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HomeMy WebLinkAboutMiscellaneous - 545 JOHNSON STREET 4/30/2018 545 JOHNSON STREET / 210/098.A-0013-0000.0 I I I I I 9-661/ Date......1--�/2-7-ZZ2 Q ' f Np oTM 1 3:°•��``- "°per TOWN OF NORTH ANDOVER � 9 PERMIT FOR WIRING This certifies that has permission to perform J C� C s t ................. wiring in the building of........... �,.L�1j!5 ............................................. at...........,Sys ;T !!wS� Sr- ,North Andover,Mass. ..... ............... ................................. Fee..��-" Lic.Nof ........... Ij / LECTRICAL INSPECTOR / Check # ( Z1_ � Permit No. Department of Fire Services Occupancy and Fee Checked d BOARD OF FIRE PREVENTION REGULATIONS [Rev- 1/071 (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Codee(MEC),527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: " //, 4// o City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) �y �� Owner or Tenant j-���n ��tnSb Telephone No. 57�_G Sri doH� Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building �2,5' (,� Utility Authorization No. Existing Service Amps Volts Overhead ❑ Undgrd ❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: W :1 '"' FO-f �n$: p}-,'( s��4.6 ai t Completion of the following table maybe waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Sus addle Fans Tr s Total . P•(Paddle) _ Transformers KVA • No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above No.of Emergency Lighting No.of Luminaires Swimming Pool rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection andInitiating Devices Tot No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained P Totals: '" Detection/Alertin Devices Municipal No.of Dishwashers Space/Area Heating KW Local❑ Connection El Other No.of Dryers Heating Appliances KW Security Systems y No.of Devices or Equivalent No.of WaterKW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP �y Te1No o. o Devices or Equivns alent OTHER: -Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. 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 such co rage is in'force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify,under thepains andpenalties ofperjury,that the information on this application is true and complete. FIRM NAME: LIC.NO.: Licensee: q Nr f!,J_ �,I-�-,-k Siature LIC.NO.: t`✓�'�I (If applicable�-enter `exempt"in th Z'cense naimber line.) Bus.Tel.No.:(t7 -a 33—116 Address: `1 k,10� _Cu (6- O �� Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's Owner/Agent I PERMIT FEE. $ Signature Telephone No. u i 4 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 4 s�• www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lelzibly Name(Business/Organization/Individual): 1141d 9, P_I-MA 1 b Address: cj '}ZI /(,SCJ City/State/Zip: Cj f OV V-, i 6,,1.11 Phone#: G Are you an employer?Check the appropriate box: Type of project(required): L❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.d 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.E] I am a homeowner doing all work right of exemption per MGL 11.[:1 Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.] employees. [No workers' 131-1 Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. r�� 1 r Insurance Company Name: U2� �t I 1 lv f Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: u off. City/State/Zip^6 • NAyV'� Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certif under the pains and penalties of perjury that the information provided /above is true and correct. Si ature: l Date: ( � l 0 Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: PER111T NO. _ / APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1 MAP KBO.}�0 , i I LOT NO. -@u13 U C)0 2 RECORD OF OWNERSHIP iDAT�IBOOK PAGE - ZONE SUB DIV. LOT NO. LOCATION 7� tel".\ (N CQAl PURPOSE OF BUILDING 6N� �p n (j A OWNER'S NAME _7J t/ ! d' ///` NO. OF STORIES O J ` �` Q gtt OWNER'S ADDRESS t'� !1L�— L BASEMENT OR SLAB S&A 'T� („ARCHITECT'S NAME J /7 SIZE OF FLOOR TIMBERS IST L7 2ND 3RD C_BJI&ILDER'S NAME �w ��J� _ SPAN DISTANCE TO NEAREST BUILDING ����� DIMENSIONS OF SILLS ---- DISTANCE FROM STREET 2 T 1 "' .. POSTS STANCE FROM LOT LINES—JSIDES 'C.1/�• REAR 2 ,- GIRDERS `REA OF LOT Y T r 3 • 6 FRONTAGE( HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW to r SIZE OF FOOTING X LjS BUILDING ADDITION Q� MATERIAL OF CHIMNEY IS BUILDING ALTERATION �i IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES EST. BLDG. COST COST PER ER 6Q. FT. Gl PAGE 1 FILL OUT SECTIONS 1 - 3 E6T. PAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED vLi ILDIN2 INSFUCTOR SIGNATURE OF OWNSKORlWTHORIZED AGENT F E E OWNERTEL.# �e-6 JE3 -Oak PERMIT GRANTED CONTR.TEL.# 19 CONTR.LIC.# H.I.C.# BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY STORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY oFFlceS _ LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- APARTMENTSLTI. FAM RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE 3 I 2 13 CONCRETE BL'K. PINE BRICK OR STONE HARDW D PIERS PLASTER _ DRY VJALL UNFIN. 3 BASEMENT AREA FULL I FIN. B'M'T' AREA _ '/. 1/I l/. FIN. ATTIC AREA _ N_O B-M'T FIRE PLACES _ HEAD ROOM MODERN KITCHENv' 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE WOOD SHINGLES EARTH _ ASPHALT SIDING HARDVJ'D _ ASBESTOS SIDING COMIACN _ VERT. SIDING ASPH.TILE --{I STUCCO ON MASONRY J_ STUCCO ON FRAME BRICK ON MASONRY ATTIC STIRS. & FLOOR _ BRICK ON FRAME CONC. OR CINDER ELK. STONE ON MASONRY WIRING STONE ON FRAME SUPERIOR I� POOR _ ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE I HIP BATH (3 FIX.) _ GAMBREL MANSARD TOILET RM. 12 FIX.) _ FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. &COLS. STEAM STEEL BMS. & COLS. _ HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ ELECTRIC 1st 13rd NO HEATING FORM U - VERIFICATION FORM " 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 local or state law, regulations or requirements. **************** pplicant fills out this section***************** r- APPLICANT: kjl,� VJ Phone —6 EJ LOCATION: Assessor' s Map Number Parcel Subdivision // Lot(s) Street _�/// t�S ��� ' C St. Number 3 ********************** fficial Use Only************************ RECOMMENDATIO OF AGENTS: 2 / Date Approved - yh Conservation Administrator �A �c Date Rejected CJ5M ents Date Approved Town Planner Date Rejected Comments Date Approved Food Inspg'9tor-Health Date Rejected Date Approved epc spector`Health Date Rejected Comments Public Works - sewer/water connections - driveway permit Fire Department Received by Building Inspector Date 5 TOWN of NORTH ANDOVER AFFIDAVIT F� cal=trr Lair aRAEnmt to pe=Lt Affiicaticn. M;L c- 142 A re-. j= t1mt the ' rar"@tirr., Lir, mit, .zeal, dmnU icn, or camtz*-ztim of as a l itirn to any ?E- e Lstir '.a00: n d bm2d cont=irg at lit one but not =re a far dwell IM—..ar to sten Oddi are adjaofft to arh res1� or $„be da-p-bCE Il , alag wL#i other x • ff�� n Est. Coa�`v � Type of Work: /`l�// �7 Address of Work s• �`'l At 5 j 1-7 Owner Name XW'A ZY/ Date of Permit Application: I"hereby certify that: Registration is not required for the following reason(s): FDr office USB only Words excluded by - Job under Dam not owner-occ�1pied puJ 1,ng own permit Other (specify) Notice is hereby given that: GW E R.S -PULLING THEIR OWN PER= 'OR DFALING W= UMEGIS MU D CON RA MRS -FOR APPLICABLE SOMME IMFROVF2� WRK DO NOT HAVE ACCESS TO THE ARBITRA. TION PROGRAM OR GUARANTY FUND uNI)r`R MOI. c. 142A- Si_vnd urr�---- pEalties of pe-rjury: I hereby apply for a permit as the agent of the .owner: Date Contractor Name Registration No. OR: Notwithstanding the above notice, I hereby.-apply for a permit as the -owner of the above property ' V127 to Ower Name Date. 7 NORTry o� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION h bySSAGMUSESS This certifies that . . . . . . . . . Z. ►�.... has permission for gas installation :, .•�:'�- - x'- — - . . . v . in the buildings of� �?���'��.�!. .' . . . . . . . . . . . . . . . . . . . . . . at ^^. . ;+� � . . ., North Andover, Mass. ree... . . .. . . .tic. No.. . . . . . . E.. . . . ��-'. . . . . . . . . GAS INSPE TOR Check# t 7V MASSA(.HUSE 1 IS UNIFORM APPLICAT ON FOR PERMIT TO DO GASFITTI (,Print or Type) /►/G,T C2 lass. Date ermit 9 �`� _ Building Location g Owner's Name Type of Occupancy P.4/ F'2AT New ❑ RenovationR placement 'I/ Plans Submitted: Yes ❑ No ❑ FIXTURES N W In Y Z ce in (,n V ).,. rn n Y N CL Q H W Vto W O v m Z 2 t„ • m LU Q cQe z O a O Z tz U W W = Z O N O W W W N Z Q to W Q W ~' Q 2 U Cd H W J H Z � � W Q Z Q }W" W J N W Z Q m Z Q Q ]C �- n Q F- z 2 O U p ca OV oc > IW- O SUB-BSMT. BASEMENT 1st FLOOR 2nd FLOOR 3rd FLOOR 4th FLOOR 5th FLOOR 6th FLOOR 7th FLOOR 8th FLOOR CLIMATE DESIGN HEATING and AIR CONDITIONING,LLC Installing 5 South Summer Street _ Check one: Certificate Address Bradford,MA 01835 Corporation 978-372-9999(phone) 978-372-0882(fax) — = Partnership Business Telephone Lic. plumber. ►- aa- Al = Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes -✓ No C If you have checked yes, please indicate,the type coverage by checking the appropriate box. A liability insurance policy til Other type of indemnity C Bond C 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 walves this requirement. Check one: p Signature of Owner or Owner's .'`gent Owner Agent C I hereby cenify that all of the details and information I have submitted for entered)in the above application are true and accurate to the best ra my knowledge and that all plumbing work and installations penormed under the permit issued for this application will be in compliance with all peninent provisions of the anassachusens State Gas Code and Chapter 142 of the General Laws. FTkle Type of License- Plumber =Plumber =Gasfiner -s�aster nature of licensed PI ber or Gas Fi�.e' own Inurneyman Q� /� License Number W 1 APPROVED tOFFICE USE ONLY) FINAL INSPECTIONS SKETCHES BELOW FOR OFFICE .USE ONLY PROGRESS INSPECTIONS FEE _ NO. APPLICATION FOR PERMIT TO DO GASFITTING NAME & TYPE OF BUILDING LOCATION OF BUILDING __._.._.._...... __ ___.—._.....___—_.._. PLUMBER OR GASFITTER _.. ...._..-------_—.--- LIC. NO. PERMIT GRANTED Dale — —-- ---- 19 — -- Gas Merc. ---.-- -----_--_— — Final Insp. ---------- ------------- Gas Inspector t Office Use Only Zip T=11mumfult of Massat4oft Permit No. 11CIRi Relit of Public Sdfctq Occupancy A Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 521 CMR 12:00 3M heave blank) _71 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`75,Aa a2o 91 '. 0* or Town of__NORTH ANDOVER To the Ins actor of Wires: the udorsigned applies for a permit to perform the electrical work described below. + Location (Street JIi Number) Owner or Tenant Pe u s o `i Owner's Address tys Jc�nnsQA Is this permit In conjunction with akbuilding permit: Yes ❑ No Ld (Check Appropriate Box) Purpos",f Building Coarsj w:r, Utility Authorization No. Exiting Service _Amps _/ Volts Overhead ❑ Undgrnd ❑ No. of Meters New Service Amps _/ Volts Overhead ❑ Undgrnd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work ". No. of Lighting Outlets No. of Hot'rubs No. of 11,ansformers �tNA s � No. of Lighting Fixturse Swimming Pool Above In grnd. ❑ gm- d. ❑ Generators KVA 0 No. of Emergency Lighting No. of RecepMole Outlets , No. of Oil Burners Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones �1 ' No. of Ranges i' No. of Air Cond. Total No.of Detection and ' tons Initiating Devices No. of bis Heat Total Total AX posale .No.of Pumps Tons KW No. of Sounding Devices .t 3: No. of Self Contained _^ No. of Dishwashers Space/Area Heating KW Detectfon/Sounding Oeviced No. of Dryers Heating Devices KW Local Municipal ❑Other 00 g ❑ Connection .}tjj No. of No. of Low Voltage 6N . No. of Water HeatersKW Signa Ballasts Wiring I. No. Hydto Massage Tubs No. of Motors Total HP W t OTHER: .; O I INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws b i"yyI hale a current Liability Insurance Policy Including Completed Operations Coverage or Its substantial equivalent. YES C NO C I Q0 4` have submitted valid proof of some to the Office. YES _ NO = If you have checked YES. please indicate the type of coverage by ai checking the app date box. r INSURANCE BOND Q OTH(:Rf❑ lease Specify) x' (Expiration Date) Estimated Value of EI r:trleal Work s C Work to Start _ Inspection Oats Requested: Rough Final Signed under the Penalties of pejury: .FIRM NAM LIC. NO.__ ' �Licenaw �\ _C_. taus 8� Signature LIC. NO. E� 7 ` 38_W ebbe Bus. Tel. No.(120 �—2"3 f91 Address S�-rte 1/vta���t0 MA O /yg Alt. Tel. No. vt OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as re-quired by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Plea"check one) \ 1 Telephone No. PERMIT FEES 3 J (Signature of Owner or Agent) r 'r,;:3':' x•5565 Date....7 TOWN OF NORTH ANDOVER 0 I PERMIT FOR WIRING 4, 11SACHUS This certifies that ....Ps"m.1........(........... (..".c4... ................................. has permission to perform ........ .. "fe........................... wiring in the building of....... .... ...... .. ................................. at...... ........... ....... ............. . orthAndoye tfss. Lic.No r��VIV....... ...... ......... ......�.Iry...... E C*TRICAINSPECTOR ;5� / 12:22 25.00 PAID WHITE: Applicant CANARY: Building Dept. PINK Treasurer Location 1�5 j, It ti 1_,Uti S No. t/ Date bo MaRTM TOWN OF NORTH ANDOVER + s • � ; . Certificate of Occupancy $ �'�s''•°''tom Building/Frame Permit Fee $ sACHUSE Foundation Permit Fee $ Other Permit Fee $ TOTAL $ s ' Check # �' U J Building Inspector i TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING n BUILDING PERMIT NUMBER. DATE ISSUED: SIGNATURE: >� � C�� � Building Commissioner/12vector of Buildings Date Z SECTION 1-SITE INFORMATION 0 ro1.1 Property Address: \ 1.2 Assessors Map and Parcel Number: Map Number Parcel umber 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 1.7 Water Supply M.G.L.C.40.1-54) 1.5. Flood Zane Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSIIIP/AUTHORIZED AGENT M 2.1 Owner of Record f CA � U5 1tSQ ►� Name(Print) Address for Service: Signature Telephone t 2.2 Owner of Record: O Name Print Address for Service: O Z M Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: License Number 11 Address i Expiration Date ic Signature I Telephone r 3.2 Registered Home Improvement Contractor ( Not Applicable ❑ v Company Name Registration Number r Address 7 ��a tuExpiration Date ^� nare Telephone v SECTION 4-WORKERS COMPENSATION(N.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 Descri tion of Proposed Work(check alE a h'cable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be ©F`F)fCIAL USE ONLY Completed 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 (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 CONTRAC.TO�R APPLIES FOR BUILDING PERMIT I, -i—�s-- f �.�-t- 'c 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 VJ'& Print Name 71616 Si of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB R SIZE OF FLOOR TIMBERS 1ST2ND 3 t SPAN DIMENSIONS OF SELLS DIMENSIONS OF POSTS DIMENSIONS 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 'i HOME.•IMPROVEMENT CONTRACTOR Registration 103317 Type - DBA Expiration 07/07/00 CASTRICONE ROOFING & SIDING C Mario T. Castricone �o eqlavCOurt'St. ADMINISTRATOR N. Andover MA 01845 - r i Town of North Andover 4 t►aR=H OtSjfLEO 61 �rO Building Department O 27 Charles Street North Andover, Massachusetts 01845 (978) 688-9545 Fax (978) 688-9542 9SSAGl1tl5� DEBRIS DISPOSAL FORM In accordance with the . ov'si ns of MGL c 40 s 54, and a condition of Building permit # the debris resulting from the work shall be disposed of in a properly licensed sold waste disposal facility as defined by MGL c11, s150a. The debris will be disposed of in/at: R Q- �kacility location Signature of Applicant Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. The Commonwealth of Massach usetts Department of Industrial Accidents ' — mce o1/nyesUgatlnns - 600 Wasliins ton Street Boston,Mass 02111 Workers' Compensation Insurance Affidavit S evl name: A v1 l 1 b location- O`() city a1• 1-} f !C -hone# ❑ 1 am a homeowner performing all work myself. ❑ f am a sole proprietor and have no one working in any capacity ...�s�w�a� wnasls�► ❑ I am an employer providing workers' compensation for my employees working on this job. address Sim ❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers'compensation polices: comosnv name ? ;•':x�:%•<J:4.;./,,,..;i ::;k;::':•C;`'• City. hoall,L ? insurance � x't Y ..;; � .. i-. '.:. �C sY.,<f�y;��c��ji 'F' f. L} �y' <�•na<t /•+-/ '` � 3 ' o;�. address: " city 1 ': phont a insurancd co� {LO.Il�P Failure to secure coverage as required under Section 15A of MGL 151 can lead to the Imposition of criminal penalties of a fine up to 51,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of noo.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 the pains and pen lies of perjury that lite information provided above is true and co ect. Signature ate v 1 Print name � �1�' i'�1 �� '�4 trZ) �'!E Phone# Cocheck e only do not write in this area to be completed by city or town official n: ermit/license# P nBuild(ng Department C]Licensing Board immediate response is required �Seleetmen's OtTice�Ilealth Departmentrson: phone#; nOther v (revised 5/95 FIA) GENERAL BUILDING NOTES/CHECKLIST- NOT LIMITED TO ITEMS BELOW POST ALL LOT NUMBERS,ADDRESS, AND PERMIT(COPY OK)..or no inspections I. 59 4 �/• t n nn 9V n r l `J 51410 Mew 'J.anopud -ON -is uno) NIM V 9NI1001 3N0�111SV� 03 9 •doid `auo)ialS ) ouew FINISH: Handrails returned to wall/newall post. Guardrails required alongside open cellar stairs. Exterior grading complete. Certificate or occupancy required prior to occupying structure. Temporary Stairs required for inspection. Re-inspection fee-$25.00(Be Ready). Certificate of occupancy required prior to occupying structure. L WORTH own of over No. 4q D Z_- LA E o dover, Mass., /J COC MICHEWICK 7d AORATED V?a��5 S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THISCERTIFIES THAT........ Found�........rA!V. ....... ../V s..O........................ ............................................ 1 g .... � Roughanon has permission to erect..... ... T � � ., buildings on.. tobe occupied as.... X06A.............................................................................................................. 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. I3 PLUMBING INSPECTOR 9 �•• VIOLATION of the Zoning or Building Regulations Voids his Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final ELECTRICAL INSPECTOR UNLESS CONSTRUCTI NS Rough ........ 4ST .... ......................... .. _Service .. .. . . ...... ............................. BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. Phone: 978-342-2660 Fax: 978-342-2699 JAMES A. TRUDEAU Adjustment Service Inc. P. O.Box 942 Fitchburg,MA 01420 claimsCaArudea uad i.com Notice of Casualty Loss of Building Under Massachusetts General Laws, Chapter 139, Section 3B June 11,2010 Building Inspector 120 Main Street North Andover,MA 01845 / Board of Health 120 Main Street E EIV North Andover, MA 01845 JU �atia Fire Department Dept. of Records TOWN OF NORTH ANDOVER 124 Main Street HEALTH DEPARTMENT North Andover, MA 01845 Insured: rank&Virginia Pe o Loss Location: 545 Johnson St ee orth Andover,MA 01845 Insurance Com ual Insurance Co. Policy No.: PHOO100638974 Date of Loss: March 14, 2010 File Number: 10-08971 Claim Number: 10010852 Type of Loss: Water Damage Claim has been made involving loss, damage, or destruction of the above captioned property, which may either exceed $1,000.00 or cause "Mass. Gen. Laws, Chapter 143, Section 6"to be applicable. If any notice under"Mass. Gen. Laws, Chapter 139, Section 3B" is appropriate, please direct it to the writer and include a reference to the captioned insured, location,policy number, date of loss, and file or claim number. On this date, I cause copies of this notice to be sent to the person(s) named above at the address indicated by first class mail. Sincerely, James A. Trudeau General Adjuster