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Miscellaneous - 5 APPLETON STREET 4/30/2018 (2)
5 APPLETON STREET 21 'T,51 g�06a0000.0 Location P to Q S4 - o No. Date �� 3 ti MORTy TOWN OF NORTH ANDOVER � R F Certificate of Occupancy $ no Building/Frame/Frame Permit Fee $ b s�CHust 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ D 0 M Check # c;?_, e 16679 'A At Building Inspector r TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLINGMU BUILDING PERMIT NUMBER. DATE ISSUED: SIGNATURE: L L Building Commissions for of Buildings Date z SECTION 1-SITE INFORMATION O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: S- S k o37 (i.� � v Map Number Parcel Number \ U' 1.3 Zoning Information: 1.4 Property Dimensions: 3-3 Zoning District Proposed Use Lot Area(so Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: D Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT rn 2.1 Owner of Record �MeS w. �_'eSimA 5 ��P1��n..� S A' Name(Pri Address for Service:L2 11 , .,... - 9 - (.%16-'t 4 a-3 r Signature Telephone 2.2 Owner of Record: w Name Print Address for Service: A z rn Si naVre Tele hone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: C S - 6 S 17-7)'% S } License Number mri A re >s - G � 6 - 74 3 at /-f ( may Expiration Date ic Sign re Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ Compan�Name J- Ape��}� S � Registration Number r r_ Z '9 749_(4o Expiration Date Si na a Telephone Q • ' r SECTION 4-WORKERS COMPENSATION(M.G.L.C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildiog 22rmit. -Signed affidavit Attached Yes.......fr No.......❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) tion ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: 19-e-4�1'rZ,dao-- t rt'_n ally •e d CL-)- -:C S ? A 4*'_-_J t u n R w rw 1 s SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be r ��FICiTS Ol+ .� x Completed bypermit applicant m 1. Building (a) Building Permit Fee �/D 000 Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing — Building Permit fee(a)X(b) 4 Mechanical HVAC 5 Fire Protection — 6 Total 1+2+3+4+5 o °u o Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, Q r-. — ,as Owner/Authorized Agent of subject r� property , Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge ) and belief 'c' 1 Print N Si ature Owner/A ent Date NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TRABERS iST2ND 3 SPAN DEMENSIONS OF SILLS r Da ENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUTLDING CONNECTED TO NATURAL GAS LINE v pt AU IS f� e ot FORM U - LOT RELEASE FORM ' � Y C f e.�o�� t7o nv,,�n INSTRUCTIONS: This form is used to verify that all necessary approvals/pedis from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *APPLICANT FILLS OUT THIS SECTION APPLICANT �`2 � S�2 PHONE-9 `�Q 6 ��r 9 L4 a3 LOCATION: Assessor's Map Number PARCEL SUBDIVISION} LOT(S) STREET r P��-'J�� ST.NUMBER. *''****""OFFICIAL USE ONLY---*********-** RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS st TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS F INSPECTOR-HEALTH DATE APPROVED S DATE REJECTED V 1 SE IC INSPECTOR-HEALTH DATE APPRa0 . Zcl O (((vvV DATE REJECTED COMMENTS ��rcv� UuJr� (�✓� �'- +L e PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE____ - Revised 9197 jm ' r Town of North Andover Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. FOR ROOFING, SIDING, INTERIOR REHABILITATION PERMITS 1) BUILDING PERMIT APPLICATION 2) DEBRI REMOVAL FORM 3)WORKERS COMP AFFIDAVIT 4) PHOTO COPY OF H.I.C. AND/OR C.S.L.-LICENSES 5) COPY OF CONTRACT 6)FLOOR PLAN OF PROPOSED INTERIOR WORK FOR ADDITIONS /DECKS 1) BUILDING PERMIT APPLICATION 2)FORM U 3) MORTGAGE PLOT PLAN (MINIMUM) 4) DEBRI REMOVAL FORM 5)WORKERS COMP AFFIDAVIT 6) PHOTO COPY OF H.I.C. AND C.S.L. LICENSES 7) COPY OF CONTRACT 8)FLOOR/CROSSSECTION/ELEVATION PLAN OF PROPOSED WORK WITH SPRINKLER PLAN AND HYDRAULIC CALCULATIONS (if applicable) 9)MASCHECK ENERGY COMPLIANCE REPORT (if applicable) FOR NEW CONSTRUCTION (SINGLE AND TWO FAMILY) 1) BUILDING PERMIT APPLICATION 2) FORM U 3) GROWTH MANAGEMENT BYLAW 4) CERTIFIED PROPOSED PLOT PLAN 5) PHOTO COPY OF H.I.C. AND C.S.L. LICENSES 6)WORKERS COMP AFFIDAVIT 7) TWO SETS OF BUILDING PLANS (one to be returned) TO INCLUDE SPRINKLER PLAN AND HYDRAULIC CALCULATIONS (if applicable) 8) COPY OF CONTRACT (if applicable) 9) MASCHECK ENERGY COMPLIANCE REPORT 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 application. NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision 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 properly licensed solid waste disposal facility as defined by MGL Chapter 111, S. 150 A. The debris will be disposed of in: rar4sFea 54-,A4+0N e0rLo-e owv (Location of Facility) Signature of Permit Applicant 03 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector 1 w The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations Boston, Mass. 02111 Workers'Compensation Insurance Affidavit Name Please Print Name: IYA Location: S e+-o V S City A n/ o.l eti rn Phone # 6 -7 y a 3 I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity 0 1 am an employer providing workers'compensation for my employees working on this job. Company name: - Address City Phone*. 6 Insurance:Co. Policy# Company name: Address C+r Phonic#: Insurance.Co. Policy# Failure to secure coverage as required:under Section 25A or MGL 152 can lead to the irnposition cf cximinalpenaHies or a;am up to,$V and(or one years'imprisonmentas wte[L.as_c hd4xwaiHesiolholmn da-S7S?P finest€(,$?1i M)-aidayagakwme understand that a copy of this statement may be forwarded to the office of investigations of the DIA for awe verification. /do hereby certify un pains and penalties ofperjury that file inrarmadw provided above is true and correct_ signature g. [Yate Print name a ti.e '' ! e-S+-A Phone.#4)s-`a c •7 y z 3 Official use only do not write in this area to be completed by city or town official City or Town Perrrutttitxnsing.. []Check I immedate response is required .a Licensing& p Selectman's Contact person: Phone A I] Health Depai D Other N 1 Q� R=140.39 yZ`� L=47.33 EXISTING HOUSE 'Po' is 31 ,899± S.F. �2. 0.73± Ac. NIr. 'QQ, Q' 1Q.6 53.47' This plan is the result of an as—built construction survey S87028'50"W performed on 1/06/03 based upon the plans and deeds recorded i Registry of Deeds. AS—BUILT �NOF R HOUSE LOCATION PLAN 3h,1o� 51 Appleton St., No.Andover, Ma. 11 „ Scale:l =40 — March 21 2003 NEW ENGLAND ENGINEERING SERVICES INC. 60 BEECHWOOD DRIVE NORTH ANDOVER, MASSACHUSETTS �, QEF =., (978) 686--1768 NORTH Town ofAndover O1....w.Mw.w •�4.. � yZ No. / 4::7 o� C OC H,CCv dower, Mass., ADRATE D PPK�,`�y S H � BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT..........'�a M e S c �S�a Foundation has permission to erect... .... buildings on ..... ..,,/Q.P...P� N C-S-,jr- - QQ ............................... Rough to be occupied as Q Ci1� r f�0Iyl r � of �/w� /4 " Owr we A-& 4- Chimney .... ,`...... provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. d n L-5 / (o ,�( yoo PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. `�' Rough * Dice-mer- A^ea s PERMIT EXPIRES IN 6 MONTHS Final +0 I't t M A t U u N — ELECTRICAL INSPECTOR kP t s(It%ftj Q A JIL. I UNLESS CONSTRUCTION STARTS Rough S e.w �. -f- r- N • 1 � ...11i�. ` T- ...... ...... .. ................................................. Service BUILDING INSPECTOR M Final upancy 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 w Street No. SEE REVERSE SIDE Smoke Det. r � a L 'ice r. S k i $ Ar-Fu i- Dates!,/ . ..... . WORTH TOWN OF NORTH ANDOVER 41 ' PERMIT FOR GAS INSTALLATION �9SSACHUSEt This certifies that .7" . . . . . . . . . . . . . . . . . has permission for gas installation . i.Q v r . .fes.h f. .t! . . . in the buildings of . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . at /., . . . . . . . . . . . . . . . , North Andover, Mass. Fee.3.. . . . . . Lic. No./! `� r. . `t'--•.ri�� �'�!. . . . . . . . GAS INSPECTOR Check# 1el- 5272 MA%AC USEM UNN ORMAPMCATON FOR PERNIITTO DO GAS ffnT'4G (Type or print) Date NORTH ANDOVER,MASSACHUSETTS Aups �e fay P Building Locations ermit# Amount$ 3a Owner's Name NewElRenovation ❑ Replacement ❑ Plans Submitted ❑ � w � >4 z o H w 0 0 0 O N 0 0 SUB -BASEM ENT ' B A S E M ENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR STH . FLOOR 6TH . FLOOR 7TH . FLOOR STH . FLOOR (Print or type)�y�S�S s 7JO�J��` � �LS f CjieQc Corp.nCertificate Installing Company Name r� �YY ` Address. (5/� ' ' �9 // ❑ Partner. Business Telephone ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter A U Sr--U INSURANCE COVERAGE• Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No❑ If you have checked yes,please indicate the type coverage by checking the appropriate box. 13Liability insurance policy [21 Other type of indemnity 13 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 ❑ 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 Gas Code and Chapter 142 of the General Laws. Signature of Licensed Plumber Or Gas Fitter By' ® Plumber ��$l Title X City/Town ❑ Gas Fitter [cense Number ® Master PROVED(OFFICE USE ONLY) ❑ Journeyman Location No. Date qti F Q,5r NORTH TOWN OF NORTH ANDOVER 3? ' 0 Nol _ F i Certificate of Occupancy $ } r r �'1s'•"° E<�' Building/Frame Permit Fee $ s�cNus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ —�-_ `� Check # i 8468 Building Inspector ` TOWN OF NORTH ANDOVER r BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REP RENOVA OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUELDING PERMIT NUMBER: C DATE ISSUED: SIGNATURE: SW Uk� Building Commissioner/I or of Buildings Date SECTION 1-SITE INFORMATION IO 1.1 Property Address: 1.2 Assessors Map and Parcel Number: A j2J2 1e-ro,, 5� ®3-1 . 13 G o Map Number Parcel Number Ale A,JdrVI A 6ly-6 FQ 1.3 Zoning Information: 1.4 Properly Dimensions: r11 K K--3 _ Zoning District Proposed Use Lot Area Fanta A 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard ed Provide Reqnired Provided red Provided a 4- 30 1.7 Water Supply MG.L.C.40. 34) 13. Flood Zone Iafomnitioa: 1.8 Sewersp Dhposal System Public ❑ Private ❑ zow outside Flood zone ❑ Maaioipal 91,01— on Site Disposal System ❑ J SECTION2-PROPERTY OWNERSHIP/AUTHORIZEDAGENT 'i,;'.i,r1c, 'ictr!Ct: Yps m 2.1 Owner of Record ` 1 �1 O\Yt14?5 lam\ C 4-IA s 14 -e,+0 w/ JL No(Print) Address for Service Sign re Telephone 1 2.2 Owner of Record: ^^ V Name Print Address for Service: z a M Sistnature Telephone Ads S%CTION 3-CONSTRUCTION SERVICES 3.9 Licensed Construction Supervisor: Not Applicable ❑ 7ZTv-An...es --T—cCl-w -- C � Licensed Construction Supervisor: License Number Address 0 b r 0$ 0 co, / / Expiration'Date �.,0 3a_ Sign cure Telephone Ism 3.2 egistered Home Improvement Contractor 4 / Not Applicable ❑ Cothpany Name G M S} Registration Number r Address let 1 '1005- Expiration a0dS- Exptrehoo Date Si a e Telephone SICTIONt4-WORKERS COMPENSATION(KG.L C 152 $ 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildin rmit. Signed affidavit Attached Yes....... No........0 SECTION 5 Descri tion of Proposed Work(check ae a ble New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) 0 Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other 0 Specify Brief Description of Proposed Work: QIP �t,n►c� SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to beOFFICIAL USE ONLY Completed by permit applicant 1. Building (a) Building Permit Fee 7 0i a O a Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)x (b) 4 Mechanical HVAC D �- 5 Fire Protection 6 Total 1+2+3+4+5 ® ®o o 1 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION S+ t•Q ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief f--� Print NTD 7 Si ture of er/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS iST 2 3RD SPAN DPv ENSIONS OF SILLS DIMENSIONS OF POSTS DIN ENSIONS OF GIMERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTNG X MATERIAL OF CHIMNEY 1S BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE '�-- FORM U - LOT RELEASE FORM rza�Ae� r INSTRUCTIONS: This form is used to verify that all necessary approvals/permitt from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. APPLICANT FILLS OUT THIS SECTION APPLICANT �Q"'^ s �Gs'r'� PHONE LOCATION: Assessor's Map Number PARCEL SUBDIVISION LOT(S) STREET A2P) C-i' 5 2-ef ST. NUMBER OFFICIAL USE ONLY OMM TOWN A TS: CO ERVATION ADMINIS RA DATE APPROVED DATE REJECTED COMMENTS M 10 OWN PLANNER DATE APPROVED DATE REJECTED COMMENTS �� - FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS-SEWERIWATER CONNECTIONS DRIVEWAY PERMIT q, � � FIRE DEPARTMENT I P�p�� � �� 11 DUMPSTER PERMIT v RECEIVED BY BUILDING INSPECTOR DATE FORM U-Revised 6.05 JMC the Commonwealth of Massachusetts Department of Industrial Accidents i Office of Investigations 600 Washington Street ;` Boston,MA 02111 V www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/organization/Individual): -7e_-4,P 3,1 1�;N g �� �e mo����,J 9 Address: 5 City/State/Zip: /yo Av\,) �dJe.2 A^q Phone#: 9 )g- 6Sr - oa 3 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 employees(full and/or part-time).* have hired the sub-contractors 6 ❑ New construction 2.[� I am a sole proprietor or partner- listed on the attached sheet t 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 required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 1 I-El 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' comp. insurance required.] 13.[:] Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.' t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic. #: Expiration Date: Job Site Address: City/State/I 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'iinprisonment, 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 certify under the pains and penalties of perjury that the information provided above is true and correct Signature: .o Date Phone#: 9 -7<F DO'S Oficial use only. Do not write in this area,to be completed by city or town offxial 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#• Information and Instructions Massachusetts General Laws chapter 152 requiresall'employersander any contraesation for their t of hire ' Pursuant to this statute, an employee is defined as"...every ...ev ry pa on in the service of another 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 thn o apartments a�eance,conand structioneorthrepair,or the occupant of the wok on such dwelling house dwelling house of another who employs Persons 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." either the commonwealth nor any of its political subdivisions shall Additionally,MGL chapter 152,§25C(7)states"N 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 certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this�af o be suvit re to sign and subm�ttd to the affidav t 1hey be to the Department of affidavitlshould Accidents for confirmation of insurance coverag e.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 hive 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 to Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bo tm of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the app ant 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 and under"Job Site Address"the applicant should write"all locations in (city or policyinformation(if necessary) has been ocopy of the affidavit that officially stamped or marked by the city or town may be provided to the townf 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 to bum 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. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia T • A R=140.39 EXISTING �21� L=47.33 HOUSE l��j• �x 016. QIP �Oa I lf. 31 ,899± S.F. u2. 0.73± Ac. ti O "IQ.'-10 92 , .00, O 103G' Iv 53.47' This plan is the result of an as—built construction survey S87.28'50"W performed on 1/06/03 based upon the plans and deeds recorded in the Re ' t of Deeds. OF AS—BUILT HOUSE LOCATION PLAN y )�►�n3 5 Appleton St., No.Andover, Ma. s�oas Scale:l =40 — March 21 ,2003 esn��o IREI°� NEW ENGLAND ENGINEERING SERVICES, INC. 60 BEECHWOOD DRIVE NORTH ANDOVER, MASSACHUSETTS Om + JEF + (978) 686-1768 No. Delta Radius Arc Len 'th Chord Lenqt Chord Bearing C1 19°19'00" 140.39 47.33 47.11 N45°13'00"E N EXISTING GARAGE TO BE REMOVED PROPOSED GARAGE IfY� 4V� 31 ,899± S.F. 0.73± Ac. 53.47' S87°28'50"W This plan is the result of a survey performed on 1/06/03, based upon the approved subdivision plan recorded in the Registry of Deeds PROPOSED PLOT PLAN 5 APPLETON STREET NORTH ANDOVER, MA SCALE: 1 " = 40' JUNE 22 2005 , NEW ENGLAND ENGINEERING SERVICES, INC. '°' V' 4°' 8P' 60 BEECHWOOD DRIVE NORTH ANDOVER, MASSACHUSETTS PUWJ DR4WH CHECKED (978) 686-1768 574 e,-. S.G.B sY. J.E.F & B.C.0 jr e , NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: r /} S�— 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 11, S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 10A. The debris will be disposed of in: . P/I pea f9 e, (Location of Facility) Signature of Permit Applicant Fire Department Sign off: Dumpster Permit D to NEW ENGLAND ENGINEERING SERVICES INC June 22,2005 Mike McGuire North Andover Building Inspector 27 Charles Street North Andover, MA 01845 Re: 5 Appleton Street,North Andover Dear Mike: Please accept this letter as a certification that the proposed construction at the property referenced above is not located within 400 feet of a wetland which is part of the watershed to lake Cochichewick. A site inspection was conducted by Benjamin C. Osgood Jr. The closest wetland is the small stream that passes under Salem Street to the west of the property. The wetland is approximately 410 feet from the proposed construction. If you have any questions please do not hesitate to contact this office. Sincerely, 6"-? C E)/ Benjamin C. Osgood, Jr.,P.E. President 60 BEECHWOOD DRIVE-NORTH ANDOVER, MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 �®RTH T0VM of over 'r '!00 INNEW LA E dover, Mass., O COCMICKEWICK %d ADRATED S BOARD OF HEALTH PERMIT T Food/Kitchen Septic System T BUILDING INSPECTOR THIS CERTIFIES THAT........�! .......r .............. ....... ..................................................... . Foundation has permission to erect... ..... p .07 ....... buildings on ...... Rough . r.. ..... ... to be occupied as..a....5. 1. .�1....C�.A ra. . ......W...PI A r.....f�.. ....l.` t .�... ..... 1l�.I � Chimney provided that the person accepting this permit sM in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Const-rjiio of Buildings in the Town of North Andover. 37 � ` O + I ` IFF �Y� / PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS COlVS T RV� 1V SI S Rough ... ....... .. Service . . . .. .... ... ...... ................................. ..... ... ............ UILDING 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. Date. HORiM TOWN OF NORTH ANDOVER p F ' PERMIT FOR GAS INSTALLATION �9SSACHUSEt .. This certifies that . . ('.(.145 S. . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . . ,J. .43 . . . . . . . . . . . . . . . . . . . . in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . .� l!t�,.� . . . . . . . . . . . . . . . . . . . . .. North Andover, Mass. Fee. . 3 . . . Lic. No..L/. .k7.'!. . . . . . • I-IN-SPECTOR Check# d ) C / 4749 MASSACHUSLUS UNDDRMAPPUCATONFO H4RMFTT0D0GASMTNG (Type or print) Date a a NORTH ANDOVER,MASSACHUSETTS ^� Building Locations Pop/Q Jd K Permit# q?Li /C} Amount$ 130 Owner's Name 5 ''4 e S' Te l 4 New❑ Renovation ❑ Replacement ❑ Plans Submitted ❑ lie.S : P k • 4 x w a a a o x H w a E o F x a Z Z C) w u ° a o a Cn Z x w g w H H H z N z H 0 0 z o w o a O w A Ch a UO a A ai a H O SUB -BA SEM ENT BASEMENT y 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR } 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR STH . FLOOR 1 ELLI I I (Print or type) Y20V'S � S S u� �S Check one: Certificate Installing Company Name ® Corp. Address 4 041 �L 1 P 4",o r // �� ❑ Partner. - 5 t4 S O, Q kA C/ 8 75 Business Telephone Y9 _ 13//0 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter �A 9!ll INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No❑ If you have checked yes,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 ❑ 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 �ode and Chapter 142 of the General Laws. Signature of Licensed Plumber Or Gas Fitter ® Plumber //g�� Tit Title City/Town ® Gas Fitter License Number ® Master APPROVED(OFFICE USE ONLY) ❑ Journeyman Location No. v , Date G491 TOWN OF NORTH ANDOVER 1 ? :' • '. gyp 3 9 # ; . Certificate of Occupancy $ cHusEBuilding/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ OG1 Check # y 17 214 �`Building Inspector Date. f AORTM 1 < . do TOWN OF NORTH ANDOVER �? �I- PERMIT FOR PLUMBING 49 ,SSACMUS� This certifies that . . . r, has permission to perform . . . . . .�!... ...... . . . . . . . . . . . . plumbing in the buildings of . .' *' !. �h. . . . . . . . . . . . . . . . . . . . . . at. . . S. . P/./? .l-P.�( . ... . . . . . . . . . . . . . . . North Andover, Mass. Fee.; !� . . . . .Lic. No.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check # 6G35 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBIN (Type or print) NORTH ANDOVER,MASSACHUSETTS Date Building Location Y',p/o Oma,- S`l' Overs Name 3-7"ef es�2 Permit# O 3 y© Amount Tyle/of Occupancy NewriRenovation Replacement Plans Submitted Yes No ❑ FIXTURES H w ` w 0 SLR» Z�DMOOR a a 3MHj" 5M HJ" s>Q-;> 71H>M gm Rom (Print or type) Check one: Certificate Installing Company Name I-5 �$ �'S S' p�v ►1 t4 Address O / 1<-e`1 9 // uD Partner. S o tALt S 377,75 Business Telephone - 779 — 777 -0 Firm/Co. Name of Licensed Plumber: 'IL( s `J u ss Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy ® 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 MassaLphusetts tate Plu i g Code and Chapter 142 of the General Laws. By: igna ure or Licenseaum er Type of Plumbing License Title l/ e'°/ City/Town lcense INumoer Master ® Journeyman ❑ APPROVED(OFFICE USE ONLY TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING i ...,; ., ,... ,'.a.,. : __ ..&?,;•*•i•'xhv �Fk' , -,,. ."..,.,, ���y� :� ,ky; a�z� �'^'J5. :�` ...�=Y � '^sk•••Y � S� T BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: (� Building Coni"ssioner/Inspector of Buildings Date Z SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: ° ^I C�`J Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided —d v 1.7 Water Supply M.G.L.C.40.11 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System 0 SECTION 2-PROPERTY OWNERSHIP/AUTHORIZEDAGENT HistoricDistrict: Yes o 2.1 Owner of Record 7^ Name(P Address for Service Signature Telephone t� 2.2 Owner of Record: Name Print Address for Service: M Signature Telephone 90 SECTION 3-CONSTRUCTION SERVICES 3.1 Ljcensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: License Number S nRAle -�,., Mn AddresD C, � S / a U® C. $ — Q—.1- Expiration Date ic Signatur Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ -'if S�,6 3 v 1.4 �.. �e�� ej a ,>~� Company Name i 6 M Registration Number r 5' /a, o�l e fir•, 5 fi Address 1 1 I l b y P Expiration Date Si natu a Telephone r SECTION 4-WORKERS COMPENSATION G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes....A No.......❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building k Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: oQhvCo W sZ c5t, i A *ttS SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be w OFFICIAL JSE tgNLy Completed by permit applicant 1. Building Ll (a) Building Permit Fee C7 v�' Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 PlumbjEE Building Permit fee tel x (b) ���_ 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Liu 6 o u Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION ,as Owner/Authorized Agent of subject property I decl e that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name Si ature of er/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINMERS 1 2ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHFVINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE FORM - U - LOT RELEASE FORM INSTRUCTIONS: This form is used.to verify that all-necessary approval/permits from i Boards and Departments having jurisdiction have been obtained.This does not relieve the applicant and`or landowner from compliance with any applicable requirements. ■sf!■ssssf!!■ffssrss■ffsf!■sa■fasssssss!!!!!f■l�srlsffsslfalaflslrslaOWN=now APPLICANT -T-;—P PHONE Cg6-------------- ASSESSORS MAP NUMBER a v LOT NUMBER �p d SUBDIVISION LOT NUMBER STREET STREET NUMBER �ffssssssisfsfslfuss!!■ ss■rssfss!•f■rff!lsss��■slsfsafalf!lssrsssfaf■Fss■ OFFICIAL USE ONLY town lifl:ffl,lflflfftoff!!•if!!!'!.■!f!!.!.■*!f!!!f!!f�!!f!!!f.!lff!!:■.!■!!.!,!-!.!!l.laf• RE ENDATIONS OF TOWN AGENTS �!!llsffs.•s!lfsrssfs■■.!lasst■ff)flfast•f■a!■■fown•asslrssss!!f!!flssla!!woman DATE APPROVED CONSERVATION ADMINISTRATOR DATE REJECTED COMMENTS ' � s TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS DATE APPROVED FOPP INSPECTOR-HEALTH DATE REJECTED DATE APPROVED 6 S C INSPECTOR-HEALTH c _ DATE REJECTED COMIy1ENTS ✓d\., `n / k C- © 1_e J +c e 1�i9 5g�v\A✓ J PUBLIC WORDS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMEhTT DATE APPROVED DATE REJECTED ------------ COVIN ENTS _... DATE RECEIVED BY BUILDING INSPECTOR ... ...... ---- _ . Q) l 1 5'-fo 3116" 5'-0" 5'-B" 5'-0" 6 275% x'44U - X 5'-0" bed "3 James room bed • 2 v closet Davlds room ---------- ---------- 11'4'x13 4 11'x11'6" ---------- Au'11^11111 4 u X " 4'-0" 2-$ ---------- C4 N closet tib Q N N X N 4'-0" 2--0" N r I inen �, Yio bed 04 Ninas roomF11 4 7 I N kids Master bath bath 10 13'Z"x11'10" 5'-1 5/16" x 4'-426" 2'-935" x 3'-016" 4'-0" x 2'-0" 43'-Il" The Commonwealth of Massachusetts d Department of Industrial Accidents Office of Investigations 0�R Boston, Mass. 02111 Sy1b Workers'Compensation Insurance Affidavit Name Please Print Name: ae S 'rho Location: ''9 P P I fi ''`r S t City No A'`j JU4&L `n A Phone # 9117' L k (=1 L 031 I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers'compensation for my employees working on this job. Company name: Address City: Phone#: Insurance Co. Policv# Company name: Address City: Phone#: Insurance Co. Policv# Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to$1,500.00 and/or one years'impdsonment_as welLas_civil..penaltiesin.theformiofaBTOP WORK_ORDER.and_a fine-of.($1.0.O.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. 1 do hereby certify u er the pains and penalties of perjury that the information provided above is true and correct. Signature ✓ Date Print name r-.c S -e C, -�-VA Phone* Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing Building Dept ❑Check if immediate response is required I] Licensing Board p Selectman's Office Contact person: Phone#: C] Health Department Other North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision 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 c11, S150A. The debris will be disposed of in: U -e I I b T<Z-A N s E-ec s��►���.�, G-e o� � e �o� (Location of Facility) Signature of Permit Applicant s Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector NORTH Town of 0 No. (15TY -_. - - i LAK 0 ''� dover, Mass., COCMICMEWICK S'RATED APF`�.�5 U BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT �a h'10 S 7�! ,%*cl � r Foundation has permission to erect......T..:^'��� .......... buildings on ......�?...... P1� F.y`oN g ............. Rough CpNej ` 1100 �o�r4 % . > Chimney tobe occupied as........................... ...........r............ ....................................................... ..................... y provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Law relating to the Insp ion, Alteration and Construction of Buildings in the Town of North Andover. 3 r17ezo y00 PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION START Rough ..Awwwr.. . ........ ...... .A. Service BUILDING INSPECTOR Final Occupancy Permit Required t® Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal No Lathing or Dry Wall To Be Done FIRE.DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE S1 DE Smoke Det. Location A PPle No. S S� Date �oR,M TOWN OF NORTH ANDOVER _ O F R .. 9 + ; ; Certificate of Occupancy $ Building/Frame/Frame Permit Fee $ CD S sACHuse 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check #9�2 15491 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER. DATE ISSUED: c5 X ic SIGNATURE: �/'L Building Commission6VIEVmtor of Buildings Date Z SECTION 1-SITE INFORMATION O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: S�- 3 Map Number Parcel Number N . IA•�/�v v•v< 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(so Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided R red Provided Q 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal 0 On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT rn 2.1 Owner of Record Slei r—,e3 'Te SVA Name(Print) Address for Service: Signature Telephone d 2.2 Owner of Record: Name Print Address for Service: Z M Signature Telephone 90 SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ S'A�,es rte Te 02, 5 o S' Licensed Construction Supervisor: O License Number Address 9 7 V,- (0 �� Expiration Date ic Signature Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name M 5- Registration Number r Address (I 1 )7 1 d r 0 616-0� -7 $ - `TS-JL." ;L O Expiration Date Z Signature/ Telephone Q SECTION 4-WORKERS COMPENSATION(M.G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. -Signed affidavit Attached Yes....... No.......❑ SECTION 5 Description of Proposed Work check au applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) 1101 Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: adc� 't- b ,Ja X $ tie C IC or G SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be n OFFICIAL IISLONLY Completed by permit applicant 1. Building 1 S, C O (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a) x (b) 4 Mechanical HVAC 5 Fire Protection 6 Total (1+2+3+4+5) Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, 4v-0 ,as Owner/Authorized Agent of subject property Hereby authorize to act on My beha S ,in all matters relative to work authorized by this building permit application. O✓•'0 /I �f O .Z Signaturl of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, -TVA e—e- S r*- S as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief A t;e, Print a t Si atur of Owner/A ent Date _11M g RM57 MOM III NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 ST2 ND3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HE-IGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE North Andover Building Department Tel: 978-688_954 DEBRIS DISPOSAL FORM In accordance with the provision 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 b M c11, S150A. Y GL The debris will be disposed of in: (Location of Facility) G.•�o Signature of Permit Appll�;nt i .� 00p Date NOTE: Demolition permit from tlje Town of North Andover must be obtained this project through the Office of the Building Inspector for 1 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers'Compensation Insurance Affidavit f Please Print Name: _-wa ti•e- A Location: ..r city tv - A V v�. w� A Phone �;�►am a homeowner performing all work myself. 01 am a sole proprietor and have no one working in any capacity I am an employer providing workers'compensation for my employees working on this jab. Company name: Address Cit c� Phone# Insurance Co. PQlicv# CQmpanv name: Address city: Phone* Jaggy-rance CA. Pollcv# failure to secure coverage as requires!under Section 26A or MCL 152 conlead to the imposition of gnat penalties.o r a fine up to$1.500.00 and/or one years'imprisonment as well as civil penalties in 016 form of a STOP WORK ORM and a fine of($100.00)a day against rne. t understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify and pains and penaties of perjury that the Information provided above is true and correct Signature G�•�� S�r 0 Date Print name Phone# �� (o • �y l� Official use only do not write in this area to be completed by city or town official' i) Building Dept ©Check if immediate response is requ#ed Builift Dept p LiCeRSing Board Q Selectman's Office Contact person Phone# ❑ Health Department 0 Ofher RIM WORKMAN'S C013 p NSATION APR-16.02 08 :54 AM E K SURVEY 9784697046 P. 01 �d fir -ft4qV JLT4 E K SURVEY INC 1 HAVERHILL,MA.4 Phone 978-461 1151 Fox 976-466.7045 MOR' AGOR� s 0' R 4%STh DEED REF. ry 7Z. PG, ADt7R ss 'OF PRINCIPLE BUILDING PLAN REF. (0037 DATE OF INSPECTION 'SCALE: l'-,*r i or 0 000s.4 r � M ' M t. 4r4a� I i T. s AUDEL M CERTIFICATION TO: 36W A4 The location of the principle structure/s This rA4rtyage Plot Plan was prepared epecificaily for ",� �f�IS1E�� a� Cfdj& mortgage purpose only and it Is not intended or represented ��Q b� with the local zoning bylaws in affect when constructed to be a property Ona or Ilnd survey.This pian is not to be used Nit.�A1t� And/or Is exempt from violation enforcement to establish any of the property linos for any purpose. No actiAn under Mons B.L. T410 VII,Chap 40A,see.7. rnaponciblilty to a endad to the larxl owner or oeeupeni. 10 Subject building is not In a Flood Hazard Arsa, This Certification 14 based on the location of survey marker O Subject building Is In a Hood Hazard Area, i of others, I Flood Hazard determined from the FIRM map#_ Dated__ N0 K-7 Town , of f D- over No i, 4 n o�A COCHIC IVi`y dover, Mass., oZ CO DRATE D S H E BOARD OF HEALTH PERMIT T D . Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT..!! � '� .....................~............. Foundation has permission to erect....�.x.. ................ buildings on ....................... r .....,............................ Rough to be occupied as... .. IV � � 1 ��!t� ® 1`r1�Z�+A Chimney .................. ..... ..... ............................... .............. ...... provided that the person accepting this permit shall in every respect,conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. 3 P) r ` 40 4 PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION ST TS ELECTRICAL INSPECTOR & Rough ................. Service BUILDING INSPECTOR Final Occupancy Permit Required t0 Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. Burner FlRE DEPARTMENT Street No. SEE REVERSE SIDE Smoke Det. A Date..j..° �...... .3.. NoRTH "° TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ,SSACH This certifies that .O.A S,1 Y� .......................... ..........r...... ................................................ has permission to perform ......... R' ..!...................................................... wiririin the buildi g of.... 'e t-' I ........................................0 ....;:,Z.... ,North Andover,Mass: Fee... ..... Lic.No.............. ... .r=<z.rr-ti .. ELECTRICAL INSPA/0 Check # 4462 VJ! LV! LVVJ �L.LL J1V•.J•7LVJ• 1. .�. VV. �.Vl lite .JLI\vyVV r1..1L VLI VL ' 001Cpie arnmonwea[1h o�PIWIC11-4 i1 Official Use Only • kvi c� ..LJeparin>enr�o�.}irs �erviced Permit No. BOARD OF FIRE PREVENTION REGULATIONS ( Occupancy ave 1p nc and Fe•:Checked (leave blank) APPLICATION FOR PERMIT TO PERFO��V9 ELECTRICAL V1/O All work to be perlorrned in at cardiuce with the Mal:--chusctts Clcetrieal Code(htEC),527Cr,(R 12.00 x` (PLC"SC PRINT 1'V INK OR TYPE.-ILL itYF VAT City of; _ To the Inspector•of fi%ices: By this application the undersigned gives notice o Itis r her intentto perform the electrical work described below. Location(Street utuber.) Owner or Tenant TelephoneNo. Owner's Addres Is tl]is permit in conjunction'with a buiidinb permit? Yes N0 . ❑ (Check Appropriate Box) Purpose of Bullding Utility Authori7-1tion No. Existing Service Amps `Notts Otierhend ❑ ldadgrd❑ No.of rtiletcrs . New Service Antps -•_hVolts Overhead❑ UndgrdNc�. o ❑ ' —� of Nuniber of Feeders and Ampacity Logation and Nature bf Proposed Electrical Wor$: Con, lesion orthe ollurring cable ntav be um ived b•ncc If +cctor•o IYtr es. No.of Recessed Fixtures No.of Ceil.-Susp.(Paddle)Fans ! °•01 Tota d I• ansfornrcrs _ KVA No.of Lighting Outlets No.of 1-lot Tubs Gcacrators I�YA No.of Lighting Fittuces Stitiinuuiu Pool ova tr- t o.o mergencl rg taug ' ! rad. ❑ rnd. ❑ Batte Units No.of Receptacle Outlets No.of 011 Burners FIRE ALAR►lY;; Yo.of Zones No.of Switches No.of Gas Burners Pro.of Deteeiiart-and Initlati vl=evices ? No.of Ranges No.of Air Conn. Tuns No-of Alerting Devices No. of Waste Disposers Heat cup tum er " ons t 0.of eli� ontatncd • Totals: Detectlan/Alert:in be vices No. of Dishtirashers SpacdArea Heating KW Local ❑ i`Imti,cipa 4 Connection ❑ Other No.of Dryers Heating,Appliances KNy Securityystera•is: No.of Devices or Equivalent • t o. of Water Kw t °-o t o.of Data tiVirit]a- Heaters Sinus Ballasts No.of Deli ir. es or _ E uiva[ent N 1'cl No.Hydrotnassa a Batlitubs No.of ecommun�catio W g t lovers Total>:iP ns iiia No.of Devires or E uivaleat OTHER: ' .teach additional detail ifdesrr ed o r as rarrdred by die LsFeeror ofWires.INSUR-A.NCE COVEILI%GE: Unless waived by the owner,no permit for the performance of electrical work ntay issue unless the licensee provides proof of liability insurance including"completed operation'coveiagc or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of some to the permit issuing orrice. CHECK OivE: lNSUTUkNCE Q/DOND ❑ OTI4ER ❑ (Specify:) Estimated V ee of Electrical Work: (When required by n]unieipal policy,) (Expiration Datc) Wort: to Start:Y /! Inspections to be requested in accordance with EIEC Rule 10,and u-pon completion. I cerrffy, tinder the p iris and penrtffies of/yerj ry that the infortuation otr this application is true all',corrrplerte FIFO NAI<IE: e)1l"4,�L � � � LIC.\O.: A L Licensee: �" Signature v t LIC,NO.: - (If applicab/a enter• ' •carp rn rite l'•e . r nib line 13us-Tel.iYd�'j� �r�� dl Address O1VNE 'S ]N I..arCJr lY: YER: I ar aware that the Jacctuee dors nor/rave the liability it]surarce toti•erage normally required by law. B� my signature below,I hetrby w�lYe 1!]Is rCgIl3rFrriCnl. 14n]tIIC(GhCCt OI1C)❑ 0��'I1Cr ❑owner's a r t. Owner/A;cnt SigIl:ttltt'C '1'cicpinonc Nu. P.rsRtl,flT F.�•L•`: ,$ J 10") Location No. Zoo Z Date NORTh TOWN OF NORTH ANDOVER O F � w Certificate of Occupancy $ Building/Frame Permit Fee $ ACNUS Foundation Permit Fee $ Other Permit Fee $ TOTAL $ -t Check # S 6445 /p/0 Building Inspector 1 TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING TIus,Sectio>a for 0t'f"x�> -U�e'OnI BUILDING PERMIT NUMBER: D� DATE ISSUED: SIGNATURE. Building Commissioner/Inspector of Buildings Date SECTION I-SITE INFORMATION I.1 Property.Address: 1.2 Assessors Map and Parcel Number: O 01-1 060 A Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: f� Zoning District Proposed Use Lot Area(so Frontage(ft) 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 34) I.S. Flood Zone Information: 1.8 Sewerage Dis psal Syst em: Public 0 Private 0 Zone 'Outside Flood Zone 0 Municipal 0 On Site Disposal System 0 SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT rn 2.1 Owner of Record ✓i S ►q PP) e to*c/ S t � Name(Print) Address for Service: 1 Signature Telephone 2.2 Owracr of Record: Name erint Address for Service: O Z M Signature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable 0 J A'iy,,e -1-4 5 4 Licensed Construction Supervisor: y 1 Pe O License Number S Address D 6 (,-.6- 7' Z 3 Expiration Date signature Telephone ;.2 Registered Home Improvement Contractor Not Applicable 0 v ,ompany Name 1 ,1 Registration Number Adress 1114, 03 _ +t Expiration Date ^ ignat a Telephone Li e SECTION 4-WORKERS COMPENSATION(M.G.L. C 152_ § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildigg permit, _ Signed affidavit Attached Yes....:.. No.......0 SECTION 5 Description of Proposed Work check au applicable) New Construction 0 Existing Building ❑ Repair(s) 0 Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition 0 Other Specify POO � Brief Description of Proposed Work: A( aJf_ 0���yN� i� coo 1 SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be O Z Completed b permit applicant � �q R'M4 'u 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of �a a Construction 3 Plumbing Building Permit fee(a)x (b) �D 4 Mechanical(HVAC) o� 5 Fire Protection CJ 6 Total (1+2+3+4+5) Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLFTED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property ► Hereby authorize to act on My be h t all mattersiY w authorized by this buildh_o permit application. Signature Owner Date '3a � A-J, SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name Si ature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS I 2 3KD SPAN DBAENSIONS OF SILLS DIMENSIONS OF POSTS DD-4ENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE t FORM U LOT RELEASE FORINT INSTRUCTIONS: .This form is used to verity that all-necessary approval/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. APPLICANT C e s' 'FC, PHONE 1'-7 - $6--q- %i a3 cell S,'eg�-coq..7x 05 ASSESSORS MAP NUMBER .f.OT NUMBER SUBDIVISION LOT NUMBER STREET A pQ i�e,-+d lv STREET NUMBER ....■.■..■�: ....■..................i'i.....■............................0a OFFICIAL I1SE ONLY RECOMMENDATIONS OF TOWN AGENTS ' `` � __ DATE APPROVED— CONSERVATION PPROVEDCO ERVATION ADNMSTRAT DATE REJECTED_� � 1 P•l' � -'_A '7i COIv_MTENTS flf►r�s=s�-�� Fez,* n •� ^- ,; =-r�a a 1�a.c,q �rG - o a rs'�rkcc r e P�ee'T �►e�a� DATE APPROVED TOWN PLANNER DATE REJECTED CO?ANIENTS DATE APPROVED F : INSPECTOR-HEALTH DATE REJECTED DATE APPROVED 1C SEPTIC INSPECTOR-HEALTH DATE REJECTED COMMENTS L'C�Cw e L 11 �' e r �/V r U TIL PUBLIC WORKS-SEWER/WATER CONNECTIONS_._ �.l i� '1 b Q G.U�� DRIVEWAY PERMIT _ G Q r TA- DATE A,DATE APPROVED FIRE DEPARTMENT DATE REJECTED CONIIv4ETS RECEIVED BY BUILDING INSPECTOR DATE N c�0 00 1 �i \n��� � EXISTING SEPTIC TANK EXISTING 50 FOOT LEACH TR CH 'D0 �o �l-Q p 0 �p 20, ,gyp,pp, PROPOSED 24' DIA ABOVE GROUND 13, SWIMMING POOL LOT D 31 ,899 S.F. 0.732 Ac. �S 53.47' S87°28'50"W POOL LOCATION PLAN 5 APPLETON STREET NORTH ANDOVER, MA SCALE: 1 " = 40' APRIL 2 2003 NEW ENGLAND ENGINEERING SERVICES, INC. 4i ' 4080 60 BEECHWOOD DRIVE 4' i i NORTH ANDOVER, MASSACHUSETTS PLAN) DRAWN CHECKED (978) 686-1768 574 s,-. S.G.B I BY: B.C.0 jr NORTH TO" Of 4 over No. & 04 0 L AIVE CQ dover, Mass.,- , _, coc-C WICK 0RArED BOARD OF HEALTH Food/Kitchen PERMIT T I Septic System BUILDING INSPECTOR THIS CERTIFIES THAT........;.q'4Q ......._40.5.......41............................................................................ Foundation' ....... ...... .... ..... ........ ..... has permission to erect.....Q. buildings on .....5 A 0604 Rough ................... in z a#fic "d Chimney to be occupied as...A...........I......A.�Av 'c. ............................................................................................9 .............. provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. 3714 swoop PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION QioTARTS ELECTRICAL INSPECTOR /* Rough .7...................................... 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. Date...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...... ............... .............. has permission to perform ......�-.Cxa,?,.r..-e... ........ • wiring in the building of........ .....kfxXi�........................................... at...... C) . . ..................%,................ Nort,h Andoiver,ML- zoo Fee...//......... Lic.No ............. ..................41.0,x lr� /ELECTRICAL INSPECTOR Check 01 4927 UJ/ LVf LVV J\gip\\i L. LL J I VV I TLJJ. i11V1 1.V 1 yV.lrlL .JLI\v yVV 1 r14V VL/ VL Cornmonwaa(lh oVM66 Official USC .1Jeparlmerr�o� Permit No. BOARD OF FIRE PREVENULATIONS Occupancy and Fe: Checked (Rev, 11!99] tle,ve blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WO RKAll work to be peribmicd in:ccordaucc with the Mass3Cllusclts Cit:Ctrical Codc(EIEC),527 CNIR 13.00 (PLL••:lSE PR11VTiNINK OR TYPE:ILL INFOR A TON) Date: % City of. �� ,/�®Aq By this application the undersigned gtv s uoUce flus or h e:rtiou to perforn�t the lectric�al of Location(Street S Number) vock described below, Owner or Tenant q/Yn.til_ Telephone i)'o. Owner's Address Is this permit in conj ctioti wi h a building permit? Yes No ❑ (Check Appropriate Box Purpose of 13ullding Utility AuUturi�lGun itio.� Existing Service /00 Amps 96 Volts Overhead Utrdgrti❑ No. ufrtileters .L Nen•Service �_ Amps /Ayovolts Overhead Undgrd❑ No. ofltiIeters:L Number of Feeders and Ampacity Location and Natu a of Proposed Electrical York: d 17 C nr leflon ofthe rollai table nra),be traiv .1 /rispccror o 1VbYs. No.of Recessed Fixtures No.of Ceil.-Susp.(Paddle)Fans ! °•°L Tota a —Transformers KV No.of Lighting Outlets No.or I-lot Tubs Generators KVA No. of Lighting I;Utures Siiinuuing Poolove ❑ rr- ❑ t o.o mergericy rg rang rid. rnd. Batte Unlis No.of Receptacle Outlets No.of Oil Burners FIRE A,LA LMs No.of Zones No.of Switches No.of Gas Burners N°.of Detection-and ' No.of Ranges No.of Air ConnInitlatina Tr�evicrs. Tons No.of Alerting Devices No.of Waste Disposers Heatyump ,LNum er " ons t o.of ell= ontanncd Totals: Detection/Alert:in Devices No. of Dish:s•ashers SpacefArea Beating KW Local ❑ i<Iuni;clpa Coan,ection ❑ Other No.of Dryers Heating Appliances KNV Security ysterxis No.of Devices or Equivalent t u. of glenKWt o.o 140 .of _ i)sta Wiring: Heaters KW Ballasts j`(o,of Ij qr,M or E uivalent No.Hydrontassage Datlrtubs No.of illotors Total IIP i elecomnrunrcations Wiring: No.1o.of Devir_es or Equivalent OTHER: . A mach additional demit if desired,or as reniire d by the hgFee[ar of Wires INSURxNCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical wort ntay issue unless the licensee provides proof of liability insurance including"completed operation'coveizgc or its subsrintial equivalent. 1'11e undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTI•iER-❑ (Specify:) (Expiration Datc) h E-sdinated Value of Electrical Wort- (When required by municipal policy.) f� Wort: to Start: Inspections to be requested in accordance with"INlEC Rule 10,and u• on completion. C' I certify, iin,14111te paink afrd perr4f/ties of erjur);that the informaden on this application is true I,— courple�tN t'II�\i Nr11•IE: Wf)G� i �L- LIC.NO.:1A367 Licensee: _ Signature LIC.NO.:�l7 (lfappliea a, neer nF 'in fhc ti rse nun ber nc.) d Bus.Tel.N07- Address: tt UAIt.Tel.No.: OWNER'S l NSUPICE 1V" VEI2: I am aware Umt the Uccisee dors not have lire iability insurarce covervze normally required by law. By my signature below,I hereby waive this requircmCm. I in die(clicck one)❑ o\\mer ❑owner's aatnt. Owner/Aaenl Signature 'relephoneNu. EPL-Ril11T FE-ES