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Home My WebLink AboutMiscellaneous - 50 JOHNSON CIRCLE 4/30/2018 50 JOHNSON CIRCLE 21.0/097.0-0058-0000.0 Town of North AndoverNOR7f� o��T,..o Office of the Planning Department ° t Community Development and Services Division 27 Charles Street North Andover,Massachusetts 01.845 Telephone (978)688-9535 Fax (978)688-9542 June 13, 2002 Mr. Gustav Kaechelin 50 Johnson Circle North Andover MA 01845 Re: Construction at 50 Johnson Circle Dear Mr. Kaechelin, I have received your request of 061202 regarding expansion of your existing dwelling located at the above address. You lot was created before 1994 and is, therefore, covered by setbacks in Table 2 of§ 4.136(2). These setbacks require that all work resulting in a surface or subsurface discharge of stormwater within 325' of a wetland resource obtain a Special Permit. Work that increases the impervious surface on the site would require a Special Permit. However, even though the property is located within the Watershed Protection District, the proposed construction does not require a Special Permit from the Planning Board provided the addition of impervious surfaces lies beyond the 325 feet distance from wetland resources. Based, upon our best information, the closest wetland resources are across the street and over 325 feet away. If there appear to be wetlands closer than this, a Permit will be required. Regardless, all work within the Watershed District requires best management practices with regard to the minimization of stormwater and erosion discharges during the construction projects in order to protect North Andover's drinking water supply. I have enclosed a copy of the recorded subdivision plan, referenced in our files, that forms the basis for my decision. Thank you for your inquiry. If you have any further questions, please do not hesitate to contact me. Very Mitchell Interim Town anner cc: Building Department BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 t i ---_ .. ' �. ' _ - �� 3 t .tet .. .:, ... ,.. ____ �. .. �__..� �y-,-,.. tr i.., r i..Jr ;,,. ..__ -, .. � ,. -. .. =.w,,, ., 6 iii' . rt1... H.�':1... �•. .. .y. r T .. ...,... i.• _r�_ y-..K.Y .. .:.w I � .� .. � - ... ,. �ti_ ,..,:.��. ... 1 `.; .. •J r�r � .. f1.� � � '`�1 ... ..• � • '. ji � " .. r w .,. `,,l r � ^_ ,. '� 'S � e � � A!..i iS�c ..a fJ n el.iMr• ''� w1 6oC 1 r 1� f 1 .. ��.._�_r..e.. /r/d�� ell wl�e AArlt I Gj^� -3fl\r7 (AJg' '�f CO eSS 6f (,v)r kf ivy wl�K, R� /� P Pi Of vu v' k" tchf,4J tk4Gk . We (; tLjld 111kr �y k�c� IAF ove am� 20N,.."S a ,r a ,�v" �SS u•e S �,c v c�o� 6,Q a w Ate o f bvfv:e wk 5 r �� II S b 1 r C- ,Por+L, f�pdw?r'r, ,Mg d t QHS (P�5 v- 12LA 3 (ka„.-) 1-1 Zo 2 — 3LI Li c,�o�k 2 � pA If OROOKSID'E s� 111"fs If the UTTONat Heritage %hy BED y w 11'01, X 1316• - O° `O CL J CL V HALL CL CL BED BED M BED 1316' X 18'0" 1016' X 11'0' 14'6" X 20'0" :r SECOND FLOOR PLAN 1,260 SQ. FT. r MORTGAGE INSPECTION PLAN %y /F 00NOVAN 1 d0 L GST SA l LOT4A. A=Z? I&9 S.F't'1 LOT(o ao co fC1 ` M � I Fb� it Ql X50 Z5,,D0 t TOHNSON CIRCLE THIS PLAN IS BASED ON A TAPE SURVEY(NOT AN INSTRUMENT SURVEY)AND IS TO BE USED FOR MORTGAGE PURPOSES ONLY. THEREFORE,THE OFFSETS AS SHOWN SHOULD NOT BE USED TO ESTABLISH PROPERTY LINES. ESSEX COUNTY DEED REFERENCE: PLAN REFERENCE: PLAN OF LAND BK. 4559 PG. 73 PL 7338 PL. IN CERT. No. BK. PG. NORTH ANDOVER I hereby certify that the existing structures are located approximately as shown and were not in violation of the zoning by laws at the time of construction,or are exempt PREPARED FOR: from violation enforcement action under,Chapter 40A Section 7 of the Mass. ANDOVERBANK General Laws.The structures are located in Zone C according to the following GUSTAV KAECHELIN F.E.M.A.map.Note:Zone C represents areas of minimal flooding. FLOOD HAZARD COMMUNITY NO 2 S009 8 BOUNDARY MAP NOGG EFFECTIV L N 93 SCALE I IN.= 40 FEET Of 414 � I :;�l/ 0;�l;,, BAILLIE & COMPANY c: LAND SURVEYING & RESEARCH 33 HOWARD STREET REGISTERED LAND SURVEYOR AP READING MA. 01867 \ W PHONE: (781) 944-2767 DATEr4 SupvFAX: (781) 944-6112 WATERSHED RESIDENTS QUESTIONNAIRE 1. Name ,!) a 4 0i2,Fs /9/0-" A Ar T X V,!! 2. Street Address �a ��Af'yjd A)• 1 w b °a,5 4 3. How many members are in your household? -� 4. What type of sewage disposal system do you have? ❑ cesspool ❑ septic tank and leaching area CV connection to municipal sewer ❑ other (describe) ❑ do not know 5. Are the plans (drawings) for your sewage disposal system on file with the Board of Health? ❑ yes ❑ no [9 do not know'- 6. How old is your sewage disposal system? ❑ 0-5 years 6-10 years ❑ 11-20 years ❑ over 20 years ❑ do not know 7. Has your sewage disposal system been rebuilt or repaired? ❑ yes C✓7 no ❑ do not know If yes, approximately how long ago? years. What was done? 8. How frequently is your sewage disposal system pumped out? '0.,1- ❑ annually ❑ every 2-4 years ❑ every 5-10 years ❑ over 10 years never 9. Have you had any problems with your sewage disposal system? ❑ yes CK no If yes, what problems? ❑ repeated pump-outs needed ❑ system clogs, backs up, or drains slowly �. ❑ odors ❑ sewage surfaces through ground 10. How many of each appliance are connected to your sewage disposal system? washing machine ✓ ► dishwasher ✓ garbage disposal L� dehumidifier drain sump pump toilet roof/pavement drains shower/bathtub 11. Please state the brand and type (liquid or powder) of detergent you use for: dishwasher A6 (t 1-A3 b.eaova clotheswasher #CAd T 14,,4x 8y L -4 12. Does your property have a lawn? 2� yes ❑ no If yes, approximately what size? ❑ less than 1/4 acre M 1/4 acre ❑ 1/2 acre ❑ 3/4 acre ❑ 1 acre ❑ more than 1 acre (Specify) acres 13. How often do you fertilize your lawn? 2 No. of applications per year J Season(s) of the yearP A L) M " 14. Please state the brand and type (liquid or granular) of lawn fertilizer you use: ❑ Check here if your lawn is maintained by a professional landscape contractor. °�° "". "° Zoning Bylaw Denial A Town Of North Andover Building Department De x 1 27 Charles St. North Andover, MA. 0184 a SSACHUSEt phone 978-688-9545.Fax,978-688-9542 5 RAlicantt: et: --/o sda Lot: �v ;j Gv est: KleC- Ke xPACjSko-j If o Please be advised that after review of your Application and Plans that your Application is DENIED for the following;Zoning Bylaw reasons: iZonin - 3 �Ncotes -3 0 Item A Lot Area Item Notes F Frontage 1 Lot area Insufficient 1Frontage Insufficient 2 Lot Area Preexisting 2 Frontage Complies S 3 Lot Area Complies 3 Preexisting frontage 4 Insufficient Information 4 Insufficient Information B use 5 No access over Frontage 1 Allowed G Contiguous Building Area 2 Not Allowed 1 Insufficient Area 3 Use Preexisting 2 Complies 4 Special Permit Required Il e S 3 Preexisting CBA 5 Insufficient Information 4 Insufficient Information C Setback Fi Building Height 1 All setbacks comply 1 Height Exceeds Maximum -- 2 Front Insufficient 2 Complies 3 Left Side Insufficient 3 Preexisting Height 4 Right Side Insufficient e `( es `� S 4 Insufficient Information 5 Rear Insufficient � Building Coverage 6 Preexisting setback(s) 1 Coverage exceeds maximum 7 Insufficient Information 2 Coverage Complies D Watershed 3 Coverage Preexisting 1 Not in Watershed 4 Insufficient Information 2 In Watershed e -T Sign 3 Lot prior to 10/24/94 N 1 Sig 4 Zone to be Determined n not allowed 2 Sign Complies 5 Insufficient Information 3 Insufficient Information E Historic District K Parking N A 1 In District review required 1 More Parking Required 2 Not in district yes 2 Parking Complies 3 Insufficient Information 3 Insufficient Information 4 Pre-existin Parkin Remed for the above is checked below. Item # S ecial Permits Plannin Board Item # Variance Site Plan Review Special Permit Access other than Fronta e S ecial Permit C -�f Setback Variance Fronta a Exception Lot Special Permit Parkin Variance Common DrivewaySpecial Permit Lot Area Variance in S ecial Permit Hei ht Variance --Congregate Hous Variance for Sign Continuing Care Retirement Special Permit Inde ende it Elderl Housin S ecial Permit S ecial Permits Zoning Board S ecial Permit Non-Conformin Use ZBA Large Estate Condo Special Permit Planned Development District S ecial Permit Earth Removal S ecial Permit ZBA S ecial Permit Use not Listed but Simil Residential S ecial Par Planned Permit R-6 Densit S ecial Permit S ecial Permit for Si n d- S ecial� Permi Watershed S et reexistin nonconformin cial Permit o The above review and attached explanation of such is based on the plans and information submitted. No definitive review and or advice shall be based on verbal explanations by the applicant nor shall such verbal explanations by the applicant serve to provide definitive answers to the above reasons for DENIAL. Any inaccuracies,misleading information,or other subsequent changes to the information submitted by the applicant shall be grounds for this review to be voided at the discretion of the Building Department. The attached document titled"Plan Review Narrative"shall be attached hereto and incorporated herein by reference. The building department will retain all plans and documentation for the above file.You must file a new building permit application form and begin the permitting process. Budding Uepartment Official Signature a Application Received Application Denied Denial Sent : If Faxed Phone Number/Date: eview Narrative '• ' lowing narrative is provided to further explain the reasons for denial for the application/ ~ it for the property indicated on the reverse side: /� k r�.� �f ,�B-:.'� ��i,��`��1•. 4F��j��`�^�), � .a�.�f�"��s,��R w`.y a,le�� 'y �`i!��.�,�p:;.�� iUON 00 N J —/ n o(,) //Iv/,j C j rCti Referred To: Fire Health Police Zoning Board —on ervation Department of Public Works Plannin Historical Commission Other BUILDING ULPT MORTGAGE INSPECTION PLAN NSF DONO v N ,.� 110, o o L OT 5A LOT-+A- A=27; 1&9 S.F t LOT(o m � !' It 4.1 t SOHNSON CIRCLE THIS PLAN IS BASED ON A TAPE SURVEY(NOT AN INSTRUMENT SURVEY)AND IS TO BE USED FOR MORTGAGE PURPOSES ONLY. THEREFORE,THE OFFSETS AS SHOWN SHOULD NOT BE USED TO ESTABLISH PROPERTY LINES. ES 1; COUNTY DEED REFERENCE: PLAN REFERENCE: PLAN OF LAND BK. 4559 PG. 73 P�.BK 7338 PL IN CERT.No. BK. PG. NORTH ANDOVER I hereby certify that the existing structures are located approximately as shown and were not in violation of the zoning by laws at the time of construction,or are exempt PREPARED FOR: from violation enforcement action under,Chapter 40A Section 7 of the Mass. ANDOVER BANK General Laws.The structures are located in Zone G According to the following GUSTAV KAECHELIN F.E.M.A.map.Note:Zone C represents areas of minimal flooding. FLOOD HAZARD COMMUNITY NO. 2600519 LARSON BOUNDARY MAP NO.�G EFFECTIV t N%J SCALE 1 IN.=40 FEET a . '' � � BAILLIE & COMPANY EJ HO A. , n t✓ .i LAND SURVEYING & RESEARCH 33 HOWARD STREET REGISTERED LAND SURVEYOR .�. READING, MA, 01867 PHONE: (781) 944-2767 DATE *b SUR'd�vU� FAX: (781) 944-6112 No 9606 Date. 2-�L- TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING Ss cmus This certifies that . .'.��! . . . . . . . . . . . . . . has permission to perform .. . . . . . . . plumbing in the buildings of . .��?5. . ��cLt C.'. A!, .. . . . . . . . . 5-D -Tc>kAsL... C,'r CU- at . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . North Andover, Mass. Fee.4.0(4?. .Lic. No..1 5 g a PLUMBING INSPECTOR Check # Z4#0 WHITE: Applicant CANARY: Building Dept. PINK:Treasurer i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY I V6 R A 6 UE P,, MA DATE Vo -./ PERMIT# JOBSITEADDRESS �()JIIHNSC)� dje�[�" OWNER'SNAME [(� POWNER ADDRESS S g[ME TEL[ FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:[] RENOVATION: ] REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NOA FIXTURES 7 FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB I CROSS CONNECTION DEVICE _.._ ..._..- _ _ DEDICATED SPECIAL WASTE SYSTEM �� '=( i I _ DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER 11��'-f-I_ hr^ �^ �-- DRINKING FOUNTAINFOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK E.. ......_' { .......I .... -... . . -ISI ..... __ LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION IL WATER HEATER ALL TYPES .t WATER PIPING OTHER INSURANCE COVERAGE: 1 have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW - - - LIABILITY INSURANCE POLICYJ6 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my_knowledge _ and that all plumbing work and installations performed under the permit issued for this application will be in comp/' ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I JR/'IES LICENSE# 590SIGNATURE MP JP❑ CORPORATION 0#PARTNERSHIP � o# LLC 0#0 0 COMI BRADFORD PLUMBING & ADDRESS CITY HEATING MECHANICAL INC. ZIP TEL Lic. #12580 Tel. #(978) 521-0262 P.O. Box 5269 FAX ( BRADFORD, MA 01835-0269 L �T ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# `y o PLAN REVIEW NOTES I i i I I 1 i rr� COMMONWEALTH OF MASSACHUSETTS 79 PLUMBERS AN0 GASFITTERS ' LICENSED AS A MASTER PLUMBER i I ISSUES THE ABOVE LICENSE TO: t I :JAMES D . MITCHELL 3.61 KENOZA STREET N HAVERHILL MA 61830-4318 E t _ 12580 05/01/14 160685 r I _ I Fold,Then Detach Along All Perforations . f i r( Location No. '� � G Date .. NORTH TOWN OF NORTH ANDOVER F a Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ s+cNust Other Permit Fee a -r $ �S Sewer Connection Fee $ Water Connection Fee $ TOTAL $ -7,.5 ,Building Inspe Div. Public Works PC q- N44IT NO. O APPLICATION ICOR PERMIT TO BUILD*�******NORTI-I ANDOVER, MA aIArNO. I.or c 2 RECORD OFOWNERS111P DATE ROOK PACE ZONE: SUR DIV. 1.01 NO. LOCA IION ` n - t' , PURPOSE OF BUILDING OWNER'S NAS\I F: NO.OF STORIES ` SIZE OV1'NER'SADDRF:SS S BAS£MENTORSLAB ARCIII TEC'1'S N.AME'. SIZE OF FLOOR TMIBERS 1 .1 2ND 3RD BUILDER'S NA�IE � ,a �/J SPAN ' DIS TANCE l'O NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET DIMENSIONS OF POSTS DISTANCE FROM LOT LINES-SIDES REAR DIMENSIONS OF GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION T1I1CKNESS IS BUILDING NEW SIZE OF FOOTING x IS RIIILDING ADDfI'ION MATERIAL.OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN NATER BOARD OF APPEALS ACTION, IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE 1NSTIIC11ONS 3. PROPERTY INFORNIATION LAND COST EST. BLDG. COST TACE 1 1:11.1.MIT SECTIONS 1-3 EST.BLDG. COSTPER SQ. FT. • EST. IILDG. COST PER ROOM I:I.FCTRIC JNIETERS p111S"r RE ON OUTSIDE OF BUILDING SEPTIC PERMIT NO. :\'I'`F.\('IIF.I)C.AR:\GL•'S MUSTCONFOILM TO STAKE FIRE RE.CLILA-i'IONS 4. APPROVED BY: I'1-.1NS MUST RE FILED AND APPROVED BV BUILDING INSPECTOR BUILDINC INSPECTOR �y f DATE FILED OWNERS TELA �Q j /17 q �17 2 A2M44 � p CONI'R.TELi/ w cON"rR.1.IC# SIC:N:1I IRF: OF OWN F.R OR AUTHORIZED AGENT FEE $ a.1 � PlAVO IT GRAN"rED _ .-- 1� Revised 5 i/5/99 .IN ---- ---- - --- ----- t.%ORTH own �,of �' - - OL dover 0 JqD CO COCM1 WTC dover, Mass., - �-9 ADRATED S BOARD OF HEALTH Food/Kitchen P E R T D Septic System BUILDING INSPECTOR THISCERTIFIES THAT....... ...... ............ .......0.1......�rz ........................................................................ Foundation has permission to erect./� .................. buildings on ... ...... . .......................... .. Rough to be occupied as....... ....... Chimney .. .... ............................................................................................................................ . provided that the person accep g th1 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. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION ;jW ELECTRICAL INSPECTOR Rough ................................................................................................................. 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................z'.....�d`e. ° s"`° '• "° TOWN OF NORTH ANDOVER p PERMIT FOR WIRING . a ',�• a �sSACHUS This certifies that ................ U/ ............. has permission to perform '6'Ds� v� ......U'd wiring in the building of ��-� ...................' ....................................... atI °...... �?.y�-�S North Andover,Mass. ..............`....... ................ ........... Fee. F Lic.No.. yg& 3 ..... ......v Check # 7 9 ELECTRICAL INSPECTOR Commonwealth of n9assachusetts official UUScaOnly y Department of Fire Services Permit No. ' BOARD OF FIRE PREVENTION REGULATIONS R vc 11 99]and Fee Checked . leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION), Date: 7—24/-057" City or Town of: 1.4. To the Inspector of Wires: B this By application the undersigned Ives notice of his or her intenti gn on to perform th g p e electrical work described below. Location(Street&Number) 5-0 .Tj>s,fy,� c oz Owner or Tenant y 1F,4Ak4, if 44+PS6A,/ Telephone No, Owner's Address Is this permit In conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No, •/0 -,361 Z12- Existing Service JOO Amps /2-,,,/ 2Seeo Volts Overhead❑ Undgrd No.of Meters I - New Service 26V Amps /�u /7-Y,-)Volts Overhead❑ Undgrd No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 61)4WL Y , Com ledon of the ollowin table may be waved by the/ns ecior of Wires. No.of Recessed Fixtures No.of Ceil.-Susp-(Paddle)Fans o,of Total' Transformers KVA No.of Lighting Outlets No,of Hot Tubs Generators KVA No.of Lighting Fixtures Swlmming rnd. rnd.Pool ave ❑ n- ❑ o. o Batte Units c4/ g ng No.of Receptacle Outlets No:of Oil Burners FIRE ALARMS No.of Zones No.of Switches No,of Gas Burners o,of Detection as Initiating Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No,of Waste Disposers eat umpum er ons o.oSelf-Contained Totals: Detection/Alerting Devices No,of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW SecuritySystems: No.of Devices or Equivalent No.o Water KW o.o o,o Data Wiring¢: Heaters Sl ns Ballasts No.of Vevices or Equivalent No.Hydromassage Bathtubs No,of Motors Total HP a ecommun cat ons ng: No.of Devices or Equivalent OTHER: Aisuch uddhlonul delull{f desired,or us required by rhe lnspec•iur of Wirer. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that suchCovera a is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCEND ❑ OTHER ❑ (Specify:) Estimated Value of Electrical Work: (Expiration Dace) (When r��uired by municipal policy.) Work to Start: 7—ZO-cY, Inspections to be requctied in accordance with MEC Rule 10,and upon completion. /certify,under the pains and penallies of perjury,that the information on tlri pll IW4k rue and complete, FIRM NAME: / LIC.NO.:� Licensee: 44,21D X4 Signature LIC. NO,: (/japplrcablc Xler "exempt"inthe license number line.) VBus.Tel. No.: 7r6SZ 6Z67- Address: 5�.AJb •s7- 44a..QFAA2"iO1+ O/d' Alt.Tel.,No.:9,72r 3 7s57 s� OWNER'S INSURANCE WAIVER: 1 am aware that the Licensee oes not hove the liability insurance coverage normally required by law, By my signature below,l hereby waive this requirement. I am the(check one)❑owner ❑owner's a ent. Owner/Agent PERMIT FEE: $ Signature Telephone No. Date �9�r . o7:'ho TOWN OF NORTH ANDOVER ° p PERMIT FOR PLUMBING ,SSACHO This certifies that . . . . . . • • • has permission to perform . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings . . . . . . . . . . • • • . . . . . . . • • at . . .) . • • . . . . . ., North Andover, Mass. Fee` > .:. . .Lic. No../.0.'?!/. . . . . . . �,,.,...�:r,-•� . . . . ,PLUMBING INSP TOR Check .H y cr t � % r 7 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) Mass. Date �� a� ffPermit # 2011 Building Location l 4 'L A22 Cif-, Owner's Name Type of Occupancy4CZ-Q�ti , L New 42- Renovation ❑ Replacement ❑ Plans Submitted: Yes ❑ No 4� FIXTURES Z N Q N Z Y �' y V1 N N Q Z W W L) Q N C7 ¢ Z N Q ¢ Q ~ Z O Z N 4 ¢ S ¢ N - LL Z - z }. JO N W y N = N F- U W N Y < M - a - � X ¢ Q z ¢ a O < Q U Z O 7 ¢ N W Q Q W '� O Q N i ¢ a ¢ ti W Q � N ¢ _ o ¢ o WW w w F- U �• !- O S C. = N F- Z O O N - _ W f✓ O U = a F- a ¢ x '� N a a o Q J ., a cc ¢ M Q O a �- 3 Uf U. Oz M 4 3 C @ O Sufi-BSMT. BASEMENT O 1ST FLOOR d 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STK FLOOR Installing Company Name Fl ANNFRV PI I IMRI IC �. uCATIAI� heck one: Certificate Address PO ROX 7ni Corporation A 770 Partnership Business Telephone '" (� " JrSZ�2 ❑ Firm/Co. Name of Licensed Plumber jUC44e—b ifs- Pt*[L�E" INSURANCE COVERAGE: I have a curre liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes F No ❑ If you have checked Les, please indicate the type coverage by checking the appropriate box. A 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 14.2 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information 1 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 un r the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State PlumbiWodnd' apter.14 f the General Laws. By l Plumber Title City/Town Type of License: Master E/ Journeyman ❑ APPROVED(OFFICE USE ONLY) License Number ��` j The Commonwealth of Massachusetts F Department of Industrial Accidents office 01101fesflyafl0tls 600 Washington Street, 7`h Floor Boston,Mass. 02111 Workers' Compensation Insurance Affidavit Build* /Plumbm /Electrical Contractors address: city state: zin' phone# work site location(full address): ❑ I am a homeowner performing all work myself. Project Type: ❑New Construction[DRemodel ❑ I am a soleroro netor and have no one worlan in ancapacity. E]Buildin Addition I am an employer providing workers'compensation for may employees working on this b .ayr r - x ap,U: irx.xan' .n. xsSYfx rx } y.�mP �'-M�- OrItD8i1•y4n87nC €�.. - atit # rs vM a�,,t�; .�..�rs�r�.�:��'w;rui�u� 'k'� ..,k, a.r t+..��"z�d..l',�. ";3�•.��:" r-„;, r;.. 4�.;'"-:%Lau.. _� F� � � . ❑ I am a sole proprietor,general contractor,or homeowner(circle one) and have hired the contractors listed below who have the following workers' coin enation olices � FYya...i.'.."�.�°"3* 5 xL"' °�`'' '*§ i V° � 3�"' y „A ' f S Wgl MMI +� s 'W UK, x �,saar"rrrk $� �•s.,§S 5r� `a '��isz.�» Oli �x 'fin +r .t�.�+ "�.r*' ►lisur��d� :,- �r� =�,s;�. .� ,x-�.` � �;"""„" �� ,�� '" � x r �z ,�, ��.� �t a*� GM..��, .... »�..�^s..K, ...:,.xw' v�w�M..cus ��c.w�:.wiv:x� �� 4 tem�u .t u� ,�, rY ��1 GlI7DpaD7lalne... m2 &5txa-xi �e+w 10,1120 M. SUM r' � sr ��" �.�"� '� -w.ws.. a P u y i DlDntr w t a Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 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 hereby certify under th pains and penalties of perjury that the information provided above is true and correct Signature > L t/ Date /- Print name l '� �U 6' r# - Phone# a official use only do not write in this area to be completed by city or town official city or town: ermit/license# P ❑Building Department ❑Licensing Board ❑check if immediate response is required ❑Selectmen's Office contact person: phone#; []Health Department ❑Other ry �t; (revised Sept.2003) -