, MA 01845 . t
_ Administrator
Not valid without signature
city,����/y U� l rl— state: zip: phone #
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 am an employer providing workers' compensation for my employees wprking on this job. _.,.
n n� II�� %
comnanv name:
U I am a sole proprietor, general contractor, or homeowner (circle one) and have hired the contractors listed below who have
the following workers' compensation polices:
company name:
address:
city:
phone #:
insurance co. policy#
Attach add�tional_s}ieet�f"nec'essary
Failure to secure coverage as required under Section 25A of 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.
7 do hereby cert" nder the pains and penalties perjury tha lie information provided above is true and correct.
Signature 4 Date �J
Print name � � %� L� Phone # �O Ar x I�
official use only do not write in this area to be completed by city or town official
city or town: permit/license # ❑Building Department
[]Licensing Board
❑ check if immediate response is required ❑Selectmen's Office
❑Health Department
contact person: phone #; ❑Other
(revised Sep[. 2001)
==
The Commonwealth of Massachusetts
_)_
Department of Industrial Accidents
Office oflnuestigations
600 Washington Street,� Floor
z
Boston, Mass. 02111
Workers' Compensation
Insurance Affidavit: Building/Plumbing/Electrical Contractors
inftirmatlon:.s
,Please PRINT lelr>bly
city,����/y U� l rl— state: zip: phone #
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 am an employer providing workers' compensation for my employees wprking on this job. _.,.
n n� II�� %
comnanv name:
U I am a sole proprietor, general contractor, or homeowner (circle one) and have hired the contractors listed below who have
the following workers' compensation polices:
company name:
address:
city:
phone #:
insurance co. policy#
Attach add�tional_s}ieet�f"nec'essary
Failure to secure coverage as required under Section 25A of 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.
7 do hereby cert" nder the pains and penalties perjury tha lie information provided above is true and correct.
Signature 4 Date �J
Print name � � %� L� Phone # �O Ar x I�
official use only do not write in this area to be completed by city or town official
city or town: permit/license # ❑Building Department
[]Licensing Board
❑ check if immediate response is required ❑Selectmen's Office
❑Health Department
contact person: phone #; ❑Other
(revised Sep[. 2001)
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the "law", 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 #enev
tity, employing employees. Hower,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, construction or repair work on such dwelling house or on the grounds
or building appurtenant thereto shall not because of such employment be deemed to be an employer.
MGL chapter 152 section 25 also states that every state or local licensing agency 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 any contract for the
performance of public work until acceptable evidence of compliance with the insurance requirements of this,chapter have
been presented to the contracting authority. L
�rn-r ��. � �,.- 77.r -.v Vis; eb."F f n
[a a f 1 ,
Applicants
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation. Please
supply company name, address and phone numbers along with a certificate of insurance as all affidavits may be
submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and
date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is
being requested, not the Department of Industrial Accidents. Should you have any questions regarding the "law" or if
you are required to obtain a workers' compensation policy, please call the Department at the number listed below.
City or Towns
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of
the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth Of Massachusetts
Department of Industrial Accidents
Office of Inuestlgations
600 Washington Street,7`h Floor
Boston, Ma. 02111
fax #: (617) 727-7749
phone #: (617) 727-4900 ext. 406
North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provithat the debris0resulting from this workn of uPermit
Numbershall
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c11,S150A.
The debris will be disposed of in:
(Location of Facility)
i n ture of Permit Applicant
4•
ate
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
Location 7 `� /Z 4) -e,
No. Date
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1 L O 8 1/10/98 08.49
TOWN OF NORTH ANDOVER
Certificate of Occupancy
$
Building/Frame Permit Fee
$
0 s`
Foundation Permit Fee
$
Other Permit Fee
$
Sewer Connection Fee
$
Water Connection Fee
$
_
S-1
TOTAL
�1
%
r
Building Inspector
25.04 MID Div. Public Works
, „ /J /.�144f %—
Location
No. Date
NORT1y
TOWN OF NORTH ANDOVER
m
Certificate of Occupancy $
`Building/Frame
s i •
Permit Fee $
TS C • E L
SSACNus
Foundation Permit Fee $
Other Permit Fee $
Sewer Connection Fee $
Water Connection Fee $
�:.
TOTAL $
u
Building Inspector
1'/10/98
08:49 85.00 PAID
•
/��� /1� /Div. Public Works
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1 ,O y,' (` \ `. �ii a TOO�7NA01[F!`IM!!C(/6 ��illOOLlQNlaocf4 y �
NOME IMPROVEMENT,CONTRACTOR .
Registration 101410-;,Typel DBA
" ;XL#
Expiration ,08/03/00 `tS h�
� f�+ R A, CROOKS SON CONST,
yet r ..Robert A
I -- Q1�. ple Blossom Road
An
.
dover MA 01810` vtt�
y,
. ADMINISTRATOR
Town of North Andover 40RTN
OFFICE OF 3� °�;to
COMMUNITY DEVELOPMENT AND SERVICES ° . p
146 Main Street
North Andover, Massachusetts 01845
WILLIAM J. SCOTT SSACMUSt
Director
In accordance with the provisions of MGL c 40 S 54, a condition of Building Permit
Number is that the debris resulting from this work shall be disposed of in a
properly licensed solid waste disposal facility as defined by MGL c 1 11, S 150A.
The debris will be disposed of in: Tauc(elac, cv, L
(Location of Facility)
Signature of Permit Applicant
>>hoA9D'
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for this
project through the Office of the Building Inspector.
BOARD OF APPEALS 688-9541 BUIIDINO 688-9545 CONSERVATION 688-9530 HEALTH 69R_ IW PT Avvwr. FRR_9111