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Miscellaneous - 48 CHURCH STREET 4/30/2018
48 CHURCH STREET 210/041.0-0014-0000.0 Date...... '..Z�. .../ t NORTH 1 "�o� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING �,SSACMUSE� This certifies that ........ �� �....... .... r. ..... ... ........ .................... has permission to perform �/jl�G'LE !�fiti� �.................... wiring in the building of alt.--I:c--.L . F:............................. at .......... .............. .North Andover,Mass. Fee.. fes . b Lic.No. ZIN ELE R[CAECTOR Check # _�L� � r Information and Instructions V 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 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,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,§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,MGL 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 until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and 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 d members or partners,are not required to cant'workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit 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 til: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' oo„i7pPTofi��vii policy,please call 11.1-ic D p3Tf^C^.�t the numn'wl:si:d .81vW. u_,Ur-uoAi:.d companies slical3 eriie, uhCli self-insurance license number on the appropriate dine. City or Town Officials 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. in addition,an applicant that must submit multiple permit/license applications in any liven 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 the affidavit that has been 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. A new 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 to burn leaves etc.)said person is NOT required to complete this affidavit: The Office 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA€12111 Tel.#617-727-4900 ext 406 or 1-8.77-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.tnass.gov/dia The Commonwealth of Massachusetts • �;� ' ! Department of Industrial Accidents .. Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Analicant Information Please Print Lembiv Name(Business/Organization/Individual):_ 1J AWA L —1% Q�U Address: �A 1fiamy�d' Ayfia2 � 1 � City/State/Zip: 1�(/Q F � n a!yaj, Phone#:9 Z F) 7d-1 -;o?a Are you an employer?Check the appropriate box: Type of project(required): 1. 111 am a employer with 4. ❑ I am a general contractor and 3 6. ❑New construction 2.�employees(full and/or part-time).* have hired the sub-contractors 1 am a sole proprietor or partner- listed on the attached sheet.S 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for mein any capacity. workers' comp.insurance. g, ❑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-worke'rs'comp. c. 1.52, §1(4),and we have no 12.[]Roof repairs insurance required.]t employees. [No workers' comp, insurance required..] 13.M Other Any applicant that checks botlM must also fill out the section below showing their workers'compensation poi icy 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. 2Conkrnetors that check this box r u-st.ttachcd ca additio.-m! th4 j,a.;yac of tF: and their workers'comp.policy information. I ant an employer that is providing workerscompensation insurance for my employees: Below is the policy andjob site information. Insurance Company Name: Policy#or Self-ins. Lie.#: 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 c n r th pains and penalties of perjury that the information provided above is true and correct i Si afore: Date: ;11111 101 011 11 d Phone#: 975— 7QJ, ?•43.t./ 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#: s m d- t9- J3- o �'`1 • r Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No.Occupanc76s�C1 BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] and Fee Checked leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 MR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFOR ATION) Date: / ,o City or Town of: NORTH ANDOVER To the Imp' ctor of Wires: By this application the undersigned gives notice of his or her intention to perform electrical work described below. Location(Street&Number) Owner or Tenant Telephone No. Owner's Address 1 c / �94 01W Is this permit in conjunction with building permit? Yes V No ❑ (Check riate Boa) Purpose of Building -sjMlo p;/& 00V Utility Authorization NApro `7'zj 2. 1 Existing Service-40 D Amps Volts Overhead Undgrd❑ No.of Meters New Service 2 Amps /e?c)/ Volts Overhead Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: X Completion of the ollowin table maybe waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires le? 15wimming Pool Above EJ ❑ o.o Emergency ig g rnd. rnd. Batte Units No.of Receptacle Outlets o.of Oil Burners FIRE ALARMS No.of Zones No.of Switches /6''" No.of Gas Burners '+To.off Dete;.tion and Initiating Devices No.of Ranges Total g a So.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons. No.of elf-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal E-1 Other Connection No.of Dryers ` Heating Appliances KW Security yf Devices or Equivalent No.of Water / No.of No.of Heaters ( KW Signs Ballasts Data N of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of E ectri al Work: �,6100 (When required by municipal policy.) Work to Start: 9 .1/ 0"7 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C GE: 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 cover a is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: LIC.NO.: Licensee: n e� Signature LIC.NO.: is y; g (If applicable, enter"exempt"in t e license number line.) Bus.Tel.No.: /� Address: - 14144,, UM= • t t dAaMl. I Aa Alt.Tel.No.: �"e le - *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. Qq 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 agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ Location No.0. Date ! ' _40RT" TOWN OF NORTH ANDOVER F A Certificate of Occupancy $ ♦ i Building/Frame/Frame Permit Fee $ sAcNust 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 2 o Building Inspector sA'^ CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 283 ,10/15/2007 Date: FebruM 21, 2008 THIS CERTIFIES THAT THE BUILDING LOCATED ON 48 Church Street MAY BE OCCUPIED AS Sinale Family Rehab IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: James Lebelle 48 Church Street Bradford Ma 01835 Building Inspector T40RTH d own Of -_ ,1 Andover No. 0 "t•.. Y +Y C% o. , dover, Mass., • T 0 LAKE COCHICHEWICK �q A004TED APS` �C S BOARD OF HEALTH Food/Kitchen PEII.RMIT Septic System BUILDING INSPECTO THIS CERTIFIES THAT �I / ) �..................... ... .......... ................................................. n L I has permission to erect........... ��" „ !� . ................... . buildings on.... .t 4 .......s ....... ........ �... .............�. ugh � i� d./►�/Q/ to be occupied as..........AO*O... ...............A0.**✓� I I� . . . .. .. . . . .. . . . .. . . ...... provided that the person accepting this permit shall in every respect conforAo the terms of the applicatio on file in a this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of �- Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUC TS gk /0- -4j-d-1rr, ............... ....................12...................... Service BUILDING INS Occupancy Permit Required to Ocmpy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough vv � F&I4 C ;�� No Lathing or Dry Wall To BeDone FIRE DEPARTMEN Until Inspected and Approved by the Building Inspector. Burner Street No. f j/ 6 SEE REVERSE SIDE _ Smoke Det. NORTH 0" 06Andover No. * - _LAK _ 8 C% o �` dower, Mass., O COCMICKEWICK �• ORATED P �5 S V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System BUILDING INSPECTOR THIS CERTIFIES THAT q...� �..1!1.................. V r �..r .... P . !�� s. ' Foundation ................................... .. ..... ............ ... .... O OO.4 �,1„�, . h has permission to erect........................................ buildings on ............. ..4............ ........... .. .... Rough to be occupied as.....fi.M.ON...4g�'�!"r 11................. .... Chimney provided that the person accepting this permit shall in every res t conform to the terms of th application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final jqq4W PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTR C�Ts ...... ........................... .......... 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 T No Lathing or Dry Wall 1 o Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE a Smoke Det. NORTH Town of 4 _ > >� _ o �` doves Mass. � ' r• d I_AK T� I� COCMICMEWICK 7�S RATED BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System L BUILDING INSPECTOR THIS CERTIFIES THAT......... ......L..� ................................................................................. Foundation Ahas permission to erect........................................ buildings on ...4.... .61#! ....S.# .......................... Rough Chimalev to be occupied as.......Q.j. ......... ...... .. .. ......•........................................................................................................ in this permit shall in eve respect conform to the terms of the application on file in provided that the perso accepting pe every p PP �inal this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. 5 P IFAm 7'" -:e+ PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. oZ S Rough Final PERMIT EXPIRES IN 6 MONTHS I T600=� ELECTRICAL INSPECTOR UNLESS CONSTRU TART 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. f pORTH 1 O 4 %.ao G {O N p e � SSS'""` APPLICATION FOR CERTIFICATE OF OCCUPANCYIINSPECTION Building Permit# fs3 ADDRESS/LOCATION OF PROPERTY : 7 f Map Parcel Lot Number SUBDIVISION ^V0 DATE REQUESTED FILED/READY FOR INSPECTION CLOSING DATE ON PROPERTY: FIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED ALL WORK AND SIGN-OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A RE- INSPECTION FEE OF TWENTY DOLLARS$20.00)WILL BE CHARGED IF THE STRUCTURE DOES NOT MEET ALL APPLICABLE CODES. Permit Issued to: Address "b SIGNED ROUTIN CONSERVATION PLANNING a DPW -WATER METER PPI SEWERIWATER CONNECTION F7 NOTE DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST DPW 44 . `c ="L Signature Fife: Application for OC form revised Jan 2007 /Dat .,�: " ._�.-,r "0°T:'tio TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 40 ,SSACMUSE� This certifies that . . . . . . . . . . . . . . has permission to perform ... . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . . . .-. . . . . . . . . . . . . . . . . . . . . at. . . .7. . . �. . . . . . .... . . . . . .�. . . . . .�. . . . . . . ., North Andover, Mass. Fee. Lic. No.J:I. t/. ' . . . . ��. . . . . . . . . . . . . ��,,""•,. � PLUMEING INSPECTOR Check # i a U MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS '7' Date Building Location �f 1(/j'�j '� Owners Name(�G��'y/!t° Lala/P fZ Permit# t � ✓9�t'21 Type of Occupancy Amount New Renovation Replacement ❑ Plans Submitted Yes ❑ No rl FIXTURES w H w x x w z z U a xz A a A o H z o w o U SLB.» RASEVUqr MFLOCIR 2M H1= ,:mH-10MCR 4M110M 5M HJ0M MH Iffm - 7M gm HDA (Print or type) Check one: Certificate w Installing Company Name JM ri Corp. Address Partner. VL'i in usmess Telephone ® Firm/Co. Name of Licensed Plumber: M A014 0 Insurance Coverage: Indicate the type of ins rance coverage by checking the appropriate box: Liability insurance policy '51 Other type of indemnity ❑ 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 Signature Owner ❑ Agent El I hereby certify that all 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 installations performed unde ermit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts Stat lumbing n ha ter 142 of the General Laws. BY igna ure or 17conseerrJUMDer Typ�Z�mbing License Title r City/Town icense TIMM Master Journeyman ❑ APPROVED(OFFICE USE ONLY 7ys� Location ���� Sr- No. rNo. � Date NORM TOWN OF NORTH ANDOVER 3? OWNWL F 9 Certificate of Occupancy $ ' ;�a"••�•tt� Building/Frame Permit Fee $ r 1 scHus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ •2GCheck #- 2 C t ) Building Inspector N�.,n BUILDING PERMIT °`,t`e° ;e,9tio TOWN OF NORTH ANDOVER F p APPLICATION FOR PLAN EXAMINATION Date Received °"^Ta Permit NO: 9ss4cHUS�� DateIssued: - 11 IMPORTANT: A licant must complete all items on this age OSA ar PROPERTY,OWN.f v Z,ONINO�'�"31vTR I`#tstor-tc D�sfrtct no 70N� nB�u IMPROVEMENT PROPOSED USE Non- Residential— Residential w ildin One family ❑ Addition Two or more family ❑ Industrial t6 Alteration No. of units: 0 Commercial Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Sec € u`let777 ❑ FkItn =31Aletlarls Wateirshe ��strt DESCRIP ION OF WORK TO BE PREFORMED: u. J �w e • 'D � �c� v✓�B� l r Gc1�ti�4� _,Ole 1.0 Identificatio P ease pe Print Clearly) ? S 7 Phone: OWNER: Name: Address `r 7.�; . CSI 'TRA xe$-�sf�rx rAddres U erUISO '' :�rQxlSti't] I�JrI Ltf15 4 + Xj Oa p Hor n.e r, provetriex� i Phone: ARCHITECT/ENGINEER Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ ` FEE:el $ S I Check No.: J �` Receipt No.: NOTE: Persons contracting with nregiste c ractors do not have acces h uar n d z g S,i nakure ofontraLr Signature of Agentl01rner The commonwealth of Massachusetts .. .Department of Fire Services Office of the State Fire Marshal. P.O.Bax 102i,St ate Road,Stow,MA 0I775 PERMIT Date: North Andover Permit No (Crtyof Town) (If Applicable) Dig Safe Num er In accordance with 1.the:provisions of NLG-L-1 48.Ghap.ter—JQas.provided in section 5 2 7MR C 34 j✓� start Date /f =•_=T1us Permitis granted to_ ���y� ��9,�fi�r �if_ Full name of person,Firm or Corporation Penui;ssionto locate dumpster. for construction/renovation/demolition of building. Corrirnents:. dumpster must be . 25 t from structure if unable to lace with required Restrictions:clearance dumps-ter must be covered with plywood or tarp end of 'work -day - ---at. ke:li!?�i�ty%i2E�r— (Give location by street and no.,or descebe in such ma - r s to pro ' adequate identiEcation of location) Fee Paid 50.00, .. Fire Chief Tlvs Permit brill expire" _' (Signature of offical granting permit) Olfcal grantingpcmdt (Title) > 4N m Board of Building Regulations and Standards m 91te &Mmv/ - X co ;)� m Z One Ashburton Place - Room 1364 = z m � Zo Boston. Massachusetts 02108 J Z W D Z m o m� Home Improvement Contractor gistra+.ion i coco , m � o �I Registration: 152740 Type: . Individual ' Expiration: `9/26/2008 6 I oo 0 M KEVIN DANIELS z KEVIN DANIELS N ; Cn y 84 BENNINGTON ST _Ilk HAVERHILL, MA 01832 Update Address and return card. 119ar1:reasgn for change. )PS-CA1 is 50M•05/06-PC8490 Address Renewal Eml ,oyment Lost-Card GENERAL CONTRACT 1 This Contract is made on ?S ' 2 ,between fHwS P Party One,of j=bMf 'T� City of �'"�` State of and ' ' - Party Two, of -( City of State of xM For valuable consideration,the parties agree to the following: Party One agrees to: ����� oao °'� jZ f V"X"Q Party Two agrees to: p CCK, �e� (� CQ K-O/e �- Zc � ✓'-( 5 C d..�V C w�l, �S CCs t Any additional terms: No modification of this Contract will be effective unless it is in writing and is signed by both parties. This Contract binds and benefits both parties and any successors and assigns. Time is of the essence of this Contract. This docume ,including any attachments,is the , entire agreement between the parties. This Contract is governed by the laws of the State of (•� 4�� ' Dated: 2 n re of Party One Signature of Party Two Name of Party One Name of Party Two The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 `rr i- www.mass.g ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): 4,CV\ at Address: ES'1 �t— City/State/Zip: ��� C �'�[ otsr 3,2- Phone #: `� ��. q 7G " 12aS 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 employees(full and/or part-time).* have hired the sub-contractors 2.'Q I am a sole proprietor or partner- listed on the attached sheet. 1 7. ❑ 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 officers have exercised their 10.❑ Electrical repairs or additions required.] 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' 13.❑ Other comp. insurance required.] *Any applicant that checks boz#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. $Contractors 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: t 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 cert'y ndert e pa s and pe !ties of perjury that the information provided above is true and correct Si ature: bb Date: /''� ZG 2-, Phone#: z , ' 4 A — � �-a 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: �R Phone#• 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 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,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, §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, MGL 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 until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s), address(es)and 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 cant'workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit 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. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials 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. In addition,an applicant that must submit multiple permit/license 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 the affidavit that has been 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. A new 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 to burn leaves etc.)said person is NOT required to complete this affidavit. The Office 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. #617-7274900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 5-26-05 www.mass.gov/dia Storage 14' 22 15' Kitchen 15' Storage 17' 5' S' CL Full Bath Dining Den Full Bath Bedroom CL 20' 21' CL L Closet 5' Bedroom Living Room Bedroom Bedroom 5' i i 11' 10, narc:h 45 1st Floor skdcn by Apex iv- I U inerts 1 i I AREA CALCULARM SLMVEARY AREA BRE AKDOAN Code Description Size Net Totals Breakdown Subtotals I 7 i i I i r I. r �• FLOORPLAN Borrower: Marcia L. Thornton File No.: 4281331 Property Address:48 Church St Case No 111780047 Clty North Andover State: MA Zip'01845-2504 Lender.COUNTRYWIDE- FSLD/Landsafe A praisal Services f F .; t Storage 14' 22' 15' Kitchen 15' Storage 17' 5' 5. CL Full Bath Dining Den Full BathL Bedroom CL 20, 21' CL L Closet I 5. Bedroom Living Room 5 Bedroom Bedroom I I' 11' i 10' -2n.+Floor 45• 1st Floor SWCh by Apex NTM Caffner$ AREA CALCULATIONS SUMMARY AREA BREA gX)WM Code Description Size Net Totals Breakdown Subtotals 1 g. NORTH Town of VIA No. -ti , AV LAK0 . dover, Mass., C 1` Q � E � I� COC MIC NE WICK V 7 ADRA7ED '9S BOARD OF HEALTH ' Food/Kitchen PERMIT T D Septic System ��� �� BUILDING INSPECTOR THIS CERTIFIES THAT . .................................................. .... ......................................................... Foundation has permission to erect................. .................. buildings on .... .t.....G..k.1� 4. %.......s.T....•.. �. Rough to be occupied as.......... . ................. ........�.^....... �N� ............. Chimney nfor o the terms of the licatio on file in provided that the person accepting this permit shall in every respect co pp Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTS Rough ..... TService BUILDING INS 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. TRANSMISSION VERIFICATION REPORT TIME 08/0212007 09:32 NAME HEALTH FAX : 9786888476 TEL 9786888476 SER.# 00OB4J120960 DATE,TIME 08102 09:30 FAX NO./NAME 819782582530 DURATION 00: 01:05 PAGE(S) Ai: RESULT OK MODE STANDARD ECM t&bRT#1 Of j7L1h6 14 41. Q BUILDING DEPARTMENT Community Development Division August 1, 2007 To"Whom It May Concern: This letter is to state that the Assessor's Property card for 48 Churcb,Street show's Haat the sftucture was built before 2004,the lot is within the Residential-4 zoning district,that one and two imily dwellings were allowed by right before 2004. The structure is coded 1014,or a two--family dwelling pec"Property Type Classification Codes",page 3 of the Massachusetts Department of Revenue. The current owner has written;a notarized statement Haat 48 Church Strut has always been;a twc4roily dwelling. They removed the up Iain kitchen appliances for renovation about 14 months ago,and then the May 2006 floods required the reallocation of their funds in order to replace the damaged beating&hot water systems. Finally, Section 9,Paragraph 9.1 of the May,2006 Zoning Bylaw states.- 9.1 tates:9.11 Non-Conforming Uses Any non-conforming building,sincture,or use as dAned herein,which law:Wly existed at the time of pnfmgc of the applicable prmvision of this or any prior by Law or any amendment thereto may be continued subject to the provisions of this Bylaw. If,the structure is dammed,then Paragraph 9.4 allows: 9.4 Building After Catastrophe Any mane-c4tdormin{g building or smmlure destroyed or damaged by fire,flood,lightning,earthquake or wind to the extent of sixty-five percent(6S"/o)or more of its reproduction cost:at the time of such damage shall not be rebuilt,repaired,reconstructed nor altered except for a pwpose permitted in that zoning district in which a..nh ti...:lA:.r.r:n l.v,ti+ev! nw nvnn.tF aer„1.,1.a waw�n;++err lrrr n L'+.nr;of Anrw�i!nr hihnraHen tier thra Rn�wl of FORTH Ot 41 �9SSqu+uS�� BUILDING DEPARTMENT Community Development Division August 1,2007 To Whom It May Concern: This letter is to state that the Assessor's Property card for 48 Church Street shows that the structure was built before 2004,the lot is within the Residential4 zoning district,that one and two family dwellings were allowed by right before 2004. The structure is coded 104,or a two-family dwelling per"Property Type Classification Codes",page 3 of the Massachusetts Department of Revenue. The current owner has written a notarized statement that 48 Church Street has always been a two-family dwelling. They removed the upstairs kitchen appliances for renovation about 14 months ago,and then the May 2006 floods required the reallocation of their funds in order to replace the damaged heating&hot water systems. Finally, Section 9,Paragraph 9.1 of the May, 2006 Zoning Bylaw states: 9.1 Non-Conforming Uses Any non-conforming building,structure,or use as defined herein,which lawfidly existed at the time of passage of the applicable provision of this or any prior by Law or any amendment thereto may be continued subject to the provisions of this Bylaw. If the structure is damaged,then Paragraph 9.4 allows: 9.4 Building After Catastrophe Any non-conforming building or structure destroyed or damaged by fire,flood,lightning,earthquake or wind to the extent of sixty-five percent(651/o)or more of its reproduction cost at the time of such damage shall not be rebuilt,repaired,reconstructed nor altered except for a purpose permitted in that zoning district in which such building is located,or except as may be permitted by a Special Permit or otherwise by the Board of Appeals acting under Massachusetts General Laws Chapter 40A. If you have any questions,please feel free to call me at the North Andover Building, 978-688-9545. Yours truly, Gerald A. Brown, Inspector of Buildings/Zoning Enforcement Officer encl. Copy of Letter Marcia L.Thornton letter Copy of Assessor's Property Card 210/041.0-0014-0000.0 cc: Building files 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9545 Fax 978.688.9542 Web www.townofnorthandover.com nog NA . � u� �r c�a Rd 1j. 7—A om&n G,,nd Aeoelz W-ald-1 lyllw� 417� -_Jlz,�J, 9AIttt ra-toL JANET L.EATON! - NOTARY PUBLIC COAIMONW.ALTHOf)AASSACHUSETTS �'t W Comm Expires Sept 26,2008 Residential Property Record Card PARCELID:210/041.0-0014-0000.0 MAP:041.0 BLOCK:0014 LOT:0000.0 PARCEL ADDRESSA8 CHURCH STREET km PARCEL INFORMATION V ...... ................ .................... ............................................ Tax Class: ........... ....Sili' i4i*... 1996 Page:*... ............Rd Condition: P Meas Date: 04/28/2004 Owner. ...... xi i i i ....................... 0W x .................... P m �.--T' 'A-Ar" :3 �il THORNTON,RICHARD W 010 P .... ..... ........ Sale Valid:....A. ......... ......... ... Water '0611ac"t"Id'........ RRC MARCIA THORNTONTot Land Area: 0.22 ..... ...................................... ............. ............. .0d.ft ................ .............-.............. ..................... ...... ...... ........... ....... .......... .aft: ..... ........ .... .......I........ ...... ................ Address: 48 CHURCH STREET Exempt-B/L% 010 Resid-B/L% 1001100 Comm-BILWO Indust-B/L% . 0/0 Open Sp-B/L% 010 NORTH ANDOVER MA 01845 RESIDENCE INFORMATION LAND INFORMATION N8HD CODE 5 NBHD CLASS: 5 ZONE: R4 ........................ . ... ... ... ....... ..... ....... 1wd :.:.......YI�.............................................�................................................................................... ..... ...... .7.......... ...... ... Story Height: 66&66�hifs 4 Up Fn Area: 875 Bsmt Area: 1134 �0.#: V .......- I ' .....::::::. ........... .. ...................i 86,252 9554 0.22 P 104 A ......HWAiihi:.................Ghfih Area: 306 1946f'Gridi Ext Wall A� DETACHED STRUCTURE INFORMATION RCNLD: 197042 . ....... ....... ....................... . ...... W .. ................. ......................... Foundation: ST Bath Wal, . .. .. ........ ......9.........460*..........................i'968' A A ....Wl/`/`56.' 6,706": .. .... PA S 254 1988 A A 50///50 2,600 G1 .. .... ... .... Heat Type: tit i6ich: "'..Year Built 1857 Sound Value: s T" ............ re. VALUATION INFORMATION ............. ............... ........... .........l4. .......................►.. Fireplace: Bi i'dir" Condition: A Aft Str Val 1: ... Current Total: 391,600 Bldg: 206,300 Land: 185,300 MktLnd: 185,300 sm�-G :..SF , i*:'�'.�'i'*�'.�'.�..i.i*: -S V Prior Total: 340,200 Bldg: 180,000 Land: 160,200 MktLnd: 160,200 Aft Gar SF: %Good P/F/E/R. 11001f73 Porch TyRit Porch Area Porch Grade Facto P 301 SKETCH PHOTO ................ .7 . .. .......... JA 22 is fm: 137t Sq.F. �1"4 Sq^ ------------- 48 CHURCH STREET Parcel ID:2lot041.0-0014-0000,0 as of 8/1/07 Page 1 of 1 14ORTH O Olt SSACHU`�� BUILDING DEPARTMENT Community Development Division August 1,2007 To Whom It May Concern: This letter is to state that the Assessor's Property card for 48 Church Street shows that the structure was built before 2004,the lot is within the Residential4 zoning district,that one and two family dwellings were allowed by right before 2004. The structure is coded 104,or a two-family dwelling per"Property Type Classification Codes",page 3 of the Massachusetts Department of Revenue. The current owner has written a notarized statement that 48 Church Street has always been a two-family dwelling. They removed the upstairs kitchen appliances for renovation about 14 months ago,and then the May 2006 floods required the reallocation of their funds in order to replace the damaged heating&hot water systems. Finally, Section 9, Paragraph 9.1 of the May,2006 Zoning Bylaw states: 9.1 Non-Conforming Uses Any non-conforming building,structure,or use as defined herein,which lawfully existed at the time of passage of the applicable provision of this or any prior by Law or any amendment thereto may be continued subject to the provisions of this Bylaw. If the structure is damaged,then Paragraph 9.4 allows: 9.4 Building After Catastrophe Any non-conforming building or structure destroyed or damaged by fire,flood,lightning,earthquake or wind to the extent of sixty-five percent(65%)or more of its repioduction cost at the time of such damage shall not be rebuilt,repaired,reconstructed nor altered except for a purpose permitted in that zoning district in which such building is located,or except as may be permitted by a Special Permit or otherwise by the Board of Appeals acting under Massachusetts General Laws Chapter 40A. If you have any questions,please feel free to call me at the North Andover Building, 978-688-9545. Yours truly, Gerald A.Brown, Inspector of Buildings/Zoning Enforcement Officer encl. Copy of Letter Marcia L.Thornton letter Copy of Assessor's Property Card 210/041.0-0014-0000.0 cc: Building files 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9545 Fax 978.688.9542 Web www.townofnorthandover.com IVORt� AndOVEA NA . VA N, c�oho rlon _;t4L la,Ae, gplUt goo OL JANET L.EATON �J NOTARY PUBLIC COIAMOHw-ALTHOFMASSACHUSETTS My Comm.Expires Sept 26,2006 Residential Property Record Card PARCEL_ID:210/041.0-0014-0000.0 MAP:041.0 BLOCK:0014 LOT:0000.0 PARCEL ADDRESSAS CHURCH STREET PARCEL INFORMATION E/s0aQe'� ...:: SAID PnOW -00, d :. Q�ld7S.,: i ad;!'iype :; ;. inape t C3ata. X,x......................+# Tax Class T Sale Date 04/07%1996 Page 0018 Rd Condition P Meas Date 04128/2004 Owner: "#cSt.Eirt,/1r00: 2251 SOI+aTyaY f'• : : .:. : .;> rt/CiidC. TrOi'fiCt ilio iwettr4r .. X.:. THORNTON,RICHARD W MARCIA THORNTON Tot land Area 022 Sale Valid A Water: Collect Id: RRC tlAtltQiMAiTIN, .: StN . irt;#pBCk RO ;i; Ali Address; <! 48 CHURCH STREET Exempt-B/L% 010 Resid-B/L% 1001100 Comm-B/L890 Indust-B/L% 010 Open Sp-B/L% 0/0 NORTH ANDOVER MA 01845 {`.Q, �(.j �y�/R�ESIDENCEy INFORMATION LAND INFORMATION '1'..: .. .: ;:.T€�t...... {Ti b ... M Si'F14:.. .. .: NBHD CODE:5 N HD LA 5 ZONE: R4 g mt Area 1434 ...:Y J!i a 4 5!»J # A #tflu-�fN ' 'VAI >.. .. X100. Story Height: 2 35 Bedrooms 4 Up Fn Area: 875 Bs "1:::*::::::' K"a Pr►!I3fmt Arai, 1 P 104 S 9554 0.22 185,252 Ext 1Nall A8 Half Saths Unftn Area $06 Bsmt Grade INOtt'y Ttlltl;;: Eki X51 i= DETACHED STRUCTURE INFORMATION `ft��f it1iia t: kr tixtit IVIz irw :. : »XI'Cit GCCi cYaid P /EfFt C4 # CiO Foundation ST Bath Qual: T RCNLD 197042 G1 S 400 .f A A 50%!/50 ... .. 6,700 If 1 O .....fi4t1t` PA S 254 1988 A A 50///50 2,600 itch: Y Heat Type. ST Ext Kear Built. 1857 Sound Value. 1Jrtle: A . . ; 1'pe .: VALUATION INFORMATION Fireplace Bsmt Gar Cap Condition. A Aft Str Vall: Current Total: 391,600 Bldg: 206,300 Land: 185,300 MktLnd: 185,300 CentcalAC N gmt Gdr;SIY Ic1 te: Att Strtsl :. . .... Prior Total: 340,200 Bldg: 180,000 Land: 160,200 MktLnd: 160,200 Att Gar SF. %Good P/F/E/R. /100//73 Porch Type Porch Area Porch Grade Factor P 301 SKETCH PHOTO ... ...�:•:::iii: : 0 22 is is 1316 S 'a •t: 1"4.Sq.R. 075 1^. 25 '7:S? Sk :jti?ki 4:iiSvv.}:.:;.:. ...n:� � ,• •�; 48 CHURCH. STREET • a' 70. Parcel ID:210/041.0-0014-0000.0 as of 7/31/07 Page 1 of 3 v 2007 North Andover Historical Commission List of 100 Year-old Structures 305 Boston Street between 460+ 500 Off Boxford Street Dr. Harry Love across from 181 Boxford Street 43 Brihtwood Ave 13 Chestnut Street Isaac Parker Tavern 41 Chestnut Street Unitarian Parsena e 60 Chestnut Street 147 Chestnut Street 169 Chestnut Street 156 Chestnut Street William A. Hall Jr. House 172 Chestnut Street Hall House-Carriage House 231 Chestnut Street Jaquith House 300 Chestnut Street Hilm Mills House 710 Chestnut Street 835 Chestnut Street The Greenwood House 857 Chestnut Street HenryBonney House 873 Chestnut Street Ben'amin Duce House 27 Church Street George Hodges double tenement 30 Church Street Samuel Downing House 32 + 34 Church Street Shattuck-Wiley House 48 Church Street Charles Scott House 54 Church Street 56+ 58 Church Street Edmund&Ged E. Davis double tenement 59+61 Church Street Harriet Kimball double tenement 64 Church Street Joes h Ladd House 1 + 3 Clarevdon Street D&F double cottages 5+ 7 Clarevdon Street Davis&Furber double cottage 10+ 12 Clarevdon Street 14 Clarevdon Street 25+ 27 Clarevdon Street 307 Clark Street Austen Farmhouse 13 Cleveland Street James P. Costello House 21 +23 Cleveland Street John P. O'Brien House 7+ 9 Commonwealth Ave t 15 Court Street North Parish Jacob Chickering House 16 Court Street Stevens Mill Agents House Way House 59 Court Street Page 2 of 22 Date. . .`. .... . .,`°°T TOWN NORTH ANDOVER PERMIT FOR GAS INSTALLATION c.•'�th �,SSACMUSES This certifies that . . . .i+./ !. .C. .!!. . . . . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . . . . . . . . . . . . . . . . . . . . . . . . . . . . in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . . . . . . . .,`l, North Andover, Mass. Fee. . .` . :. . . Lic. No.. . . . . . . . . . . . . . . .... . . . . . . . . . . . . . . . . . GASINSPECTOR Check# y MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FITTING (Type or print) Date NORTH ANDOVER,MASSACHUSETTS Building Locations �18 INIUI?cAl 57" Permit# Amount S S4`4 Owner's Name New❑ Renovation ❑ Replacement © Plans Submitted ❑ Cn Uw w W o U z a °� H c a a U N Z o x5W a 3 c a + SUB-BASEM ENT j BASEMENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8TH. FLOOR (Print or type) Check one: Certificate Installing Company Name-7-,, 1�/�[,L O/i'/-1 ✓ /�� LL1 Corp. Address d- 13 d X S 7,?, ❑ Partner. e-4kj4PassrP I;? *q Business Telephone 971 6 1(!5-- 9 50 Y ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter 7r/Yv,Y/v4,s �l 4 Md e�9 INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. YesEl No❑ Ifyou have checked M,please indicate the type coverage by checking the appropriate box. Liability insurance policy ® Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver. I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: ❑ Signature of Owner or Owner's Agent Owner ❑ Agent 1 hereby certify that all 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 installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Glias/Code an Chapter 142 of the General Laws. �z�c� By: Signature of Licensed Plumber Or Gas Fitter Title ® Plumber �t Y � 3.3 City/Town ❑ Gas Fitter License Number ❑ Master APPROVED(OFFICE USE ONLY) © Journeyman N MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Date Building Location ya' 4111/?C/7 Xr- Owners Name/V.4)'3//�9 71-1A9e vias Permit# � Amount Type of Occupancy /,�f.�'t'1/�.v New ri Renovation Replacement ® Plans Submitted Yes ❑ No FIXTURES w H 5�» BASEUM In Hf= M Hj" 3M IMM 4M MOM 5M HDM 6M FUXR 7M ILOM SII3 FIDCI2 (Print or type) Check one: Certificate Installing Company Name 4A./ 10 El Corp. Address /00 13O X S 7Z rl Partner. eojj4 s-1 f IVtG IV 4 471-3—f'— Business Te ep one q?Y 61T 5--9 rd y Firm/Co. Name of Licensed Plumber: 7710 A?,*f —'414 Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy M Other type of indemnity ❑ 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 Signature Owner Agent ❑ I hereby certify that all 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 installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Pl�Code and Chapter 142 of the General Laws. By igna ure of Ocensea rtumoer Type of Plumbing License Title � YK J? 3 City/Town icense IN—um—Mer Master ❑ Journeyman APPROVED(OFFICE USE ONLY ED pORT►i BUILDING PERMIT 0 "'%.10 .a'�ti TOWN OF NORTH ANDOVERF APPLICATION FOR PLAN EXAMINATION Permit N0 ?,� Date Received �reo �SSACH�1`�E� Date Issued: d a MPORTANT:Applicant must complete all items on this page .41 LOCATION PROPERTY OWNER Print MAP NO 460 PARCEL: W ll-( ZONING DISTRICTHistoric District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: emo i ion Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: Identification P ea T pe or Print Clearly) OWNER: Name: S � ek Phone: Address: CONTRACTOR NamePhone: Address: Supervisor's Construction License: S 7 c/ Exp. Date: ll l Y- 'Z 7 Home Improvement License: X--)• 7 Cf o Exp. Date: ' 24- ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ �� FEE: $ Check No.: �c3 Receipt No.: 2D NOTE: Persons contracting w•h unreg'st re contractors do not have access to the 7gu anty fun Signature of Agent/Owner Signature of contractor Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private(septic tank,etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS DATE REJECTED DATE APPROVED CONSERVATION lQ� COMMENTS DATE REJECTED DATE APPROVED HEALTH COMMENTS i Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit Located at 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster on site yes no Located at 124 Main Street Faire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA– (For department use ❑ Notified for pickup - Date -- -----.._._....................__......----............._......__... ---._._.-..._.._........._._.._._....._—._._._...._....... Doc.Building Permit Revised 2007 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 Location No. - Date NORTH •° TOWN OF NORTH ANDOVER T?O°t,` •,�O D Certificate of Occupancy $ AGMUBuilding/Frame Permit Fee $ . JS , Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 2G � � .; Building Inspector And Town of over- 1h No. 2- over, Mass. Av" O LAKE COC MIC EWICK 7�ADRATED 5 '9S BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System EMU% � � /� BUILDING INSPECTOR ..................................................................... THIS CERTIFIES THAT............ ��� .! ........ ......................................... Foundation has permission to erect........................................ buildings on ......Yk5 .................. Rough to be occupied as...........,�?....**gy .! .......... .. .....Q n..�.. Chimney e provided that the person accepting this permit shall in eve sped conform to terms plication on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough 00000 Final 36PERMIT EXPIRES IN 6 MO S ELECTRICAL C CAL INSPECTOR UNLESS CONSTR N TS Rough ....................................................... .............. Service BUILDING INiP*E OR 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. i 91te #-/ Board of Building Rcgulat'ons and Standards % One Ashburton Place - Room 136.1 #, j Boston. Mas4''achusetts 02108 Home Improvements'ontractorgistration Registration-:, 15P740, Type: . Inlividual Expiration: 2008 KEVIN DANIELS KEVIN DANIELS 84 BENNINGTON ST HAVERHILL, MA 01832 - Update Address and return'card. 119ar1:reason for change. Address Renewal Emp'oymcnt Lost Card j 6PS-CA1 r 50M-05/06-PC8490 ;` ��!e -�ainiazo�.u�.ea�t! a�,/f�,Ciaaccc�u�aella Board of Building Regulations and Standards ' Construction Supervisor License Lic$ns� CS 57485 Birthdate: 11/14/1970 11/14/2007 Tr# 4731 tstricton 00 KEVIN E DANIELS 84 BENNINGTON ST HAVERHILL,MA 01832"' Commissioner