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HomeMy WebLinkAboutMiscellaneous - 51 LINCOLN STREET 4/30/2018 / 51 LINCOLN STREET 210/056.0-0017-0000.0 ' 1 Date..-r 7�A4 ...... NORT#1 AAO TOWN OF NORTH ANDOVER • - PERMIT FOR GAS INSTALLATION SSAOHU5E1� A This certifies that . . . r!�' . . .65;�5 . . . . . . . . . . . . . . . . / has permission for gas installation . . ./.lP. a in the buildings of . . 4!/ !Vo.44. . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . : . . . . . . . . .. NorthAnd ver, Mass. Fee. z .qP Lic. No.. J/' i !- GAS INSPECTOR Check# ?-Of�tw- X156 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) -. Mass. Date �� �� 1Z Permit # Building Location �I' 1�1�CDU� 5�� Owner's Name 7NOMAS PR,ISCOL L_ UC?L6 AkiQhAK9_, MAL Type of Occupancy lslfjL�� New ❑ Renovation ❑ Replacement ❑ Plans.Submitted: Yes❑ No ❑ N N W N 2 Y Z c N N N U 0: f. x N N rt O U N = �, J i N W O U m E 7f z Cr o W 4 a � o � a } W a r m r o :+j w a c � N N Ch U W = N Z d � O. 0 W W W N W Z a Z !t W X W - W i' = N it W O > u r w J W Z C W }" >-a fig ® Z O Z 4 O try = a w > X W Z. < 6 'S O 0 Z a � � c d J U � Y a CL `r o SUB-BSMT. BASEMENT 7STFLOOR 2ND FLOOR 3RD FLOOR Lam- 4TH FLOOR STH FLOOR Q 6TH FLOOR 1 66 7TH FLOOR ' 8TH FLOOR Installing Company Name COLUMBIA G ,S GF MASSACHUSETTS Check one: Certificate # Address 55 MARSTON STREET X7 Corporation 1862 LAWRENCE, MA 01841 - 231Z ❑ Partnership Business Telephone 9 7 8-691- 640 6 ❑ Firm/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 O If you have checked yes, please Indicate the type coverage by checking the appropriate box. A liability insurance policy ( Other type of Indemnity❑ Bond El OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required b 9 q Y Chapter 142 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 I have submitted(or entered)in abopplication are true and accur,4te to the best of my knowledge and that all plumbing work and installations performed under the permit iss f r this application will n 06mpliance with all Pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene S. (/ Fty/Town T e of License:Plumber Signature of Licensed Plumber or Gasle Gasfitter Master License Number Journeyman APPROVEDO FICE SE ONLY I BELOW FOR OFFICE USE ONLY' FINAL INSPECTION SKETCHES PROGRESS INSPECTION FEE ; APPLICATION FOR PERMIT TO+DO GA.SFITTING NAME & TYPE OF BUILDING LOCATION OF BUILDING i PLUMBER OR GASFITTER LIC. NO. PERMIT GRANTED DATE _19 GAS INSPECTOR :I 7 'r Location � No. c� Date 1 q -3©� Q� NpRT„ TOWN OF NORTH ANDOVER 0:���•o •,tip F � i Certificate of Occupancy $ S ' C SICMUs t� Building/Frame Permit Fee $ l Foundation Permit Fee $ Other Permit Fee $ TOTAL 3 $ OZ D Check # 03 15905 BwldIng Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT 10 APPLICATION TO CONSTRUCT REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING '• ,may$'in`;'i.�,x'�,^'' K;,�.,v`Z``.. c 3 _ t :Tom* -s": m,,;-n. n.K v*- "°`':`�"a '`�., ' +n" ' cg Section for Official Use Onl BUILDING PERMIT NUMBER: DATE ISSUED: '/1- 3 / a? I I fftk Z SIGNATURE: A-A cc Building Cotnniissi2ag/Ins Wor of Buildings Date 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 51 Zt A/ CcLiv 47`- ✓ 6'� ✓ Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: 0 4t�*y t" � Zoning District Proposed Use Lot Area Frontage ft 1.6 BUILDING SETBACKS(ft) F-t STAT N 5 L A'8 Fly N m Front Yard Side Yard Rear Yard Required Provide Required Provided Raluired Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ zone Outside Flood Zone ❑ Municipal On Site Disposal System ❑ 2.1 Owner of Record N Al Pie►SCO t L V � tT1� C,G1,k, Name(Print) Address for Service L/ — 0 O Q RTI Signature Telephone N 2.2 Authorized Agent �t.11y N 1G� h rT tt r�.y2/1js !�2 ?L D Name Print Address for Service: Z Signa Le Telephone z M ,� y 90 3.1 Licensed Construction Supervisor Not Applicable ❑ OGGtiZ,Gc9 ✓ Address License Number Licensed Construction Supervisor: Expiration ate rS i Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ 0 Atl `2 seF b4-,A -r -rC , 7�z2� 2 —10-711 7 Company Name j Registration Number M t;/ he N A l-G Address —o.2 S Expiration Dae ^^Z �t� Telephone Y SECTION 4 R�t11�7�ItS C+I�3MFEN�A'£�©H(,' 6. :�l� � Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yea....... No.......❑ SECTION S,;PRUFSSI©NA L bFIT A C0NSTR>EJCT �NERlRitia > S l3ll #$�t5 tdTES � CONSTRIfiCT#©N COI�II"1CIIfLPItTA Cl4fR if6( i'TAIz �5, ' ?(3► ENEb SI'A ) 5.1 Registered Architect " r Name: Address Signature Telephone I Area of Responsibility , Name: Registration Number � Address: Expiration Date Signature Total Not applicable ❑ Name: Address Registration Number � Signature� Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 44 l+ U C G\ Not Applicable ❑ Company Name: Responstb e m Charge of Construction 4 • S� +� .< <, .�:_��� ,�� (rick all.appi�c,�ble� New Construction Rf Existing Building ❑ Repair(s) 0 Alterations(s) ❑ Addition 0 Accessory Bldg.- ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: 12, X 2'f e A A,4 A, 2)6a/-6 USE GROUP Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ IA ❑ A4 ❑ A-5 ❑ IB ❑ B Business 0 2A ❑ C Educational ❑ 2B ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ IInstitutional ❑ I-1 ❑ I-2 ❑ 1-3 ❑ 3B ❑ M Mercantile p 4 0 R residential N R-1 ❑ R-2- ❑ R-3 ❑ 5A ❑ S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND OR CHANGE IN USE Existing Use Group: #0 u A -V t a G✓ Proposed Use Group: Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34: ON BUILDING AREA EXISTING if applicable) PROPOSED Number of Floors or Stories Include Basement levels Floor Area per Floors 0—X Total Areas r Total Height ft t w,&-LLf Independent Structural Engineering Structural Peer Review Required Yes ❑ No SECTION 10a Owner Authorization- TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT -11-6 M 120 as Owner of the subject property Hereby authorize , . Z . -�`7- to act on My behalf,in all matters relative two work authorized by this building permit application -T/7/© 2- Signature of Owner Date N- 911 M- I, UC t AATas Owner Authorized gent Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury j"2.4 P4/GAAA TT Pnnt Name i Signature of Owner/Agent Date : fir _ N Item Estimated Cost Dollars to be � Completed bv t applicant1. Building (a) Building Permit Fee l 7 0 0, 0 0 Multiplier 2 Electrical (b) Estimated Total Cost of f g o o G Al Construction from(6) / 3 Plumbing AjG A/ Building Permit fee (a) X(b) / c 4 Mechanical(HVAC) IV G Al 5 Fire Protection G A L-' 6 Total (1+2+3+4+5) 4 Check Number t�F.=iT Ski ✓,; 3j SJW? - r Ut-0 � f h:�T-� 1 L.e 9�f i.: �'Jry,� ,{:.a`,4t�." �YZ:�IfM1 �.. �.� �Z�Sa a �.5s'�k.t ilt :.:J t r�. -�;i,A 'r �`', .':�5. I,� BASEMENT OR SLAB �x l S T !11/ G- k SIZE OF FLOOR TIMBERS IST 2No Sao 2 t L „ SPAN 2 Z X DEMENSIONS OF SILLS x C P,7" DEMENSIONS OF POSTS U1LT v P 2X DIMENSIONS OF GIRDERS Z X U HEIGHT OF FOUNDATION THICKNESS ON SIZE OF FOOTING X t--,K /S7` /W G MATERIAL OF CHIIANEY IV 0 AI& IS BUILDING ON SOLID OR FILLED LANDS p L L l9 IS BUILDING CONNECTED TO NATURAL GAS LINE Al .� n. a3y,� Ss a r� _„4-kv,+'`+2�:k.�s��'fi�-�E,'i` -��• y � ,� rr X, I ci kA, aotE ti �e�sc®fi1 9. 19 L c 5�%6/o North Shore Public Purchasing Group ` 4 E.f�ESS Sales Customer Service (617)388-6255 FAX: (617)324-4333 (617)388-6224 �fc- h0 FORM U — LOT RELEASE FORM a INSTRUCTIONS: This form is used to verify that all necessary approvals/permits 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. *****************************APPLICA/NT FILLS OUT THIS SECTION*********************** APPLICANT /&411 Co r l PHONE ��� 6 g� ��a 0 LOCATION: Assessor's Map Number PARCEL_ d SUBDIVISION LOT(S) STREET L I c v I ST. NUMBER--5- USE UMBER -5-USE ONLY*********************************** REC MENDATIONS OF TOWN AGENTS: CONSERVATION ADMINIST ATOR DATE APPROVED 6 DATE REJECTED F COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9\97 jm t i - I I I , I � .K t-- t KQ A,C- �GQI�Q' AC • - - - �x�" SG XPi/' . r I IV 7'Y , I it I 1 ! I � � 1 I 1 { t , ! � r ► t 3 1 , G 1 1 I I � 1 I 1 1_ COY i z ►f � 1 — } I f 1 � ne6 r I , 2 r I I s t I 1 I I h_ •XAe/l2/GIF Il�ATT I QZk— —JO-Tif +74P 0 23 X43- 41� ��o� t I -- North II o h Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54 a condition on of BuildingPermit ermi t 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 ol 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 ACORDMCERTIFICATE OF LIA<311ILITY INSURANCE DATE(MM/ 07/03/20022002 PRODUCER '(978)887-4900 FAX (978)887-2404'*$ THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Edward F. Sennott Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 16 South Main Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. 0. Box 457 Topsfield, MA 01983 INSURERS AFFORDING COVERAGE INSURED Maurice Hatt INSURERA: Hartford Insurance Group 4 Harris Road INSURER B: Boxford, MA 01921 INSURER C: INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR POLICY EFFECTIVE POLICY EXPIRATION LTR TYPE OF INSURANCE POLICY NUMBER DATE MM/DDIYY DATE MM/DD/YY LIMITS GENERAL LIABILITY 08 SBA DH3605 09/15/2001 09/15/2002 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY FIRE DAMAGE(Any one fire) $ 300,000 CLAIMS MADE M OCCUR MED EXP(Any one person) $ 10,000 A PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GE N'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY JECTPRO- LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO EA ACC $ OTHER THAN AUTO ONLY: AGG $ EXCESS LIABILITY EACH OCCURRENCE $ OCCUR D CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND TATU TORY LIMITS ETH- R EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ ERT WILL BE MAILED DIRECTLY FROM CO. E.L.DISEASE-EA EMPLOYEE $ OTHER E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER ADDITIONAL INSURED;INSURER LETTER: CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Town of North Andover BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY Town Hall OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Peter Sennott/LA ACORD 25-5(7197) ©ACORD CORPORATION 1988 I I I I it 1 ,, �arra�n_a7tul�� of..l�rr,xsr��jrtdell3 BOARD OF BUILDING REGULATIONS** License: CONSTRUCTION SUPERVISOR } Number: CS 023993 Birthdate: 11/28/1929 Expires: 11/28/2003 Tr.no: 7857 \ Restricted: 00 MAURICEG HATT ,�,� 4 HARRIS RD c BOXFORD, MA 01921 Administrator NORTH %_E D Town of Andover No./Y - - �-oC L AA1_1 dover, Mass., •30 �� %9 ORATED SS H BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR "D.ffl�'5co / THIS CERTIFIES THAT...... o /..... .............. ...............1............................................................................. Foundation a *Y has permission to erect.......a......ay.......... buildings on ... �..,... /.. ..C.O...I/✓ ............. Rough to be occupied as... .............................. .....�........ N sF" N/y� 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. est//#? �(a^5.• , 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 11!:! 0000...... `... ......:.......................................................... Service 41000 BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. ( I 1. The Commonwealth of Massachusetts 1 Department of Industrial Accidents r Office of Investigations Boston, Mass. 02111 ers'ComPensaton Insurance a nc e Affidavit vitWork Please print Name: r I Location: C Phone am a homeowner performing all work myself. 01 am a.sole proprietor and have no one working in any capacity 1 am an employer providing workers'compensation for rrty employees working on this job. Company name- L -� Address y 9 n KJ S j j Phone k US-.71 ed-7 I s. ctie Via►. l-/fes -=G-9 P�tC O S/� I t 3 6d 6� Address ,A=- lnsur pAik '®to secure rouerage as required under Section 26A or l 152-cmt !hrttte and/or one Years imprisoiuner►t as weft as civil penalties in the.torm of a STOP WOF C Dente's,of ai fine up to$1:500.Oo understand that a copy of this statement may be.forwarded to the Office of and a fare of($itb pp)a day against me. t Of the.CIA for coverage ioa: t do herby certify under the pains and penabes of padzmy that the i*rr»ahan provided above:is true ani!cofrect Signature Date z Print name n- -, Phone# Official use only do not write in this area to be completed by city or town official- 0 if immediate response is ngaued ❑❑ Building Dept- building Dept Licensing Board Cantact person: El Selectman's 0 fficL Phone# ❑ hlealth Department ❑ Other I'VOR"(MAN's CO MPENSArioy I I I —ocation No. O Date lIORT►/ TOWN OF NORTH ANDOVER '. Certificate of Occupancy $ Building/Frame Permit Fee $ s,CHU Foundation Permit Fee $ _ + Other Permit Fee RA22 $ 5` TOTAL $ Check # 40 15 U 7 7 / Building Inspector f TOWN F RT ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH ASO}NE OR TWO FAMILY DWELLING _ �':tfe: �.2 .� €�.�� ;ts.et '�.s•k���'F'.;?.��i'k �.�,. ..�_,�� �� ��t�. ��� a.���tr ��� �3�-�"���'��������"���y� �'��.�' BUILDING PERMIT NUMBER. "" `"` DATE ISSUED: SIGNATURE: C Building Commission for of Buildings Date SECTION 1-SITE INFORMATION 1.1 —Property Address: 1.2 Assessors Map and Parcel Number: L /Ale GL Al 57 - Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zonin District Pr osed Use Lot Area. Fronta a f1 BUILDING SETBACKS.ft Front Yard Side Yard Rear Yard Required Provide R •red Provided R red Provided Q U 1 5— 1.7 Water Supply M.G LC., 54) 1.5. Flood Zone Information 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site DisposalSystem ❑ SECTION 2-PROPERTY OWNERSIIIP/AUTI•IORIZED AGENT 2.1 Owner of Record �O ) COL L Name(Print) Address for Service: f Si lu�of Q7�- • T lep C.� 2.2 Owcord: Name Print Address for Service: Signature Tele hone M SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ M-duly/ GFX 7 7" Licensed Constructiot?Supervisor: S U Z 3 L g License Number Address Signature 2 S-8-7- 5-V 2-r Expiration Date Telephone a® C 3.2 Registered Home Improvemenf Contractor Not Applicable ❑ ornpany Name' 10 7. 117 Registration Number ram tddress mature L ��7 ro Expiration Date -. Telephone r SECTION 4-WORKERS COMPENSATION(NLG.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.......0 No.......0 SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) Al Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition (X Other ❑ Specify Brief Description of Proposed Work: U SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be g } r _ Completed by parnit applicant ,aa 1. Building (a) Building Permit Fee t a Multiplier 2 Electrical /� �j -(b) Estimated Total Cost of �-- `�` t/ r Construction / 3 Plumbing Building Permit fee(a)x(b) 4 Mechanical ACS' 5 Fire Protection 6 Total 1+2+3+4+5 Z XPi O Check Nuiribei SECTION 7a OWNER, THORIZA ON 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 mattes relative to work Wifiborized by this building permit application. Signature of Owner .Date SE,CTITION 7b OWNER/AUTHORIZED AGENT DECLARATION ,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 z BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2 2 5C. 3 Pz— SPAN DIMENSIONS OF SILLS 2 X 6 p T DIMENSIONS OF POSTS 2X Lf DIMENSIONS OF GIRDERS _;_--- HEIGHT OF FOUNDATION i_X d.. THICKNESS L u S /7cJ G SIZE OF FOOTING t-X I P f t X MATERIAL OF CHUNEY �-- IS BUILDING ON SOLID OR FILLED LAND ' IS BUII,DING CONNECTED TO NATURAL GAS LINE ,---- I E ✓�rx �� _ ' �tji 7 0 BOARD OF BUILDING REGULA- i ONS LI _4R censo: CONSTRUCTION SUPERVISOR, I _ SUR Number. CS 023:93 Birthdate: 11128/1929 Expires. : 11/28/2001 Tr.no:• 10505 Restricted To: 00 MAURICE G HATT 7 HARRIS Rb - C�•..��!���°� BOXFORD, MA 01921I . Administra#or i ` NOME IMPROVEMENT CONTRACTOR t = 1 _ Re istr . 4 ation 107117 Expiration: 0712912002 g Type. Individual MAURICE G. MATT Maurice Matt � ' I � "arris Road ADMINISTRATOR Boxford MA 61921 i I I � I . I I I . North Andover Building Department II Tel: 978-688-9545 i I I I DEBRIS DISPOSAL FORM li In accordance i t e 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 pro erly licensed solid waste disposal facility as defined by MGL c11, S150A. The debris will be disposed of in: (Location of Facility) Signature of Permit Applicant V-41­1�21"' Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector I N�ORTII T 0" .0 �Jr - Ove r No. 00 / C' 0 LA 0 dover, Mass., C) /2 COCHICHEWIC ORATE,o 0 0 BOARD OF HEALTH Food/Kitchen rER. MIT T E Septic System BUILDING INSPECTOR THISCERTIFIES THAT.... TPY�............T..kt.sCOY................................................................ ......................... Foundation has permission to ~..... ...... buildings on ...:��./......... ................ ... Rough Chimney to be occupied as... C12...... I. ........Gay-.-,a X_ R o 4L......... .......................... .. .... . ..... .... provided that the person accepting this permit shall in every respil c-n-f-o-r-m.....to....the e.terms r-.m_s...o.f.the e application- - -o-n-file-in Final this office, and to the provisions of the Codes and By-Law) relating to the Irippection, Alteration andConstruction of Buildings in the Town of North Andover. 0"� 01 6—t 000— 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 A.......U..... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough 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. a { ; I The Commonwealth of Massachusetts Department of Industrial Accidents _ Office of Investigations _ Boston, Mass. 02111 Workers'Compensation Insurance Affidavit A Please Print Name: 1� . j2, C'car.t 2' M A/x`21 C 7-7 Location: City A/ A A,22061 L Pf Phone am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity 0 aI am an employer providing workers'compensation for my employees working on this job. Company name: R -A . C6 G& /-)A-r Address 4 N 14 9'?/s l2 0 City: Ag'a r-0,0 V Phone#: q 7,r- Insurance Co. H IJ 147'f-c,9V Policy# Company name: 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 the pains and penalties of perjury that the information provided above is true and correct` Signature //'sem C�cv,.�,� � Date I o 6/ i Print name Al A Lm .4-;z P9 ;- Phone# S(=7- X'6) 2 5— Official use only do not write in this area to be completed by city or town official' Building Dept E]Check if immediate response is required Building Dept p Licensing Board Selectman's Office Contact person: Phone A Health Department Other FORM WORKMAN'S COMPENSATION i ' ''E L. T_ _ P 'LAN k o 51 .Lncoln Sttee" North AndoVer., ::Mass Scab e 1" 3d'' Date;; November 16, 1977 a p �I � '.- '- _ , .•�/�'l'..7 ��I/t!y` .!','�`1 -i y I (�€€'' .Y � 3 S �St .y. � i'.i -.-_ t i F r•i 76 4' ��+�+ '.�'f''c i�c- - 1 `T ,:'C � 1� "t � 1. � ,� � t III � � tea .. �, �r0� �is+�.t� F� 4 ,a � � �� � � ti, } •t tn?`-"a rr �, �T �a���• ,. '�p t .�a xy*7 (x ♦ � t t. .r t ..c � ;{�' 1 4 n' F F � 4 ti t �R +n .t i�,�T t 4 ... 4 i 1 4: r, w�j "'.+ J .� x'� ; �, > .aE Lt+�:: to i.y�, ,xc �vh '� � p; t^^ ,�• t a i,~ � 1 a v'.i d � k .r.,o., * � v '' �, _ �'Y -. �r�Y��,F L ,s ,t�, atw is}�, ,yj� k;`;�'n'G� -• a�s� e•s. � •*+',� " 1'a a,4"3 '"` ,.c iy Tw'y'a• t t`i r.•y; `Y. ' 1 9 r 'L}°,ya �� tfi� p F- r y4 i� .. :,� q � ��,. �����..i��t �,x - �•i I �.. "�3 P �.ri �r by�v�c > F' '� ��a��'�-�•{ t }br ��.''rS' �`-;�,��h¢ £^9 - �� f a � �-� x i, i ,fir of .sem i'F 'arid• .�a'i t „f,�>t� ^E � � k 1 ':! +.;�,..,,,,,,. r:,.r 1 I F ,,*.' �� }, s•* y� a f - a 4 '....!�t .N r �°'.�i3„h fix, -k,F°''yP•. 1 _, o Y aw, y-.,:..i t '� r ,„',: '�h�� �'t ^+ '- r •v +v< .,., i;w '3 t s °w'r_ri ay.- -�. � t '+ >, 1F,:,i1�y t' r 4t �' •4;,e E F N. # . `/ C,•. - . '�__a a k' .. h ,'L"'`" 'o ,a' 'd.�3i}a' :3 G� a,r4Y '.S'.E'N'•�:t'"' a 4?' «`n T v i, mar _. •,xT. ♦ a c "Here ' ' . r.. . ; }.�certifyth �the builditrg'on�r; - fpfoperty. fitly izs located as' shown` on plan:'.- sand Compl ied with the uBu� l ding and Zoning.F i , Y.; iaws';of' th'e Town t�f ?North�tlrtdover taken�cons�trizcted. } �T, CHARLES E. Iffy " a CIVIL 'ENGMtP }' : AWRE�tCF"" MASS - s <rtw s-. e P, a:,t'# - z... Win. e- T" l bo nat Ltse:, c3ffsets fob establ�sh1 9 " lot �'xneS dor the ereCtioh of fence$ key i r�7 C/ a11As;',� hedges, t Date. . . Of HQRoT1y ,� 1 o? TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION �9SSACMUSEt h This certifies that - �--. . - has permission for gas installation . . . . . . . . . . . . . . . in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . ,at , , . . . , North Andover, Mass. 'Fee .f!. . . Lic. No..,�2� . . . . . . . . . . . . . . . . G - GAS INSPECTOR Check# 36 . 4 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING k`S� (Print or Type) //-/j Building l _ /. Mass. Date %" Permit # c�(00 Building Location � O�L %d6"I' 1l C f Owners Nam _ i 4, T-- vel Type of Occupanry i New p Renovation ❑ Replacement 2' Plans Submitted: Yesp NoC] ' N NW y 1� N W V W J. W O V m r = q) O W r < Z 0000 Z O }' ¢ C H ¢ N d V yr = N Z < ¢ O D W W Z W r- r s a }. Z J r Z �. W W Q O > u. 1W- V J 4 W Z < W < C F' W m Z O Z W O iA S < W > C W 2, < ¢ _< o a co J V C > p o. O SUB—BSMT. BASEMENT ISTFLOOR ' 2ND FLOOR 3RD FLOOR _ 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company Name f e--Aeiz T Q . �-1m MA Tri H2O Check one: Certificate ` Address_ C'n,�[N•�r�ry L ( ❑ Corporation M ' 7'N :e fJ OI a • D ❑ Partnership Business Telephone 92 — 7 (7-7 1 2-'Firm/Co. Name of Licensed Plumber or Gas Fitter "RO A E P T A A M r}1 t9 Tr�J r INSURANCE COVERAGE: I have a current I' billty insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked Yes, please indicate the type coverage by checking the appropriate box A liability insurance polity 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 C3 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 Mowledge and that all plumbing work and installations performed under thei for this application be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 f aP one Laws. ttTj of License: C Plumber n ure of cen u or titer Title _ tter er License Number !Ua3 ) City/Town Journeyman BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES PROGRESS INSPECTION FEE NO. APPLICATION FOR PERMIT TO DO GASFITTING I NAME A TYPE OF BUILDING LOCATION OF BUILDING PLUMBER OR GASFITTER LIC. NO. I PERMIT GRANTED 1 DATE 19 OAS INSPECTOR