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HomeMy WebLinkAboutMiscellaneous - 5 FRANCIS STREET 4/30/2018 5 FRANCIS STREET 210/014.0-0001-0000.0 r Location No. Date Y NORTN TOWN OF NORTH ANDOVER 0 - 9 + Certificate of Occupancy $ )M4U Building/Frame Permit Fee $ -� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # f Building Inspector r� TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER G DATE ISSUED: rn SIGNATURE: ic Building Commis4oner/I for of Buildings Date z SECTION 1-SITE INFORMATION O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number n 1.3 Zoning Information: 1.4 Property Dimensions: Zoning Dia6d Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided RegWred Provided 1.7 Vater Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSIIIP/AUTHORMDAGENT Historic District: Yes No m 2.1 Owner of Record V) So tl�ame(Print) I Address for Service: W i Signature Telephone 2.2 Owner of Record: Name Print Address for Service: z M Signature Tele hone 90 SECTION 3-CONSTRUCTION SERVICES icens struction Supervisor: Not Applicable ❑ Licen Construction Supervisor: t _ License Number L-l N!D S 14-It lel vl� , fl�{�`rt'i�-c�t.t�,j'� , r Expiration Date S nature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ parry Name m ti Registration Number r Address z Expiration Date G) Signature Telephone • 4 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 0 Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: CLQ K S 'r—AA— SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Com leted by permit applicant 1. Building a ( ) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X tb1 4 Mechanical(HVAC) 71./ 5 Fire Protection 50 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 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 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 Mature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS iST 2ND 3RD SPAN DIN ENSIONS OF SILLS DIMENSIONS OF POSTS DM ENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY f 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 a}1 necessary approval/permits from Boards and Departments havingjurisdiction.have been obtained. This does not relieve the applicant and or landowner from compliance with any.applicable requirements. I Waa a 0&0 a a a a WS Em 0aaaa..aaaaaa■aa■aa0aaa■■aaa0aa.a0aasaaaaaaaaaaa.aa.aaaa..a■ APPLICANT ©y c_e_, `•- J(y�, PHONE g'a S -2 ASSESSORS MAP NUMBER LOT NUMBER SUBDIVISION LOT NUMBER STREETc'o�nc: STREET NUMBER ........a.....aa..aaa...aaaa■aaaaa a-am aa■aaaa.aaaaaaaaaaaa.aaa..aaaaaaaa..aa.■ OFFICIAL USE ONLY snows ...aa...a.a■■aa.■aaaaaaaat'a.aaaaaaa■aaaaaa■aaaaa■aaa..uasaaaaaaa.aaaa.a■ REC ATIONS OF TOWN AGENT'S M.a■ ■■■e..f.".s..■a..>.■.-a.■■a....a■a.■■tea.■a■*sea..a.ra.a....a.Sam..anaamaam . f . (� DATE APPROVEDp O,q. CONSERVATIONADMINIS TOR DATE REJECTED CON%dENTS TOWN PLANNER DATE APPROVED DATE REJECTED CONMIENTS DATE APPROVED FOOD INSPECTOR-HEALTH DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COIQIMENTB PUBLIC WORKS—SEWER/WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPARTMEItTT DATE REJECTED COMM NTS RECEIVED BY BUILDING INSPECTOR - DATE y�� MORTGAGE .1N FEU14UN PLAN NORTHERN ASSOCIATES, INC. 342 N.MAIN STREET ANDOVER MA 01610 TEL: (508) 474-4410 FAX (508) 474-5067 MORTGAGOR: JOYCE L. SMITH DEED REF. 1050/0295 LOCATION: 5 FRANCIS STREET PLAN REF. 4509 CITY,STATE: N.ANDOVER ,MA SCALE: 1 = 20' DATE: 4/19/97 JOB #: 97/1906 N )a >13 441i t v q+/- -Q 105,27 i > --t- 1 �- M I 10,00 S.i /— w I O �\ HS,#5 9r CL/ 1 STY,WD. tri - - - - n o 105.27' FRANCIS STREET r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers'Compensation Insurance Affidavit Please Print =mini Name: N-C (ts� 4ZX.o e C__�b . Location: CitV JNVV • O I Phone aam a homebAer performing all work myself. 1 &lam 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. Policy# Companyname: Address City: Phone#: Insurance Co. Policy# Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of($100.00)a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify under p\ains allies of perjury that the information provided above is tare and correct Si nature St Date `- 9 Print name - �A\ Phone# C17 3� �a l y Official use only do not write in this area to be completed by city or town official' Ej Building Dept ❑Check if immediate response is required Building Dept Licensing Board p Selectman's Office Contact person. Phone#. Health Department Other FORM WORKMAN'S COMPENSATION Official Use Only. Permit No. /lrFi s��ld?2ZU�rfl'�ls�f�7�f.�SS���'2l!S�77S Dyo-�mr«wa P Sway Occupancy&Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00 (Please Print in ink or type all information) Date To the Inspector of Wires: Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location(Street&Number Owner or Tenant Owner's Address Is this permit in conjunction with a building permit Yes 0 No 9 (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Vofts Overhead I Undgmd a No.of Meters New Service Amps Vons Overhead 0 Undgmd 0 No.of Meters Number of Feeders and Ampacity. Location and Nature of Proposed Electrical Work Total No.of Lighting Outlets No.of Hot fuse No.of Transformers KVA Above f In a No.of Lighting Fixtures Swimming;Pool gmd a gmd 11 Gener2kNS INA No.of Emergency Lighting No.of Receptacles Outlets No.of Oil Burners Battery Units No.of Switch Outlets No of Gas Burners FIRE ALARMS No.of Zone Total No.of Detection and No.of Ranges No of Air Cond Tons Initiating Devices Heat Total Total No.of Diposal No. Pumps Tons KW No.of Sounding Devices NoJ of Self Contained No.of Dishwashers SpacelArea Heating KW Detection/Sounding Devices a Municipal a Other No.of Dryers Heating Devices KW Local Connection No.of No.of Low voltage No.of Water Heaters KW S' ns Bailases Wiring No.Hydro Massage Tuds No.of Motors Total HP OTHER: INSURANCE COVERAGE. Pursuant to the requirements of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES= NO have submitted valid proof of same to the Office YES= NO - If you have checked YES please indicate the type of coverage by checking the appropriate box. INSURANCE - BOND - OTHER - (Please Specify) (Expiration Date) Estimated Value of.Electrical Work$ Work to Start Inspection Date Resquested Rough Final Signed under the Penalties of perjury: FIRM NAME LIC.NO. Licensee Signature UC.NO. Bus.Tel No. Address Alt Tet.No. OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws.And that my signature on this permit application waives this requirement Owner Agent (Please Check one) Telephone No. PERMIT FEE $ (Signature of Owner or Agent) 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: NA (Location of Facility) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector NORT1y Town of 0 — s No. 6414 o� dover, Mass., cSI37*'a0 LAKE D O y COCMICMEWICK �� ORATED till V BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR � I THIS CERTIFIES THAT � ..................... .......:.................................................. Foundation .......................... ........... .... has permission to erect... .....�. �..Y-buildings on ...... ...FAA ............. Rough a %cuS......... ..... �e. to be occupied as..* 0 �� d!�'.0 ` .1J% rl�r 04 Dpi•! 14AM 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-La s relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. A/7; +N! Iw a DIf PLUMBING INSPECTOR VIOLATION of the Zoningor Building Regulations Voids this Permit. O V ! N { ^�' ry �0 Rough 9 g �v Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION T TS. ror Rough A ............................ ........ 1:060 .................... ............... ... Service BUILDING INSPECTOR Final Occupancy Permit Required to 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 SIDE Smoke Det. Date. . . . . . . . . ... .. • NORTIy o� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION '�qh �,SSACHUSEt . This certifies that %/. . :.: . . .'. . /�. . , .!.:�. . `� . . . . . . has permission for gas installatiotl '. . . . . . .! �' r . . �. . : .. .! .:� . . in the buildings of . . . . . . �! . . . . . . . . . . . . . . . . . . . . . .. at . . . . . .�.�� .�. .'. , North Andover, Mass. Fee: ... . . . . . Lic. No.. . . r. . . . e GASINSPECTOR Check# ' J MASS APPROVAL # MASSACHUSETTS UNIFORM APPLICATION F R PERMIT GASFITTING . �; (Print a Type) � p' �G{' 7��'>`pQ c L/.►Mass. ate Pem-A .� Building Location Owne.'s Name - Type of Occu New p Renovation a Replacement Q Plans Submitted: Yap No n c G Y = G Q y a to 0: O W W Me O U t7 J Q < 30 = 2 O F L Z O u < a 0 z 0 h- in :u W e. c < yOj W h J z t = Q E a C W ~ tit u = q Cr C ut S p. HW m 2 0 ~ W O M S a",: < : O O la . Q 'Z Q O Z IV 7 O d J 0 SUB—BSMT. BASEMENT IST FLOOR 2HD FLOOR I I I 3RD FLOOR I 4TH FLOOR STH FLOOR 6TH FLOOR I TTH FLOOR ( I 8TH FLOOR Installing Company Name YANKEE GAS Check one: Certificate Address 140 SOUTH MAIN STREET :3 Corporaticn 103C MIDDLETON, MA 01949 [ Partnership Business Telephone 978-774 ' 2760 Firm/Co. Name of Licensed Plumber or.Gas Fitter WILLIAM R, HAR R T S 1 INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which me--s the requirements of MGL Ch. 142. Yes M No 0 It you have checkedrtes. please indicate the type coverage by checking the z.r,Vopriate box. A liability Insurance policy 13 Other type of indemnity O Bond p OWNER'S INSURANCE WAIVER: I am aware that the licensee does nct 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: Owrtie�.j Agent❑ Signature of Owner or Owner's Agent hereby certify that all of the details and information I have submitted(or entered)in abore a,—;4 cn are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issueC for Uus applkwk rr' be in pl' all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gg��trri gy Tof License: Plumber gnalure c mber a mer Title Gasfiner Master License Numt,a 3785 J City/TownJourneyman fjPhXNEffTTFZE USE ONLY) �Li Date...........................r....... Of 40 oT� 4 � 3r , ,, TOWN OF NORTH ANDOVER p PERMIT FOR WIRING •-, +r7ss^cHusEt This certifies that ' .: ................ ...:..:.!..... .�.... i�.;-n ....................... 1 has permission to perform .............. wiring in the building of ' at..{...� :r .................... :.-1�.............................. ,North Andover,Mass. Fee ?............... Lic.No!..... ..:77.......x. ......:. ELECTRICAL INSPECTOR Check # 'LJ '_- " 0 TBE C'0W0AT9EAL7H0F3 S4C'USE7TS Office Use only DEPAIwTAffiVTOFPUBLICSAMY Permit No. ",rold ! BOARD OF FIRE PREVE\rH0NRW UI 9TIONS 527 CNIR 12.-00 Occupancy&Fees Checked IS APPUCATIONFOR PERMIT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dat Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street&Number) Owner or Tenant Owner's Address 7C vt C 1 7 r Is this permit in conjunction wit a building permit: Yes® No (Check Appropriate Box) Purpose of Building i z! Utility Authorization No. Existing Service OD Amps I e/Zg/aVolts Overhead Underground C No. of Meters New Service Amps / Volts Overhead Underground r--J No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total KVA No.of Lighting Fixtures Swimming Pool Above Below Generators KVA round round No.of Receptacle Outlets No.of Oil BurnersNo.of Emergency Lighting Battery Units No.of Switch Outlets No.of Gas Burners TZ— oA Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones Tons No. i7 Disposals No.of Heat Total Total No.of Detection and 'J Pumps Tons KW Initiating Devices No.of Dishwashers Space Area Heating KW Ng.of Sounding Devices No of Self Contained Detection/Sounding Devices No.of Dryers Heating Devices KW Local Municipal Other Connections No.of Water Heaters KW No.of No.of Signs Bailasis No.Hydro Massage Tubs No.of Motors Total HP )THER• IL 2'_(� 1�/Sf/arc /6U.4i�t/� (�:�. /2av7P( tV#14 2-A C [✓ �4r+ e �. -rwo .D d e t`� ✓air t A,-(- mance(-overs PtmantiDtheoWtrenlentsofMassachusetts Gerhal Iaws {�Xcls iaveaaWALiatdtykEw&=PblicyiwkdTCc)nTkteopmhomCDvwaworltsabstntlAapvakit YES NO mesubmitiedvatidlxoofofsametothe 0ffica YESMy 7T If}�ouhavechecl�lYES,please indicate the type ofcovetageby �e�lgthe box ISURANCEE BOND OTH M (Please Specify) / ExlmationDate c./rl Cli Estirn&d Vahae of Fbctncal Wotk$ /dam, olktostart /3-01/ IrlspeCtionDateRequested Rough t fl l// �� Final ;ned underTe Rnallies of perjury: 2MNAIVIE IiomseNo. u-isee e;1 Sig-law f ? -G ���----� lioenseNo BusmessTel No. 2 F/-)7r Y-/ O6,V rhx(Z Alt Tel No. ''� l-55-5' i0 } VNEIZ'S INSURANCE WAAUII I am aware that the Lice does nothave the instuance coWtidge orits stlbStantlal equivalent as rogmed by Massachusen General Laws that my sigila ire on this pemrit application waives this requirement ease check one) Owner ® Agent U Telephone No. PERNIITT FEE$ rgnature ot 7wner or Acrent u The Commonwealth of Massachusetts d Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers'Compensation insurance Affidavit Name ` , �? n e Please Printne Name: Location: City A414Phone # I ani a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity 0 I am an employer providing workers' compensation for my employees working on this job. Company name: Address City: Phone#: Insurance.Co. Policy# " Company name: Address Citi: Phone#: Insurance Co. Policy_#_ Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to$1,500.00 and/or one years'imprisonment_as.well_as_civil..penattiesiniheform-of-a STOP WORK_ORDPR_and.a.fine of_($1DO.OA)..a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. G --- C Date —1�- - D f Signature V Print name T��l� �/ �, ✓ ��r� �� Phone Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing Building Dept ❑Check if immediate response is required L] Licensing Board F-1 Selectman's Office Contact person: Phone#. ❑ Health Department Other Date.... ........ AO To"I + TOWN OF NORTH ANDOVER 0 Io ANN& p PERMIT FOR WIRING SA This certifies that ........ 7..1............ . ..................................... has permission to perform ..... .............................................. wiring in the building of........I.-I2.1 L.!... .................................................. at....... ...... ......... ...... North Andover Mass--,, Fee.3-5..,.� Lic.No. /�t��....... -ELECTRICAL INSPECTOR Check # Official Use Only Permit No. DooV.ad°a PUR&Satiety Occupancy&Fee Checked BOARD OF FIRE PREVENTION REGULATIONS.527 CMR 12:00 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00 (Please Print in ink or type all information) Date ri A /;J �-- To the Inspe or 6f Wires: Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location(Street&Number S+ Owner or Tenant Jby Owner's Address Is this permit in conjunction with a building permit Yes No ❑ (Check Appropriate Box) Purpose of Building S F a�$ Utility Authorization No. ,J/t4 Existing Service /C U Amps_ /k JJ,Y cm Voits Overhead 8--- Undgmd ❑ No.of Meters New Service ./Amps Voits Overhead ❑ Undgmd ❑ No.of Meters i Numt&of Feeders and Ampacity c� Location and Nature of Proposed Electrical Work en29= f Total No.of Lighting Outlets No.of Hot fuse No.of Transformers INA Above ❑ In ❑ No.of Lighting Fixtures -3 Swimming Pool gmd ❑ grnd ❑ Generators INA No.of Emergency Lighting No.of Receptacles Outlets No.of Oil Burners Battery Units No.of Switch Outlets -3 No of Gas Burners FIRE ALARMS No.of Zone Total No.of Detection and No.of Ranges No of Air Cond Tons Initiating Devices Heat Total Total No.of Di sal No. Pumps Tons KW No.of Sounding Devices No./of Self Contained No.of Dishwashers SpaceWea Heating KW DetectionfSounding Devices ❑ Municipal ❑ Other No.of Dryers Heabnq Devices KW Local Connection No.of No.of Low Voltage o.of Water Heaters KW Signs Bailases Wiring No.Hydro Massage T,u-ds n No.of Motors Total HP OTHER: { � le INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES= NO = have submitted valid proof of same to the Office YES= NO = If you have checked YES please indicate the type of coverage by checking the appropriate box INSURANCE = BOND = OTHER = (Please Specify) (Expiration Date) Estimated Value of le rical Workb Work to Start S t l Inspection Date Resquested Rough Final Signed underthe PendRies of pe'ury: FIRM NAME b LIC.NO. r J_-)-s' __,r Lkensee M o.AZ1 Z7_ Signature LIC.NO. !-r3 "20 .J cY '/ us.Tel No. 92 F" 7-7 /_ / Address Z. a g c A, Alt Tel.No. OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws.And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) Telephone No. PERMITTEE $ 3,� (Signature of Owner or Agent) Location v No. Date HORTN TOWN OF NORTH ANDOVER Certificate of Occupancy $ • i y �s Nus9 <�' Buildin /Frame Permit Fee $ t Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 30 —r Check # D�� �J 5 J 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: l K7-� o SIGNATURE: Building Commissioner/Inspector of Buildings Date 7 -_1 L( � ra Z SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 0' �za AJC I S Map Number I Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning Distrid Proposed Use Lot Area Csdo Frontage ft 1.6 BUILDING SETBACKS ft Front Yard . Side Yard Rear Yard Required Provide R Fred Provided red-. Provided 1.7 water Supply M.c.1-C.40. 54) 1.5. Flood zone Information: 1.9 Sewerage Disposal System: public ❑ Private ❑ Zona Outside Flood Zone 0 Municipal 0 On Sita Disposal System 0 SECTION 2-PROPERTY OWNERSE IP/AUTHORIZED AGENT 2.1 Owner of Record -zs-D y Ci S11, 1 W Name(Print) Address for Service SignatVe r Telephone 2.2 Owner of Record: 4 Name Print Address for Service: a Signature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ E VIA 14A Licensed Construction Supervisor: License Number Ada? � � Iv P>ND�vE2 ty,4,n AllZ t Expiration Date Sign T V Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ 541144 14,1 o/U.5 b !� L -�- /Z.E C4,1 D D ,Company NameIq ,0 Registration Registration Number Address Expiration Date ,i nater Tel�hn, r . SECTION 4-WORKERS COMPENSATION(MG.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 buildipg permit. Signed affidavit Attached Yes....... No.......0 SECTION 5 Descri tion of Proposed Work check all applicable) New Construction ❑ Existing Building Repairs) ❑ Alterations(s) 0 1 Addition 0 Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: 319: 66&C6y1 A-17 SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be Completed by permit a hcant 1. Building +� (a) Building Permit Fee �i DD v o Multi lief 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)x(b) 4 Mechanical (HVAC)Q 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize .TIE P 5 f wt t-�,O Ai S to act on My beh If,in all matters r lati to work authorized by this building permit application. Si atur of er Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, .��ILS S f wt t4 dNs 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 Sf FF s c r•<.1 we d yr Print Name 2— Signature r-Si ature of Own A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TMERS 1ST2ND 3RD SPAN DMIENSIONS OF SILLS DINIENSIONS OF POSTS DRAENSIONS 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 A4, t`o'o11N0waAeall�i a! fla uuc�usel�s 4_4 a, T Board of Building Regulations and Standards 1� HOME IMPROVEMENT CONTRACTOR r Registration: 115970 Expiration: 5/4/04 Type: Individual SIMMONS BUILDING&REMODEL .IFF SIMMONS 729 BOXFORD ST N ANDOVER,MA 01845 -� Administrator �e f omonana�eal!/a � d�fir.�ac/%uecl�i ` BOARD OF BUILDING REGULATIONS L License: CONSTRUCTION SUPERVISOR t Number: CS 016532 Birthdate: 12/11/1943 Expires: 12/11/2003 Tr.no: 11665 = -- Restricted: 00 JEFFREY M SIMMONS 729 BOXFORD ST N ANDOVER, MA 01845 Administrator The Commonwealth of P4ass achusetts 4 Department of Industrial Accidents r Office of Investigations I Boston, Mass. 02111 i Workers'Compensation insurance Affidavit Please Print Name: l IVS Location: C Phone 7 R7- am a homeowTfer performing all work Rhyself. �1 am a-sole proprietor and have no ona working in any capacity OMAN i am an employer providing workers'compensation for my employees working on this job. Gon3pany name,• Address G Phone I cam • .0 baarYv rname• Address City: Phone Insr rranr .Ca►. 7�iL�v� /&S , Co _ and/or one a meted under mon 26A o►NIf�E.t2 carr fel bafCinlq�d utrr�inatD of a flee years'w*wb nrne"t as wen as CM pow#,es in the foErrt of a STOP t11KN3fC 014 and efu►e d 3?tIR ��' widenstand that a copy of ttfis Ott may be forwzrded to rhe Offioe of k ct pta for cauerage v �`�`� /do herby certify under the pains aril penatles of paowjr yW thgkftmefto p ileo above is true a►rtfcarect Signatureis z arint name :16iC-� Phone# —h Z hTicial use only do not write in this area to be completed by city or town offiicia- ©.Check ffirrrmediate Msponse is0 Budding Dept ' building Dept p Licensing Board x►tact person E3 �plectr»an's Q fico Phone Q Health Department D 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: (Location of Facility) Si ture of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector 1 OW11 Ul .ruluv v cL .r- No. 70 �� 4 -- --- /f o�A COCA 0 dover, Mass., CRATED p`?���5 S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT...... m .�...........�.. QQ ..... .... 11*" 0 ... ... Foundation S' has permission to erect.../���`��. buildings o*14PJ61 rA ....... Rough .. ..... ....... ..........................!�....................... to be occupied as �A" P {� 0 r Chimney p ........... ....................... .................................... ................................................................ ...... 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 elating to.the Inspection, Alteration and Construction of Buildings in the Town of North Andover. I t X3 do & i PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR Rough 00 ................. ........... ............................................................................... 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 Until Inspected and Approved by the Building Inspector. Burner FlRE DEPARTMENT Street No. SEE REVERSE SIDE Smoke Det. Date.. . .. . . ... . .. . . ..... . z WORTH 3�Ory.,,.o ,e�tiaL p TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION h SAC MUSEt'( This certifies that . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . has permission for gas installation . . . . . . . . . . . . . . . . ... . . . . . . . . . . in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . ... . . . . . . . . . . . . .. . . . . . . . . . . . . .. North-Andover, Mass. Fee. . . . . . . . . Lic. No.. . . . . . . . . . . . . . . . . . . . . . . . �,a, . . . . . . . . GASINSPECTOR Check# MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) Mass. Date - 1 0 Permit # �o Building Location__ S )rg q C,1 T Owner's Name_ �m> Thi Type of Occupancy_ r49191' New ❑ Renovation ❑ Replacement [ Plans Submitted: Yes❑ No ❑ N -- N a X W N N W U Z OC � � N N a N0 W x 0 7 N s W W cc O U m r- y , , x O u F- < Z Z O }- w a 4 a O O W 0 W a z z k0- N a0. C: a > 4 C: 0 z a y Ix a W a m F' W t- z z a uzi -' < a t- H r N o >z 0 w J � W �, o Z o� x a S O 0 UU. :33 G d J U C Y D a F- O SUB-8SMT. BASEMENT ISTFLOOR 2N0 FLOOR 3R0 FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing Company Name BAY STATE GAS COMPANY Check one: Certificate # Address 55 MARSTON STREET �O Corporation 1862 r LAWRENCE! MA 01840 ❑ Partnership Business Telephone -68,7-:1105 ❑ Finn/Co Name of Licensed Plumber or Gas Fitter Francis X. Corkery INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes K No ❑ If you have checked res, please indicate the type coverage by checking the appropriate box. J,� A liability insurance policyOther type of indemnity❑ Bow ❑ 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/gent Owner[] Agent❑ hereby certify that all of the details and information I have submitted(or entered)in abo plication are true and aomgte to the best of my knowledge and that all plumbing work and installations performed under the permit issu f r this application will n mpliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene i Type of Ucense: Title Plumber Signature of censed Plumber or Gas Gasfitter City/TownMaster License Number 8697 IC S ONL Journeyman O BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES PROGRESS INSPECTION FEE NO. APPLICATION FOR PERMIT TO-DO GASFITTING • f i� NAME TYPE OF 13UILDING ��. •;` ' LOCATION OF BUILDING. PLUMBER OR GASFITTER LIG NO. PERMIT GRANTED DATE .19 GASINSPECTOR a Date./.7. NORTH TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACMUS� This certifies that . . . . . . . . . . . . . . . . . . . has permission to perform . . . . /.i .. . . . . . . . . . . . . plumbing in the buildings of . at . . .-,). . . . . . . . . . . , North Andover, Mass. Fee. ta. ". . .Lic. No.. c , l . . . . . . . . . . >. . . ..12-.. ..2 . . . . . . PLUMBING INSPEdOR Check # j :.l . O �3� v MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Date ,/2- 1 �- Building Location ✓L /C/c i ' Permit# r Amount .2,1; r- Owner ` / C e New Renovation Replacement Plans Submitted Yes No ❑ FIXTURES Ln ce Cr F W Ln Ln Cr x A SLID-BM &�SIlVINI' � BE HDCR A M HIDCR �HIDCit, 4M H JOM SII3 H j" 61H H JOM 7IH HIDCIR SIH HDM (Print o ) Check nCertificate Installing Company omp anyNam �14 41t-1- � -eCorp Address (-p Fox- YI Partner. `Vl c "'V-c(.o u -e►Q Business Telephone / 13—Firm/Co. /� Name of Licensed Plumber: �' 0 Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy 0-- 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 El Agent ri 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 sta on 'rfo�rmneunder P rmit Issued r this appli n will be in compliance with all pertinent provisions of the assachuse atluCode d Chapter 2 of the ral Laws. By 1gna ure of Lilensedum er Wef Plumbing License Title City/Town IN MOW Master Journeyman ❑ APPROVED(OFMCE USE ONLY f � � � � �---- _ �. _ _ _ ,'; - j I +, r i ,, �_