The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 477 BEAR HILL ROAD 4/30/2018 w 477 BEAR HILL ROAD 2�oiosa.ao�Iaa000.o ii I II 1 Location_4%7 66-79-� A,CL No. � '� Date Of N°"7" 14 TOWN OF NORTH ANDOVER �C? A Certificate of Occupancy $ * Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee �dL— $ 7b fi Sewer Connection Fee $ tJ4aWater Connection Fee $ ,Vp4. a-a y TOTA %v 1 1 r ` •.`�a,~ Building Inspector `°by Div. Public Works APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE I / P,fP KVO. LOT NO. 2 RECORD OF OWNERSHIP iDATE BOOK PAGE — �)NE • I SUB DIV. LOT NO. OCATION ��•I �� '- PURPOSE OF BUILDING WNER'S NAME `'�^ NO. OF STORIES SIZE J !/P —1"ER'S ADDRESS `-1 A]�N r U �/1 1) �,\ j / Y} n BASEMENT OR SLAB _ ARCHITECT'S NAME 1'1 IU Ili 1" I--L---„Lrr.4e1/,1. SIZE OF FLOOR TIMBERS IST 2ND 3RD ILDER'S NAME y/�(�(� yy� (l(1\n ,r- //�` SPAN -- DISTANCE TO NEAREST BUILDING 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 3 PROPERTY INFORMATION INSTRUCTIONS LAND COST SEE BOTH SIDES / ST. BLDG. COST PAGE 1 FILL OUT SECTIONS 1 - 3 EBT. BLDG. COST PER Ob.VFT. U PAGE 2 FILL OUT SECTIONS 1 - 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 NP APTR VED BY BUILDING INSPECTOR BOARD OF HEALTH SIGN A OF O N R A THORIZED AGENT FEE O rp— PLANNING BOARD PERMIT GRANTED h G1 19 _ BOARD OF SELECTMEN 1 u OWNER TEL. CONTR.TEL,# BUILDING INSPECTOR CONTR.LIC.# BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY sroRIEs 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 B 2 13 CONCRETE BL K. PINE BRICK OR STONE HARDW D PIERS PLASTER _ DRY WALL UNFIN. 3 , BASEMENT AREA FULL FIN. B'M'TAREA _ '/ 1/1 1/1 FIN. ATTIC AREA _ NO_B M'T FIRE PLACES _ HEADROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE �_ WOOD SHINGLES EARTH _ ASPHALT SIDING HARDVJ'D _ ASBESTOS SIDING COMMON VERT. SIDING ASPH. TILE ---{I_ STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. 8 FLOOR _ BRICK ON FRAME CONC. OR CINDER BIK. STONE ON MASONRY WIRING STONE ON FRAMESUPER_ ADEQUATE ORPOOR I� NONE 5 ROOF 10 PLUMBING GABLE HIP BATH (3 FIX.( _ GAMBREL MANSARD TOILET RM. 12 FIX.( FLAT I SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE _ FORCED HOT AIR FURN. TIMBER BMS. &COLS. STEAM STEEL BMS. & COLS. _ HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS 01 l B'M'T 2nd _ ELECTRIC 1st 13rd I NO HEATING naQ 13 _ . .. �. . � ��f�� FIN L Pt��°� i�'��G� _ __ _ �" �t�31�, S s own of 6 0 n(dovelr 0 No. DRIVEWAY ENTRY PERMIT" ® K er, Dass., a 1 c ti HErvict! - SA BOARD OF HEALTH e 4 THIS CERTIFIES THAT.............. ...(1 ... C.�. .Rt ,. Q. l. .................... c °® BUILDING INSPECTOR has permission to erect ..................•. uildiifgs on ,, ... ..... .•• n Rough a .. .. to be occupied as.. .. ... .. .. .... .....:................................. Chimney Final provided that the person accepting this permit shall in every respect conform to the terms of the application on file in PLUMBING INSPECTOR this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Rough Buildings in the Town of North Andover. Final VIOLATION of the Zoning or Building Regulations Voids this Permit. PERMIT EXPIRES IN 6 ONTHS ELECTRICAL INSPECTOR Me O�F'glUNLESS CONST , Seugh � Service 010 e . .... .... ... .. ....... Final �- : ® BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Final Display in a Conspicuous Place on the Premises FIRE DEPT. Do Not Remove Burner No Lathing to Be Done Until Inspected and Approved rb STREET NO. Lathing p y Smoke Det. Building Inspector 11 n b x als r N V/ �1/ -,!,,i , I�Mlllu - - 1 0 �f A P lry�e?lcpll a f Cx J "lo J I.0-k, kk A"A \1 N 0� 6 r;7 1 k 1••iJ _..1i b.,1J•., L.. ,.. nr+L, P1.'ny, _ 1It "Al OARAM S CONT. IN BOND HFILO ll!_M.4 0AR9 Ce NI'.IN 8_1nP 8 AA1 _ 1=U �- �'C^H9 CON Y.W t1oK''J`L`"n i+l _ --� � 'I - - -._---'- ---� 1 �- --. __...y-" — -- - - - -- '-- - � �_ - �•�`_— _ arm"a`-o � , z -- ' - 6- .— --T- . I 6 r,fl�eAue �lz'o C Eo1R WAYS _ry b3 eARSQ 11'oC.uoTn hnYi LLE / � •�0'N,.1. ILl - NPN --. --__ ----_ _I- _ _ CL(J, -Z'L" jVr(A CAT CCF ALTEwkIATE BARS v -�3 YAR('. �11'e.C, e.Y1\wA V$ t I- \ ' CVT OrF AL1 11 C III _ / f , - NAT GRb. l CVT OFF ALT CRN ATC {/ARS 0 —' — —a- - � -- \ /Ar ,IST 1M1: J.i SLVN rC•b1,.-G I 1 ,,,_J CVT oIf ALTCRN�TC \�A[ARHG 100 o-•T R SC FOOT / w i . I \ ;T"IRD DnK / I5'-0-.-. FRO. POOL RAr/�.rr1 ,jY>_ • �1.[t�4�-0 b I J5. - --- Y - — rard _ _ sLw.•s'-o �D BARS d 6�O.C. - r_t B11[S G1 4•J G I O it! DABS C-bv� O.C. 1• . Or �P'3 SANS 2 (.•• o c. - CVT M[ AS HOT[b NA:.alm J '! �• BC.w CEN CVl orp a-CS ��' �' CVT •FF D 1 A! LIpT•r 12 i - CVT orr Aa NOT[O 'R. • 1 �lEV- __ ul 1 ' 17 C.ur OPF ALTCR- �/r + GUT OFF FYFRY f .0 V7 Clip /.LT E:4NAT E: - 9 11ATc SANG 'r (�rN.RD [�a }r ea Ra ,�y In VT o.a ALT(R Alt, Tytto- ' RA.•1P g n NAT[ DA[ JE V. S _ f "CLC AK LiI, LWL TO BE E)tc_N- _ �cyi 2` CLEAR tS n N C ON GL CONE. COV(R • AY'CP HY 11.171:7. - -- CONE.COVr. 111 �J _-FL7S K-Dy �___.� I " 1 I O" i'-Or 1.-O. !�-Ol I'_O• 1'-O" v 1 1_D I 1'-O L'-O MOTE .,_ _ 1 - FLOOR fsL INF-�9 eARS1 �o 11_p•I bI,:CN510"s v 4o NN ARE TXc MIN I11v Al gyp."o.D.p.rT IA WAYS'TYP. y> CVT OP, ALTCRNATE AARS� _ RCaUIr CD A.0AY Or IN f_RC AS[D TD r avrT CVRVA'TVR or POOL.. FOUNDATION SURCHARGE WALL SECTION EXPANSIVE SOIL WALL SECTION i>EEP END RAMP or 6-dFILL WALL SECTION STANDARD WALL SECTION —_ ----- 2-0" EL[cT,II13 V. FON. ONO11NbINa Vi wIFY O/,RrIMF. PRION To avPrr IHG. F 11 AME AND .-{ _L.._• 1- - FOR G.HN/R L IAL Po.l R ] S'I ------ GRATE �FI ASiER ALI _•`- }-G` A,14- FVCKP"f AL-NDTEP --•- I- - _--_ALL 1 VRFACC WAYF.R 9"ALL iVN FACCC 6i MRv O.Ile --- • ORAIA AWAV FVOA Pn.oL• -,••,jZ�'-,3� 7T_�f V Y. CtLIST,PO o•YINa y TO/ DF•OMD •LAM _ ---- WATER P L-IL "' •'fI I ��1y1 j ' . i f 43 3 3/D M'NIMU!A ROOF JUNC710N OOx \• p PLASTER [HTILrL Pool, ,J4 yy •1+' o n.ARS er-" Pian View l � 1 + Ir CRouND .LATER 1S ' \ ( ` - - LONGITUDINAL POOL S:CTICA\ • 'TRANSVERSAL POOL SE CTK)N I I r v �� I N r1E.ra'n I \ HCr J1LRLb IWS'1 ALL ~J -'-'-'^- f ,1 REL HYDRu 9TAi1C. ICr `Fl r.2 ri't YALvr As FER LrcRS. �' I 1TELUAL 1✓ coNSTRUCTION IK-TESTES L.A C N •�V L1 P, _ ._ 14 ARCA.tc DCSIGHA'1 EO WAT(NT AHLE` L---k 1A, r� DT GF4ADIRC; Drv�S19H A h1rDRUS1kT%C - GENE PAL F IFI�OrCir• tC?1 P.CLICF YAI.VC .,n ALL BE ,+9Tn LL(.b. O ceNS - 41 c_TION !.JALL nN LORM TO • 7E:Nr UIl CING STE.Y_L SMA,L C.04 FeRM TO /I.�.T.M. OL 110 uAT'O'JS c.rL .^,[PT. or °LJ6 �. SAF I.YY Ce LL' E'STANDARDF. A-IS ANO A ]cS L.A1,S ,;NA-L br A. H,N•I+„,`•I or 3o U-.Aw[TIYS • :JI:.N i UOARI: NGT PEXN%,VEU OR ppoLS. LIS' TRAIT S CVCV F'(:ETIN Dr PT'H AI'' BJARD: COnStr'UCIIDn: SCCCIDR • 11EALTH 11CPA�MEVT APPROVAL REQ✓.dED FOK r,Lk_ JUrL f.L C. MMrRG1AL. TVPr PCO.. • cS,. + TE S.N11 8<' MACI.INC IJIxED AqD APPLIED PNEUMATICALLY. MAIN DRAIN LIGHT NICH= DeSI'-gn. V.Ix SMALL YE .11e PA n;- cEMC. PNEUMATICALLY. O Fo..a ARD A NAL[ PAerra _ _ --- SANG C1 S'/z) L^-r'S OMP. STRCHC,R. of 1.D. ►c- G t a Dqs. -'- O71/1SC DI lt�A.: r•,rrM.-1 To LrCAL :,C OI AVO gASCO VIE•: O SAT CR_C[MC NT FIAT10 SHALL NDT' F,(C[Eb �'�f GALS. '. AAr ER A.'RC Ag OU F,u -Y �LE,c 1. SIT[ AND APPrJVc;� ;/ArU[AL... PUMP sUCTl01i OP?VA•f: •A.17•il[: µ4 �E['T er' TVP of BOND ♦iCAM�ExC[�T. VIER SACK OF r.L-ENT -- •F3 BAR$ 12-D.0 .hl ►110K'.J� ANYULV.ATIJNS fKON TI-F.Sf, rc•rU1T l.+N'•, • ,:LJRC C:UNITE BMJ A WATER FOG SPRAY THRX17 -n ACS A, C)+( 1 C wi- RF[\UIRL SLIPPL t" N rRAKV t UTAIL-S t C A LCLILA r'.• ; - FOR FOUR CONSE CLrr1VC DAYS MINIMUM. I POOL- Ll[VC L • .1 � - Y-_ '•R I!O rj RO'J/.� 1dAT,[K .riMALL BE AT .j VL C1AL HOYr; ' `\\ FOR COMMERCIAL P-11 P-.14. )k TAOIVI M Fel _e AHD A N!.[.rFRT -NLI w [•_.••,[ ,A io1•NCf( TALI_ [} Pr*n ICCAIILC - A[-44 C[CTIoH[(F erM H,+IT+y _ S pLOV,oL .F['NCIN IJ Ca McLTA%ew WITH ;►i C,h, EV,CV I[ R[RV.-D v+.[RF 'ILL ' f Ler.Al. Ge/t RCRVIWE? VN7% PP.IeR -TC, CCr.,!p;1.ICY, rc C11'.Rs - Z'-4. { • CTwI;AL S.IALL c..FOLM T• LscAL �.Or ---JJJ--- I ' Rr IV.R L/ACN/ II [A Au LR LING MAIN OR AIR �IHE (�1 Co c C1AL offLV �� j[> MAIMD0R_AIAJ_oHLv I '��// \J 3rAN0AAD SWVAWNG COOL FOR: f G U N I T E CO., INC. ADDRESS: A6 JPEPVS4JIC ,eA CATY SKIMMER . FILLSPC(ff DETAIL. �V84.? . SEE ALSO DETACI+EO qO'F DLA•N DR/IWiH6l t FORM U TOWN OF NORTH ANDOVER a LOT RELEASE FORM SUBDIVISION ASSESSORS MAP SUBDIVISION LOT(S) PERMANENT ADDRESS (ASS GNED BY D.P.W. 1,-STREET C-I&PLICANT Z�Zj�J(�� L/4 Z—Z fQ El PHONE ATE OF APPLICATION ) TOWN USE BELOW THIS LINE PLANNING BOARD DATE APPROVED TOWN PLANNER DATE REJECTED CONSERVATION COMMISSION --- "� � OAT DATE APPROVED CONSERVATION MIN. DATE REJECTED BOARD OF HEALTH r� /y ! DAT E APPROVEU HEALTH SANITARIAN DATE REJECTED DEPARTMENT OF PUBLIC WORKS DRIVEWAY PERMIT SEWER/WATER CONNECTIONS FIRE DEPT. RECEIVED BY BUILDING INSPECTION DATE This form shall be signed by the agents of the Planning and Health Boards, the Conservation Commission prior to the issuance of any building permits for the subject lot. This form shall not releive the applicant from the compliance of any applicable Town requirement or Bylaw. LaMarche Associates 5 North Road, P.O. Box 250 Chelmsford, MA 01824 800-349-1525 Fax: 978-256-8590 April 14, 2015 Building Commissioner/Inspector of Buildings NORTH ANDOVER, MA 01845-2116 Board of Health/Board of Selectmen NORTH ANDOVER, MA 01845-2116 NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASSACHUSETTS GENERAL LAWS, CHAPTER 139 SECTION 313 Claim has been made involving loss, damage or destruction of the property captioned below, which may either exceed $1,000.00 or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate, lease direct it to the attention of the writer p and include a reference to the captioned insured, location, policy number, date of loss, cause of loss and LA file number. Insured: FRANK I & CAROLYN.S LAZZARINO Loss Location: 477 BEAR HILL RD NORTH ANDOVER, MA 01845-2116 Policy Number: PHOO100833873 Date of Loss: 02/27/2015 Cause of Loss: Ice and Snow LA File Number: MA-2-28765 On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail. Colleen Carroll Adjuster LaMarche Associates,Inc.-800-349-1525 Page 1 of 1 LaMarche Associates 5 North Road, P.O. Box 250 Chelmsford, MA 01824 800-349-1525 Fax: 978-256-8590 March 2, 2015 Building Commissioner/Inspector of Buildings NORTH ANDOVER, MA 01845 Board of Health/Board of Selectmen NORTH ANDOVER, MA 01845 NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASSACHUSETTS GENERAL LAWS, CHAPTER 139 SECTION 3B Claim has been made involving loss, damage or destruction of the property captioned below, which may either exceed $1,000.00 or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws Chapter 139 Section 3B is appropriate, p please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss, cause of loss and LA file number. Insured: CAROLYN LAZZARINO Loss Location: 477 BEAR HILL ROAD NORTH ANDOVER, MA 01845 Policy Number: PPA0100206640 Date of Loss: 02/27/2015 Cause of Loss: Water LA File Number: MA-2-27001 On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail. Colleen Carroll Adjuster LaMarche Associates,Inc.-800-349-1525 Page 1 of 1 Date.....4.'.3.'......4!.... ,iORTM "° TOWN OF NORTH ANDOVER PERMIT FOR WIRING s � ,>• a �,SSACHUS� This certifies that ...... J s � ... ..... L.� . .". .............. . .......... ...... .. .. has permission to perform �i ............. ....yie.. T wiring in the building of.......... ........................................ at............y.7..7. �L/�.� .......... North Andover,Mass. Lic.No. .'-1- . fcL CTRICAL INSPECTOR Check # .5i5- 76 8164 AMERICAN CLAIMS SERVICE Pce%0, MULTI-LINE ADJUSTERS ADJUSTER Am. BUILDING COMMISSIONER OR BOARD OF HEALTH OR INSPECTOR OF BUILDINGS BOARD OF SELECTMAN 1600 Osgood Street North Andover, MA 01845 RE: INSURED: Frank Lazzarino PROPERTY ADDRESS: 477 Bear Hill Road, North Andover . POLICY NUMBER: PHOO100833873 LOSS OF: 02/13/14; Property Damage FILE/CLAIM NUMBER 30754 PD Claim has been made involving loss, damage or destruction of the above-captioned property, which may either exceed $1, 000 . 00 or cause Massachusetts General Laws, Chapter 143, Section 6, to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim file number. Craig Gillespie Claims Representative On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail . Unless we hear from you within the next 10 days, we will not be obligated to pay any portion of this claim to you. Date 02/27/14 7 KIMBALL LANE, BUILDING C, LYNNFIELD, MASSACHUSETTS 01940 TELEPHONE (781) 245-9516 • FAX: (781) 245-1077 <. -,-•#ff§8# 11VVCarin yr massachusetts official useOnly y Department of Fire Services Permit No. llzz BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked ev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL All work to be performed in accordance with the Massachusetts Electrical code 0ORK (PLEASE PRINT'W AW OR TYPE ALL INFORM Y70N) Date: 6 City or Town of: NORTH ANDOVER By this application the undersigned gives notice of his or her inter To the I pe or of Wires: to erfonn the electrical work described below. Location(Street&Number) 7 Owner or Tenant Owner's Address Telephone No pj�� -o Is this permit in conjunction buildin p rmit? Purpose of Building Yes ❑ No (Check Appropriate Boz) Utility Authorization No. Existing Service Q?Y& Amps / Volts Overhead ❑ Undgrrd❑/ No. of Meters New Service Amps / V . Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity olts Location and Nature of Proposed Electrical Work: v Completion 01 the followin table maybe waived by the Inspector of Wires. No,of Recessed Luminaires No.of CeL1 Sus No.of -� p.(Paddle)Fans Transformers oral No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- o. o mergency lg No.of Receptacle Outlets No.of Oil B d• BatteryUnits - Burners FIRE ALARMS No. of Zones No.of Switches No. of Gas Burners o.of Detection and No.of RangesInitiafixw Devices No. of Air Cond. otal No.of Waste DTons No. of Alerting Devices isposers eat UMP umber ons o. elf;Contained Totals:." "" of Detection/Alerfin Devices No.of Dishwashers Space/Area Heating KW amici al ❑ p• Other Connectio No.of Dryers n r'3' Heating APPliances KW Security Systems:* No.of Water KW _ o.of o of No.of Devices or E uivaient Heaters Si s Ballasts. Data Wiring: No.Hydromassage Bathtubs No.of Devices or Equivalent No. of MotorsTeleco Total mmunications OTHER: No.of Devices or E uivalent Estimated Value o El ctrical Work: mach additional detail if desired, or as required b th =_y`? (When required by municipal policy.). g y e Inspector of Wires. Work to Start (p Inspections to be requested in accordance with MEC Rule 10,and upon completion INSURANCE C RAGE: Unless waived by the owner,no the licensee provides proof of liabilitypermit for the performance of electrical work may issue unless ce including completed operation"coverage or its substantial equivalent. The undersigned certif es that such cove is in force,and has exhibited proof of same to the CHECK ONE: INSURANCE BOND ❑ O'B Permit issuing office.. I testi under ❑ (Specify:) .fy, the pains and penalties of perjury,that the in orin . FIRM NAME: CApn f on this application is true and coneplete Licensee. N�eC S' LIC.NO.:_Jjf S'3?(� (If applicable, enter"esem "in t e e umb n .) a LIC.NO.: Address: Bus.TeL No.: *Per M.G.L c. 147,s.57-61,security work requires D Alt TeL Na.: Lice OWNER'S II1'SURANCE WAIVER; I am aware thathe ee does not Safehave'the liabilitynse Lic.No. required by law. By my signature below,I hereby waive this re insurance coverage.normally Owner/Agent requirement I am the(check one) (] owner []owner's agent. Signatare Telephone No. PERMIT FEE:$ h , � �'� . 4 7 Y �. OT The Commorrfwea th of H=Sachuseft j Department of Industrial Accidents K ! Office Of lnvestiQations ra 4 1' 600 Washin ton Street Boston, jIL4 02111 ti� z Workers' Compensation Insurance Amada Builders/Con Applicant Information tractors/Eiectricians/Ptambers Please PrintLe,ib Name(Basinrss�orgs,aiza6o&indMdual); .f. • Address: City/State/Zip: Phone Are you an employer?Check the appropriate box: ' 1•0 i am a employer with 4. ❑ I am a general contractor and 1. Type.of project(requites: 2,Demployees(full and/ part-time).*. flare hired the sub-contractors 6. ❑Naw construction .I am:a so}e proprietor or partner- listed on the attached sheet 1 7• ❑Remodeling ship and have no employees T}r g mor em sub- contractors have & kin form Demolition g . e m an � Q n Y capacrty workers comp.insurance. [No workers'comp,insurance 5. ❑ We are a corporation and its . 9• ❑Building addition required-] officers 10 have exercised the' •�1 ctrical 3•❑ I sin a homeowner doing all work right of exemption per MGL 11.• repairs m addrbons myself•[No-work=`cornp. ❑Plumbing repairs or additions P c..152, §1(4),�and we have no 12, Roof . insurance required-]]t empiaytres, [No workers, ❑ repairs comp, insurancemquh&]. 13:0.Other *Any appficartt that checks b #I moat also fill out the section below ehDwing their worked'bompensetion of f ?Homeowners who submit this affidavit inditatdng they am living an woflr end then hire outelde cvn � � information ;Contractors that check this box musraetaohed an additioasf sheer Showing uactont must submit Anew affidavit indicstiq such. trtg the rrarnc of the ottAcctnd and their workers' cam .Policy f arc anemployer P f3 �Y inffornuttion. that-is ro ' , yn;tndiag:warkers eontpensatfoR insurance or infornratinn. } '�10Yft% Below is.the policy and job site Insurance Company Name: lT/ Policy#or Self ins.Lie.#: Expiration Date: Job Site Addressc Attach a copy of the. in. CitY�tate/Zip' workers'co pensation policy declaration page(showing the policy on mber and expiration dste� Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal expiration d of a fine up to$1,500,00 and/or one-year imprisonment,as well as civil penalties in the form ima STOP WORK ORDS Of up to$250,00 a da R and a fine y against the violator. Be advised that a copy of this statement may be forwarded to investigations of the A for insurance coverage verification. the Office of Ido hereby certify un a P penalties of perjury that the information provided above ' true and correct Si tore: Date: Phone#: Of j`�cial use Wady. Do not write in this area,to he cOn fleted by city or town of iida( City or Town: Permit/I.ieease# Issuing Authority(circle one): 1. Board of Health Z Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector b Contact Person: Phone#: ' C ' Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,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 ofthe'foregoing engaged in a joint enterprise,and includireg the legal representatives of a deceased employer,or the receiver or bustee•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,construction orrepair work an 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,§25C(6)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,MOL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work tmtil acceptable evidence of compliarrce with the insurance requirements of this chapter have been presented to tate contracting authority." Applicants Please fill out the workem'compensation•affidavit completely,by checking the boxes that apply to your situation and, if necessary, supply sub-contactors)name(s),address(es)mind phone number(s)along with their certificate(s)'of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to cavy workers'compensation insurance. If an LLC.or LLP does have employees,a policy is required. Be advised that this afitdavit.may be submitted to the Department of industrial t Accidents for confirmation of insurance coverage.. Aliso 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 rogarding the law or if you are required to obtain-a workers! compensation policy,pleasc-call the Department at the numberlisted below. Self-insured companies should entertheir self-insurance".license Dumber on the'appropriate line. City or Officials' Please be sure that the affidavit is complete and printed legibly. The Department hes 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%%-M be used as a reference number. in addition,an applicant that.must submit multiple permitRicm=applications in any given year,need only submit one affidavit indicating•current policy'information(if necessary)and under"Job Site.Address"the applicant should write"all locations in (city or town)."A copy of~Ebe affidavit that has bean officially stamped or marked by the city or town may be provided to the applicant as proof that a valid-affidavit is on file for future permits or licenses. Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit no bum leaves etc.)said person, is NOT required to complete this affidavit The Office of Investilptions 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 Dopartrnent's address,tteiephone and fax number. The Commonwealth of Massachusem Depar cnt of Indust ial Accidents Office of Eauestigafaons 600 Washington Sheet Boston, MA 0:2111 TeL#617-7274900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#5l 7-727-7749 www.mem.gov/dia Location' No. Date MORTiy TOWN OF NORTH ANDOVER O?O,tt`•D ,•,MOOS p Certificate of Occupancy $ Building/Frame Permit Fee $ 1'�s'""''•t� Foundation Permit Fee $ J�C HUSE Other Permit Fee/%.rG-,�$ � y Sewer Connection Fee $ Water Connection Fee $ TOTAL $ t-,10 � Z Building Inspector 04/29/99 14:56 25.00 RAID Div. Public works PERMIT NO. / 3.3 APPLICATION FOR I)E10111T TO 3UIL1)**"""NORT11 ANDOVER, IIIA I%I,No . 1.01.N0. �jG7 2. IM011001—O \'NLI(SUIP DATE BOOK PAGE MIt,E SUB BIV. 1.0 Nl). X kIIUN Ll yam`/ PURPOSE lN=1)IIIIUING \VNER'SNAME � NO.(N SfONtIES SIZE r \VNER'S ADDRESS BASEMENf OR SLAB _ 11 ST HD RD ACI III E(-I'S S NAME SI OR L2:OF 1-1 OTIMBERS 1 R 2 3 BMI UL•R'S NAME SPAN UISIANCE—IoNEARESI BUILDING, DIMENSIONS 01:SILLS DIS I'ANCE I RO M S I RLE 1 DIMENSIONS 01:POS I S DIS I ANCE-FROM LOT LINES-SIDES REAR DIMENSIONS OF GIRDERS AREA OF LOT FRONT AGE I IEIGI IT O N:FOUNDATION •I-I I ICKNESS I IS BUILDING NEW 51 Z Of-,I(XIIING a X IS BUILDING ADDI IIONI MATERIAL OF CIIIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID(It-fit LED LAND WILL BUILDING CONFORM TO REQ IIREMEN FS OF CO)i)E IS BUILDING CONNECTED 10 TOWN WATER BOARD OF APPEALS ACTION, IF ANY IS BUILDING CCNJNECfEI)TO TOWN SEWER IS BUILDING CONNECT ED TO NA I URAL GAS LINE INSTIIC'I-IONS 3. PROPER LY INFORMA TION LANUCOSI II`` ESl. BLIx;.COS f r T/ Oy PAGE I FILI.OIIT SECTIONIS 1-3 0 174 EST. BLDG.COST PER SO2. FT. EST. 811x'i.0YSI 1'ER R(IOM EI EC-TRIC MEI LRS I IIIST BE ON O HTSIDE ON:BUILDING SEPTIC PGIt1 11l NO. AI'IACI IEIF:GAR AGES mus TC(N roRmTOSTATEFIREREGIILA'THNNS a. APPRO\'EB BY: t- PI-ANS MUST BE FILED AND APPROVED BY IIIIILDING INSPECfOIt BUILDING INSPECTOR i DA 1:11 l_I) U Q / OWNERS IELY �f CONI R.'I I:I.b. � % i^% •1 /1 / ! U CONJIit.I.101 l F dam/ SI(1NAHIRLON:ON'NLROIt I UI0RIZI;DAOI.NI I I III.C.II J L PI HIM I(;RAN I I-D 19 M+p R T!y Town of dover AT Q r� C- m 131 �('��+ dower Mass. °p coc.iiciieJvTt�t� > > e ADRATED P BOARD OF HEALTH PERMIT Food/Kitchen Septic System BUILDING INSPECTOR THISCERTIFIES THAT..... ............. ..... ....... ................. ............... .. ...................... *.............. Foundation has permission to ere ...... �...... ....... buildings on ... g ........ .t ............. Rough ................ .. ......... tobe occupied a ...... .... ......................................................................................... Chimney ............. provided that the person accepting this permit shall in eve pact conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-La's elating 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 � ELECTRICAL INSPECTOR o Rough ................................................................................................................. 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 Smoke Det. e \ HOME IMPROVEMENT CONTRACTOR I" Registration 124589 Type; INDIVIDUAL Elpiration 07/22/99 Frank S. Tridenti 140 Autran Ave _. tom N ndover MA 01845 ADMINISTRATOR • i y