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Miscellaneous - 565 CHICKERING ROAD 4/30/2018 (2)
565 CHICKERING ROAD J 210/084._a002g_0001.B J/ I i i f' li ,I Phone. 978-632-2660 Fax: 978-632-2662 JAMES A. TRUDEAU Adjustment Service Inc. P.O.Box 7 Gardner,MA 01440 �i„uus,�i ���rdeauadi.com Notice of Casualty Loss of Building Under Massachusetts General Laws, Chapter 139, Section 3B January 9,2018 wilding Inspector 120 Main Street North Andover,MA 01845 Board of Health 120 Main Street North Andover,MA 01845 Fire Department Dept. of Records 124 Main Street North Andover,MA 01845 Insured: Rose&Dove Gourmet LLC Loss Location: 565 Chickering Road,North Andover,MA 01845 Insurance Company: Preferred Mutual Insurance Co. Policy No.: BOP 0100701704 Date of Loss: January 7,2018 File Number: 18-16080 Claim Number: 18100704 Type of Loss: Freeze-Up 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. 1' Claim has been made involving loss, damage or destruction of the above-captioned property, which may exceed $5000. If any notice under Massachusetts General Laws, Chanter 175, Section 97A is appropriate, please direct it to the attention of this writer and include a reference to the above-captioned insured, location,policy number,date of loss and 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 f; 1 I 1 BUILDING PERMIT of NorarH I �t4 LED �6 40 TOWN OF NORTH ANDOVER o APPLICATION FOR PLAN EXAMINATION _ ze16 o . ,. Permit No#: Date Received � � � �,Q�RgTED PPa",�5 �SSACHV`��� i Date Issued: 06 ©-IL Z1016 IMPORTANT: Applicant must complete all items on this page i LOCATION C41C Z JA r P t PROPERTY OWNER Print 100 Year Structure yes no Historic District es no MAP PARCEL: ZONING DISTRICT: H Y � Machine Shop Village yes no i TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial �� AjwRepair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other _ ❑ Septic ❑Well ElFloodplain ElWetlands q Watershed District O Water/,Sewer- DESCRIPTION OF WORK O BE PERFO MED: 2--c xv eb I,e Jn Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name: Phone: I Email: Address: L Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ S'/>/l0• t9 0 FEE: $ Check No.: Receipt No.: D�,6 �— NOTE: Persons con racting with unregistered contractors do not have access to the guaranty fund -- Plans Submitted ❑ !'lens Waived ❑ TYPE of sEWE . GE DISPOSAL Certified Plot Plan ❑ S$aM I , � Public Sewer ped Plans ❑ well El El TanniUb/1Vlassage/BodyArt El S PrivateTobacco Sales wllllmingpools E (septic Tank,etc. ❑ El '1 PennanentDumpster on Site Ztood Packaging/Sales t O 1 THE FOLLOWING SEcTI �® Il\(TER®EpgRT`i�IENTgL SIISS S ®�F � F®��®FFICE USE ONLl° t I PLANNING � DEVELOPMENT Reviewed On COMMENTS — Signature — CONSERVATION Reviewed on ` Si nature COIV ME NTS HEALTH Reviewed on Si COMMENTS nature I Zoningt Board of Appeals: Variance, Petition No: Plannin Decision: Zonin g Board p g Decision/receipt Submitted yes l Comments _1 Conservation Decision: Water& Se Comments �. veer Connection/8-I � �'o nature pate "-90 iueer: SigraatDrivewa Per I ure: mif I ted FIFE-DEP,gRT Loca t 24,Maincstreet TernpDUrn�S er o Located ��eerpeartrnengsgnafueo/. n site :yeS 384 Osgood Street ® Notified date p ate COMMEN78 ----�- -------------------- -------- - Doc.Buildiup perrnitRevi; Er pskeC p evo'* t,�°'� P��auk ox Svc 10e a44�' 01vatiapc�s over o>16: a�4 a oa a 8-0 a>>eases Q Ox' ped`:4WW the tb t '- 'V0 uam�tt `�gev,Sea2�tA m �e�m -ORTH 4,so 0 �0 �_ l�•:`. 13UILIDING PERMIT - � T®WN OF NORTH ANDOVER ,� - FORPLAN EXAMINATION cR ;p1 APPLICATION �j16 a, �Rare� ,,✓ /„ Date Received �ssacH__777 us`` ®d � must complete all items on this page �j Umbo —, r OfstO rdes. yes ano / h1 '�ar Structure,arOa °strict es no willag e yes no /-oo-7// ®��� Off/OOr a J pier 766 or/®� nFkfOr70r Soo f7on ���� �tA®� O a ��at %-1 100-4 rn� NO Clr®/3 re \ 9'c,,- 'ae NO "p1pro Vol Of I DST BASED ON$125.00 PER S.F. for Pt NO.: s tie guaNanty fund p Ok4p Ca// of have acces --- - 'ed2614 C Finai/ --------------------------- ----- ohta�t Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) ® Notified for pickup Call Email F Date Time Contact Name Doc.Buildinb Pennit Revised 2014 I Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWER-AGE DISPOSAL Public Sewer ❑ Tanuing/MassageBody Art ❑ Swimiming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF o U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals:variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments i Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town]Engineer: Signature: Located 384 Osgood Street FIRE�DEPAR�TMI=IV,T TTempiDumpster on site .yes. _ no. L•ocatedlati1241 MainiStreet FirerDe fflkft'm-ent4signaitijee/ddte ,.,, COMMENTS Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits Building Permit Application Workers Comp Affidavit Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract Floor Plan Or Proposed Interior Work Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks Building Permit Application Certified Surveyed Plot Plan Workers Comp Affidavit Photo Copy of H.I.C. And C.S.L. Licenses Copy Of Contract Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And A Hydraulic Calculations (If Applicable) ) Mass check Energy Compliance Report (If Applicable) Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) Building Permit Application 4- Certified Proposed Plot Plan Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract 2012 IECC Energy code Engineering Affidavits for Engineered products OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 BUILDING PERMIT %AosaTN 1/y TOWN OF NORTH ANDOVER o APPLICATION FOR PLAN EXAMINATION 12-�© - R . ,. Permit 1Vo#: W16 Date Receivedo� � � � "°RgTED �SSACHUS�C Date Issued: 06 0:7. Z101 IMPORTANT: Applicant must complete all items on this page LOCATION P t _ PROPERTY OWNER � Print 100 Year Structures yes no MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family El Addition [I Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial k-Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition El Other _ - _ . Septic_ ❑ Well El Floodplain ❑Wetlands ❑ Watershed District 0 Water/Sewer. DESCRIPTION OF WORK O BE PERFO MED: R-,�L Post eb w e /I/'t cJ ��_71n, Identification- Please Type or Print Clearly OWNER: Name: Phone: Address: Contractor Name: Phone: Email: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $� l>/l0. `� FEE: $_� Check No.: Receipt No.: �,� NOTE: Persons con ratting with unregistered contractors do not have access to the guaranty fund LocationF "ql No. l Z Date n/. UZI Z�l� • - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $�, Foundation Permit Fee $ Other Permit Fee TOTAL $ T I Check Building Inspector',) NORTH Town of � L Over O 10 L_ . -0 1 No. a — * - : - * � ih ver y , Mass, 401S 06 Z��O T O LANE COC NIC Nl WICK%V A�R�TEO s V BOARD OF HEALTH Food/Kitchen PERMIT T L Septic System ►,,, BUILDING INSPECTOR THIS CERTIFIES THAT .... ,.. �� .... Al A'ov- ........6t I!, has permission to erect .......................... buildings on ...... ................................ Foundation Rough to be occupied as ...56...'�......... ....... ....................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in 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 Final PERMIT EXPIRES IL6 *00N THS ELECTRICAL INSPECTOR UNLESS CONST S = Rough 000— Service " .. Final BUILDING IN TO GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. rp n DOVE Artful and Affordable Gifts for Everyday Occasions 1 authorize 21S1 Century to change out our roof top l-1VAC. system Quoted at $5000. Thank you, Kellee Twadelle Owner 565 Chickering Road, North Andover, MA 018445 Tel: 978-689-4141 Fax: 978-689-0707 www.roseanddove.com VERMONT MUTUAL GROUP BUSINESSOWNERS POLICY DECLARATIONS V_ 89 State Street, PO Box 188 Montpelier,VT 05601-0188 To report a claim call your Agent or the Company at 800435-0397 Policy Number: BPI 1022879 - RENEWAL POLICY Type of Billing:DIRECT BILL TO INSURED Named Insured/Address Agency/Address 21ST CENTURY HEATING AND AIR INFANTINE INSURANCE, INC. CONDITIONING LLC PO BOX 5125 7 GLENDALE DR MANCHESTER, NH 03108-5125 NASHUA, NH 03064-1635 (603) 669-0704 POLICY PERIOD From 06/16/2015 To 06/16/2016 M 12:01 A.M." 'Standard Time at your mailing address shown above. INSURANCE PROVIDED BY: VERMONT MUTUAL INS CO. TOTAL POLICY PREMIUM at inception is: $905 and at each anniversary. IN RETURN FOR THE PAYMENT OF THE PREMIUM,AND SUBJECT TO ALL THE TERMS OF THIS POLICY,WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. BUSINESS DESCRIPTION Form of usiness: LIMITED LIABILITY COMPANY DESCRIBED PREMISES Prem. No. Bldg. No. I Location/OccupancyLocation/Occupancy Morta eholder Name and Address 001 001 HEATING/AIR COND CONTRACTOR (See Schedule of Mortgageholder(s) - 7 GLENDALE DR BPDEC5 - If Applicable) NASHUA, NH 03064 PROPERTY-Limits of Insurance for BUILDINGS $ . Actual Cash Value - Buildings Option (Y/N) . Automatic Increase - Building Limit (pct.) % BUSINESS PERSONAL PROPERTY $ 5,000 EARTHQUAKE DEDUCTIBLE(pct) % DEDUCTIBLE$ 250 OPTIONAL COVERAGE/EXTERIOR BUILDING GLASS DEDUCTIBLE$ 250 OPTIONAL COVERAGES-Applicable only if an "X" is shown in the boxes below: Limits of Insurance 1. ❑Outdoor Signs $ per occurrence 2. F1 Tenant's Exterior Building Glass $ 3. Interior Glass ❑ Basement/ground floor level ❑All Floors included 4. ❑Employee Dishonesty $ per occurrence 5. ❑Money&Securities(Special Form Only) $ Inside the Premises $ Outside the Premises COVERAGE EXTENSIONS 1. Optional Higher Limits-Accounts Receivable $ 2. Optional Higher Limits-Valuable Papers $ ADDITIONAL COVERAGES Optional Higher Limits- Forgery and Alteration $ LIABILITY AND MEDICAL PAYMENTS Except for Fire Legal Liability, each paid claim for the following coverages reduces the amount of insurance we provide during the applicable annual period. Please refer to Paragraph D.4. of-the Businessowners Liability Coverage Form. Limits of Insurance Liability and Medical Expenses $ 1 )000,000 Medical Expenses $ 5,000 Per person Fire Legal Liability $ 503000 An o9b fire or exiosiorl FORMS/ENDORSEMENTS ATTACHED TO THIS POLICY: (See Sc o orms nd E ors - BPDEC4) COUNTERSIGNED (o 10 XIS B o (DATE) ( THORIZED REPRES NTATIVE) THESE DECLARATIONS TOGETHER WITH THE COVERAGE FORM(S), COMMON POLICY CONDITIONS, FORMS AND ENDORSEMENTS, IF ANY, ISSUED TO FORM A PART THEREFORE,COMPLETE THE ABOVE NUMBERED POLICY. Includes copyrighted material of the Insurance Services Office, Inc. Copyright, Insurance Services Office, Inc., 1997 INSURED COPY 05/05/2015 (SWOL) BPDEC1 01/10 The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 www mass gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/organization/Individual): Address: �.�,., City/State/Zip:A29X,4-/A Phone k Iwo,3 .23..3 Are you an employer?Check the appropriate box: Type of project(required): 111 am a employer with_employees(full and/or part-time).* 7. eNew construction 2f;?l am a sole proprietor or-partnership and have no employees worsting for me in 8. Remodeling any capacity.[No workers'comp.insurance required.) 9. Demolition 3.O 1 am a homeowner doing all work myself.[No workers'comp.insurance rogtrired.)t 4.[:]]am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q Building addition ensure that all contractors tither have workers'compensation insurance or arc sok I LE ]Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5.❑1 am a general contractor and I have hired the sub-contractors listed on the attached sbnct. 13_Q Roof repairs These sub-contractors have employers and have workers'comp.iaszaaoce.t 6.❑We are a corporation and its officers bavc exercised their right of occmption per MGL c. 14_❑Other 152,§1(4),and we have no employers.[No workers'comp.insurance required.] ;Any applicant that checks box#1 must also till out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tCootractors that check this box must attached an additional sbect sbowing the name of the sub-conaactors.and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. 1 am an employer that u providing workers'compensation insurance for my employees. Below is the policy and job site fnformation. Insurance Company Name-.- Policy#or Self-ins.Lic.#: Expiration Date: lob*Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 und/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 fay against the violator_A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance :overage verification. do hereb ly under thepains andpenaldes ofperjury that the information provided above is true and correct ;iiznature: Date: 'hone# Ofjicial 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#: Informati®n and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written. An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However,the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall witbbold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable tvidence of compliance with the insurance coverage required:' Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply your insurance company's name,address and phone number along with a certificate of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required.Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Departrnent at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year_Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number. The Commonwealth of Masswbusetts Department of Industrial Accidents ofue of Investigations 1 Congress Street,Suite 100 Boston,MA 02114-2017 Tel.# 617-7274900 ext 7406 or 1-877-MASSAFE Fax#617-727-7749 www-mass.¢ov/dia i COMMONWEALTH OF MASSACHUSETTS USA 10=07 0 am 0 BOAR OF r SHEET METAL"WORKERS ••• ISSUES THE FOLLOWING LICENSE ASA 4d. Hgt: 70i MASTER UNRESTRICTEDI t: 03GND64281 M 170 ; Eye: BRO" DENNIS P GALLIEN 3.DOB: 03/28/1964 r19Haic BRO 7 GLENDALE DR r 4b.Exp: 03/28/2019 is.Sex: AA f fN: �IASHUA,;NH 0306 1635:: I`W \ IU 1 r .DENNIS f7 GALLIEN 7 GLENDALE DR u 3g'_--- NASHUA NH 030641635 �n� m� _x,•a�� •�.._•�.. .e •�_�a�_,w��. 3011 03128/2018 20519 ! r- r i NORTF� BUILDING PERMIT ,�— pF�t�Eo "tio TOWN OF NORTH ANDOVER 02 ryE.rd._ ••''n•'46 Om APPLICATION FOR PLAN EXAMINATION ~ 70 Permit No#: Date Received R�reo CH S �t Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION PROPERTY OWNERV/AaI ' Z�09 ` Print 100 Year Structure yes no MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 0 One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ommercial Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands 0 Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: e � Ide ric Yon- P11e se yp r Print Clearly OWNER: Name: Phone: ql,�TL Address: Contractor Name: Phone: Email; Address: Supervisor's Construction License: Exp. Date: I Home Improvement License: Exp. Date:_ I ARCHITECT/ENGINEER Phone: ' Address: Reg. No. 1 FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Ll2- Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ,�ign�S ature of Agent/Owner Signature of contractor i Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/MassageBSwimmin ody Art ❑ g Pools ❑ . ❑ 4 Well Tobacco Sales ❑ Food Packaging/Sales ElI Private(septic tank,etc. ❑ permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ i COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: . = - Located 384 Osgood Street FIRE DEPARTMENT - Ternp Dumpster on site _ _ - L•ocated at 124 Main Street yes -no _ Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Pennit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits o Building Permit Application ❑ Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract o Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) a Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Li Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 Location No. Date • - TOWN OF NORTH ANDOVER } • Certificate of Occupancy $ h� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# 2 j Jilding(nspector r OE,,O-TN 1H 'rSAC Hu5E4 CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number N/A Date: October 26, 2015 THIS CERTIFIES THAT THE BUILDING LOCATED at 565 Chickering Road MAY BE OCCUPIED AS a retail store " Rose and Dove" IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Kelle Twadelle 565 Chickering Road North Andover, MA 01845 Bui dmg Inspector Fee: $100.00 Receipt: 29540 Check : 2242 �pevt� OL,�g4CD obi f�O 1 � xnp `n NORTH ANDOVER BliDNG DEPARTMENT 1600 Osgood Street North Andover Tel: 978.688-9545 . Fax: 978-688.9542 BMUM FOAV 1.�`if1R TOi�.ltr'CLERK DATt..NAME: 6cx 2n& Q:fi lll_=� Ttcl ' ADDRESS; ZONIN IaIBT.RIO i: TYn0F3BU8JNE8S.. BU ILDINI'r`LAYOrUT PROVIDED: YES � NO AVA11,A.TER PARKING SPAM: ZONIla G EY LAVA"USAGE: YES NO T7IT,1 ` OIfP SZGITAIJPP�E i BUSINESS FORM FOR TOWN CLERK ZA Home Occupation(1939132) An accessory use conducted within a dwelling by a resident Aa resides in the dwelling as his principal address, which is clearly secondary oto the use.of the building for�ving ptuposes. Homo occupations shall 'include,"but not limited to the following uses; personal services such as furnished by an artist or instructor, but not occupation involved wift motor vehicle zepairs, beaa4r parlors, animal kennels, or the conduct of retail business,or the manufacturing agoods,which impacts the residential nature of tho neighborhood', 4. For use of a dwelliizg in any residential district or multi-family district for a home occupation,the following conditions shall apply: a. Not more than a total of fhree (3) people may be employed in the home occupation, one of whom shall be ihe--ovaier of thdh6mosicadpation and residing in said divelling, b. The use is carried on strictly within the principal building; c. There shall be no exterior alterations, accessory buildings, or display which are not customary= with residential buildings; . d. Not more than twenty five (25) percent of the exi-bg gross floor area of<fhe dwelling Unit. so used, not to exceed one thousand (1000) square feet, is devoted to'such use. 7n connectionwith such use,there is to be kept no stock in trade, commodities or products which occup3r space beyond these aimits; e. There will be no display ofgoods or wares visible from the street; f The building or premises occupied shall not be rendered objectionable or detrimental to the residential character of the neighborhood due to the extezior appearance, emission of odor, gas, smoke, dust, noise, disturbance, or in any other way become objectionable or detrimental to any residential use within the neighb orhood; g. Any such building shall include no features of desiga not custamaq in bindings for residential t?se. Signature Date i i L �N . 1 Location No. Date F i) . - TOWN OF NORTH ANDOVER s n1 Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee-Sk TOTAL $ Check 4t n Building Inspector 1f NORTH *' Q��tLED rbTIO oc 0 2 = TOWN OF NORTH ANDOVER D�A "��"��"�`� * g7ED SIGN PERMIT DR �Pa ,�y �SSACHUS�� DATE: October 2, 2015 PERMIT: 005-2016 THIS CERTIFIES THAT Kellee Twadelle has permission to erect. on-565 Chickering Road — Rose & Dove — 48X312 — "Rose & Dove Gift Shop" i provide that the person accepting this Permit shall in every respect conform to the terms of the application on file in this office, and to the provisions of the Codes and By-Laws relating to the Sign Regulations in the Town of North Andover. Violation of the Zoning of Sign Regulations, Section #6, Voids this Permit. INTERNALLY ILLUMINATED SIGNS ARE PROHIBITED Inspector of Buildings Amount Paid:$48.00 Check 2208 Receipt#29450 ti SEEN Z ERMT APPILIIcCATYGN 1600 ,sgood Street B uRding 20,Suite 2-36 T O.F 1`�®RTH-ADO +]R; Date: 4 L 15 Site Owner � i Name of applicant who is purchasing the sign. -2�2 S �C�{� nn ��// Phone#of applicant who is purchasing the sign— `�Q L4 (1 7 .2- 5, ' Site Address �l Name of sign company �-79 Phone# --NH-2,011 17 I Size of Proposed Sigh How attached: a)Against the wall L/ Illumination: a�N®�nYlu�iraated b)Roof b)Internally illuminated c)Ground c)Exteimally illuminated d)Other MaterialsU6GX__-C(6c� Proposed Colors: Background 10\� �� Lettering � Border_ a Cost of Si • Reg,anured Attachments: I`�®te: N®pea�ra�aeattlteuxa ®r y'e� Phgtographs of building p ary sign shall be rected,or erdd until Material sample application on the Appropriate forth fiunished by the Sign Office has been file Color sample with the Sign Officer containing such information including photographs,plans Site or Plot Plan(Required for.all free-standing signs) and scale.drawings,as he may require,and a permit for such erection,alteration, -Drawings of proposed sign or enlargement has been issued.by him. Such permit shall be issued only of the Other,specify Sign Officer determines that the sign.complies or will comply with all applicable provisions,of the By-Law. , Will signoverhang any +". $ y public road'or walkway des ( ) I�]'® , If Yes,Name of Agency who will provide liabiliV insurance: - .. AN 1NCOIA]PP]LlCATION�,L NOT BE ACCEPTED _ DATE]SIDLED: Receipt# Check# Kevised 10.31.2006porm Sign Permit Application DIVA ®IF APPI✓1CAN� APPROVED • I 7REr 9.2845 PLACE NON ILLUMINATED SIGN SAME SIZE WITH NEW NAME Raised 3/8in black flat cut letters w/ faux wood print mounted on 1/4in Alucabond installed on wall. $3950 plus tax 3 Y _ .. tw EXISTING • � 0 E-MAIL:info@harveysigninc.com 978.794-2071•FAX 978.686-1841 CUSTOMERS: Please proofread carefully and sign only if all is correct. INTERIOR/EXTERIOR SIGNAGE Additional charges will be added if any changes or corrections are requested after customer signs off. FABRICATION.SERVICE•INSTALLATION This must be signed and e-mailed or faxed back before start of job 30 OSGOOD ST.METHUEN,MA 01844 X Signature/Date NOTE:LAYOUTS ARE THE EXCLUSIVE PROPERTY OF'HARVEY SIGNS'.ANY UNAUTHORIZED USE OR DUPLICATION WILL RESULT IN A 20%CHARGE PER OCCURRENCE PER THE VALUE OF THE COMPLETED PROJECT.0 HARVEY SIGNS 2015 ALL RIGHTS RESERVED. (f-nintancuaa&L a//t"1a:t:nachicuclb. Orticial Use Only PermitNo. 12-0-61 _ = oUtrPa�dmenl o�.�iro�orui.ced ' BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked [Rev_l/071 (leave blank.) APPUCAT90N FOR PERMIT TO PERFORM ELECTR9CAL WORM All workc to be performed in accordance with lheMassaetrusms Electrical CodaC],- 7 CTvIR 12.00 (PLEASE PRINT EV EOf OR TIDE ALL INFORM—I TION Date: / f City or Town of: To the 17spector of!;Fires: By this application the undersigned gives notice ofhis o her intention to pierfibuniflie electrical work described below. Loention(Street&Numb Owner or Tennnt 2121 01)-1 C.,A Do 1 Cl-f SkAo 11'1 TK- Tot ephona No. Owner's Address Shyn 7s this permit in.conjunction with a building permit? Yes ❑ No (Cliecic ApproprinteDox) Purpose orDuilding Utility Authorization No. L'xisting Service Amps / Volts Overhe.nd ❑ Undgrd ❑ No.of Meters New Service==i� Amps,_ _ 1__ Volts., _Qvr� ��-�a_n Undgrd ❑ rTo. of Meters zc Date..... Llr....... r orving fable mart be warred b-p the Inspector all NOwT## .No. of Total 03?°;"';;'; ~ao� TOWN OF NORTH ANDOVER Transformers 3CVA 9 PERMIT FORR}WIRING Generntors lCVA l o.o I mergencyLrg trng o + EJ "40- Units $s+cHus� FIRE, ALARMS No.or?ones No.orDetection and _ ,/� �---1 ��7"' Initiatine Devices This certifies that ................ / (J ?................ ..............................tr....................... E . // s No.orAlerting Devices has permission to perform .................... ............... ....................... ........ ............. o,of sell=Contained ,/� Detection/Alerting-Devices wiring in the building of............�1''..5..5....... . .Pc........................................... Municipal ........... . g g Local ❑ Olhcr _ Conncctron at ...........................-r.. 7/C✓� A✓wGL.......�..J� Mass. Security ysrerns:= ................. ......... .............n.....,North Andover, 5ecur•i S No.of DevicesorE quivniant Fee......Z� ' Lic.NoA..J... �'2 �!. ..... ............ DAtl Wiring:. .... . . car INS CE o / No.ofDevrces or I; uivnlent / Telecommunications Wiring Check# bpi No.of Devices or Equivalent tnn , ! 1 0 9 f U ifdesired, or os required by the Inspectar of I unicipal policy.) orlc to Start Inspections to be reques!_ed in accordance with IVIECRute 10,and upon completion. INSURANCE COVERAGE: Unless waived by Ilse owner,no permit for the performance ofelectrical work may issue u the licensee provides proof of liability - urance including"completed operation"coverage or its substantial equivalent. I undersigned certifies that such cove ga is in Force,and has exhibited proofofs a to t e permit issuing office. CHECK ONE: FNSURANCE BOND El OTHER ❑ (SpeciFy:) /� 1 cei11,unndertha pains an 1 penalties ofper'ury,thar int ttion an!tt7 s up licntloir is trete tied coy FIRM NAM.G: --� Pnip/e[. �1 U A P C �( LIC NO.,6 j, 1M. Licensee: 2" O Q Signature 4b LIC.NO: (Ifappllcoble, t empt"in th license numberli e) Cl�l�'1 Bus.Tel.No. - Address: G t Alf_Tel. No.:� - n r 1 -Per-M.G.L.c. 147,s,57-61,security w rlc requires Department ofPublic Safety"S"License_ Lic.No. OWNER'S 1 NS1lR"CE WAIVER: I am aware that the Licensee doesnot have the liability insurance coverage norm: required by law: By my signature below,I hereby waive Ibis requirement_ I am the(check one)0 owner ❑owner's i =r:Otivner/Agent :::_...:• • ,.,...:. _ .:a,.: Signnture Telephone No. PEIZ.l1'f1T.PERE: S „N 'gown of Andover 0� .en.��0\ Massachusetts [` *1 36 Bartlet Street Electrical Inspector - 9s` ;7 Andover,MA 01810 Paul Kennedy (978)-623-8306 acgW ELECTRICAL PERMIT FEES Fax Number: (978)623-8320 (revised September,2012) Office Hours: 8:00 am.- 10:00 a.m. t Commercial Base Fee $50+ $1 each device Residential New Dwelling Up to 200 amp service $225 k Each add. 100 amp's $20 Multi-Family New Condo/Multi-Dwelling(per unit) $225 Residential- Service/change/alterations 1 hose-200 am $60 Multi-Family/Single Family 3 phase-200 am $110 Each add. 100 amp's $20 Additions/Renovations/Replacements (Maximum.Fee$225) $50(min.fee) Outlets,switches,plugs, Iuminaires,etc. $1 each device Residential/ Appliances $50(min.fee) s Commercial($50 base fee+) $10 each appliance Air Conditioning and Heat Pumps $50 Temporary Service $50 ; Residential Generators/Solar Panels (service additional cost) $100(base fee)+ Additional Equipment $25 each 1 Commercial Generators/Solar Panels (service additional cost) $100(base fee) Per ICVA $1+ i Additional Equipment $25 each Residential Audio/video/data/phone-systems/ $50 Fire alarm/security systems Commercial Audio/video/data/phone-systems/ $50 base fee+ Fire alarm/security systems $60 Commercial New Construction and Alterations Base fee $50+ Per 1,000 sq.R.of Construction Space $100 Service/Change up to 200 amp $150 a See Electrical Ins ecto for price above 200 am Maintenance Permit/Repair Blanket Permit(up to two electricians) $200 Over two electricians(per air) $50 Office Furnishings/Partition Relocations $50.00(base feej+ Per Circuit $10 Transformers(non-utility owned) $50 ' Miscellaneous Carnival rides $50 Demolition $50 1 Feeders or sub-feeders and panels $30 (each 100 amp.capacitor fraction thereof) Motors,per hp or fractional part thereof $4 Siding (re-seggrin service,lights,plugs) $50 Si2!S ` $50 Meters $20 Swimming Pools In-ground $100 Above-ground V $50 Commercial $200 General Fees Re-Inspection Fee $50 -Inspection after hours(minimum fee) $200 Working without a permit Double Permit fee p0K711 N eA` Y P S�cwusa CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH;ANDOVER Building Permit Number /-/ 9 Date THIS CERTIFIES THAT THE BUILDING LOCATED ON MAYBE OCCUPIED AS IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. CERTIFICATE ISSUED TO 4meeleAv c5C 1Imo / Bf" 41 A)4 - ,Z - Building Inspector j Town of over o ` 'IWO dover, Mass., ` 3o deo � ADRFITED BOARD OF HEALTH PERMIT ;T D Food/Kitchen Septic System �► va N v � 4 OLDING INSPECTOR THIS CERTIFIES THAT..........................................pa"I. .... ?.►/....... ..........A11�r�IM�i...S f..... I� Foundation / has permission to erect.....�..so 4* N1v r" S.�.Ir:'....Ck�.�!.. ...*.M�.y P buildings on ..... l to be occupied as...... ............. ..................... �r � �,..". ' Chimney ........ ..................... . .............�........................................ provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Finale this office, and to the provisions of the Codes and y-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. g y _ PVWBTNG INSPECTqR VIOLATION of the Zoning or Building Regulations Voids this Kermit. u o>S v v PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUCTION STAR S EL IC�AI o ! Cf 3v ............................. e� ter/ ?' BUILDING INSPECTOR nal Occupancy Permit Required to Occupy .building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal No bathing or Dry Wall To Be Done /44 FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner I� --_-- __ _ -- Street No. SEE REVERSE SIDE �! Smoke Det. — —I "t,Eo BUILDING PERMIT TOWN OF NORTH ANDOVER F A APPLICATION FOR PLAN EXAMINATION Permit N0: Date Received 3,y SSACH►15� Date Issued: ' d IMPORTANT Applicant must complete all items on this page s10a - k :OC 1T1 :t� � 14 W, r 'g iio �x� !� MR TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition 0 Two or more family ❑ Industrial ❑ Alteration No. of units: 0 Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other FL�1 1Wetlan ktetl� 31 �t� { j � �•y r r _.F ION OF WORK TO B PREFORMED: � � DESCRIPTION E a� n 1 - A y 2c— CLU Idepti.fication Please Type or Print Clearly) �J OWNER: Name: t'eq (aoc' �'✓I Phone: -Li 3 Address: %2, Sem � �� ��;�e rr"P�° �Sl�,,�c� / SC -n �q .FS F, f� y�" j 4 " '' $ �, ,f } ^4 t ;'' -a u i � st� ', S• Y o-a ¢ W2 At ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$1255..0x0 PER S.F. Total Project Cost: $ iFEE: $ � ` � Check No.: lo Y�� Receipt No.:I-�-o NOTE: Persons contracting with unregistered contractors do not have access to the guarant?und r r Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales El (septic tank,etc. ❑ 1 Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING &-DEVELOPMENT ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED CONSERVATION ❑ . ❑ COMMENTS I DATE REJECTED DATE APPROVED HEALTH F]DATE COMMENTS Zoning Board of Appeals: variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments r Conservation Decision: Comments Water& Sewer Connection/Signature & Date Located at 384 Osgood Street Driveway Permit 'i� 1R MEDT T -..... __..._ y � Itristet`�{ Slt@ �/e5 x r a nth > r LvcaaeGl� 1 'Nl�rin Stet 5 e " DOC.BUI F�Ire�Dapatr>�eiris�� iatre/tlak � a ; xz i .xv• .tea x � ..; .� � -:s�¢ , �,.�^s S0L ,Do,'o,' 1NSPECT,ONn� VICE _ -I__� Revised 2.2� V1 Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: i ELECTRICAL: Movement of Meter location, mast or service droprequires q approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine i NOTES and DATA— (For department use ❑ Notified for pickup - Date Doc.Building Permit Revised 2007 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) Li Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 Location G'K No. I Q� Date �aRTM TOWN OF NORTH ANDOVER F41 9 Certificate of Occupancy $ �'�a"•�•°''<� cMu9 Buildin (Frame Permit Fee $ s� sa Foundation Permit Fee $ Other Permit Fee $ TOTAL $ — Check do 1116 2056b �._-- Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIE,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING for BUILDING PERMIT NUMBER. DATE ISSUED: rn X SIGNATURE: Building Commissioner/IEEQEtor of Buildings Date Z SECTION 1-SITE INFORMATION O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: GJ-- Er-) C In�C.Yere 4CcY yJ_ -Q0 ve.r 1MO 1$y Map Number Parcel Number k ,R j 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed d Use Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard RegWred Provide ReqWrcd Provided R red Provided v 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 ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT r—Histurt District: rn 2.1 Owner of Record PFC., Ge-,h Am � sig 5A--p 1-s Dt v e Nai Print) Address for Service �l P is-14NO , -Sc a59�2 Signature Telephone 2.2 Owner of Record: Name Print Address for Service: O Z rn Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ n, Licensed Chnstruction Supervisor: L2 0 16 � �Jf M 31 I ��� l,�,e n _�," License Number r s I ? /;� r Expire on Date Si lure Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ v Company Name rn Registration Number r Addre s Cn 07,Y- - Expiration ate ^� nature Tel hone G/ 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.......0 SECTION 5 Description of Proposed Work check applicable) New Construction ❑ Existing Building Repair(s) Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: . — c me Sof N5��`� GvC-\Je- OocQ \6-tr `ooc.JcQ ©�c,� �e e \� oc��_ -T v,s4c 1' t+n Cw.�J�vc.O.o4 ���_ ��cJ�oo4l� " �� t L C �� Qe\n eir� , %--6 SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant 1. Building (a) Building Permit Fee 3� eK.,o.00 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 3 C1 ocx> oa Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize_ to act on My behalf,in all matters relative to work aut'hehzed by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT I DECLARATIIOON� I, �.Ow=g A _� Cg)oz�m o j a J�11� ,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 Lwpax-A mazl2E� i VPrint ame ature of Owner/A ent Date NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIIVMERS iST2ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHRANEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 0 .qO PROPOSAL NUMBER: 496 q o114 c� David Gorham �` 1/vi `� 617/899-7051 11/20/06 11 Tuder Court St. Bradford MA 01835 C� �� batten in seam rubber roof installation 565-595 Chickering Rd. N. Andover, Ma 01845 1. Clean entire roof area of excess gravel and remove penetrations that are not being used. Frame in existing opening. 2. Supply and install 1/2" woodfiber board insulation mechanically fastened. 3. Supply and install a new Batten-in-Seam rubber roof system. 4. New rubber roof membrane shall be .060 in thickness. 5. Supply and install new 1/2"x4" plywood nailing strip to the entire roof perimeter for the installation of new perimeter metal flashing. 6. Supply and install new flashings to all remaining roof penetrations. 7. Remove and dispose of all roof penetrations that are not being used. 8. Supply and install rubber flashings to all walls. 8. Supply and install .032 bronze aluminum perimeter metal flashing to the entire roof perimeter. Thirty Nine Thousand and 00/100 Dollars 39,000.00 Payment to be discussed. M.C. Contracting warrantees workmanship for a period of 10 years. PSC 900 Series 950 Log for Personal Printer/Fax/Copier/Scanner Property of: Apr 30 2007 4:06PM Last Transaction Date Time Twe Identification Duration Page Result Apr 30 4:05PM Received SDS, Inc 0:32 1 Error 283* * A communication error occurred during the fax transmission. If you're sending, try again and/or call to make sure the recipient's fax machine is ready to receive faxes. If you're receiving, contact the initiator and ask them to send the document again. THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA 71991-0000 WC 897-28-23 13889 -----------------o 3-82-12o6-01-- .-•.-• . - . PENNSYLVAN I A FOR .- MC CONTRACTING INC &M Member Companies of 62 CONSTANT I NE DRIVE American International Group TYNGSBORO, MA 01879-0000 EXECUTIVE OFFICES: 70 PINE STREET, NEW YORK, N.Y. 10270 SEE NAME AND ADDRESS SCHEDULE - WC990610 LD# M CLUETT COMMERCIAL INSURANCE AGENCY INC WORKERS COMPENSATION AND EMPLOYERS 8 PEMBROKE ST LIABILITY POLICY INFORMATION PAGE KINGSTON, MA 02364-1109 INSURED IS PPiEVIOLIS P©LfCY NL&4BER CORPORATION REWRITE 0089 2823 OTHER WORKPLACES NOT SHOWN ABOVE:SEE NAME AND ADDRESS SCHEDULE - WC 0610 REM 2 POLICY PERIOD 12:01 A-M.standard time at the insureds mailing address FROM 12/27/06 TO 12/27/07 REM 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA S. Employers Liability Insurance: Part Two of the policy applies to the work in each state listed in item 3.A. The limits of our liability under Part Two are Bodily Injury by Accident $ 100,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 100,000 each employee C. Other States insurance: Part Three of the policy applies to the states, if any, listed here: AK AL AR AZ CO CT DC DE FL GA HI IA ID tL IN KS KY LA MD ME MI MN MO MS MT NC NE NH NJ NM NV NY OK OR PA RI SC SD TN TX UT VA VT WI ITEM 4 The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Estimated Total Rate Per Estimated Remuneration Premium Classifications Code Number "itineration Annual®3 Year N Annual Q 3 Year SEE EXTENSION OF INFORMATION PAGE - WC7754 TAXES/ASSESSMENTS/SURCHARGES $691 EXPENSE CONSTANT(EXCEPT WHERE APPLICABLE BY STATE) $284 MA MINIMUM PREMIUM �500 MA TOTAL ESTIMATED PREMIUM $20,269 If indicated below,interim adjustments of premium snan as mane: E] Semi-Annually E] Quarterly Monthly DEPOSIT PREWUM ENDORSEMENTS(FORM NUMBER) SEE ATTACHED FORM SCHEDULE - WC990612 01/03/07 PARSIPPANY 82 u�= Issue Date Issuing Office Authorized Representative WC 00 00 01 39967 M.C.CONTRACTING,INC. 10471 Commonwealth of Massachusetts 8/27/2007 100.00 f M.C. Contracting, Inc. CSL#85086 renewal/stephen obrien 100.00 4MDUCT LT104 UM VM 9379 ENVELOPE NESS To Reorder:7-800-225-6380 or wwwnebs.00m PRIPOW M U-SA A S w, f PCo _ Postage i.41 61— —s it Certified Fee= $2.65 Return R -" P r M (Endorsement Receipt p M Restricted Delivery Fee (Endorsement Required) V0.tJ O . 0 Total Postage&Fees $ +�.U+ r' p ';" nj ent TO r Nb�- � �. C3or PO BoxNo. ----------------------------------- Paid . - Paid by: ...Cash $3.25 Change Due: -$0.19 Order stamps at USPS.com/shop or call 1-800-Stamp24. Go to USPS.com/clicknship to print shipping labels with postage. for other information call �_onn_neu_l tcoc Ueparzmenr of lnausrrtat Acetaenis Office6f Investig.4dons 600 Washington Street s Bostvn,M 40 2111 www.mass.govldia . Workers' Compensation Insurance Affidavit: guilders/Contractors/Electneians/Plumbers Applicant Information Please Print Legibly Name (Business/Oiganization/Indiaduat):� .,.•(1 Address: ��- q .City/State/Zi � C� Q� I Phone —5D I a=::::- Are,you an employer? Cheek the-appropriate box: Type of project(require(!): 1am a employer with 4• ❑ I am a general contractor and I have hired the sub-contractors 6. El New constliledon employees(full and/or part-time).* 2.❑.I am a sole proprietor or partner- fisted 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. El We are a corporation and its - required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner.doing all work right of exemption per MGL I t.❑ Plumbing repairs or additions c. 152; 1(4), and we have no Myself. [No workers' comp. § 12� Roof repairs insurance required.] t employees. [No workers' 13'a Met insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information: t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such: tcontractors that check this box must attached an additional sheet showing the narne of the subcontractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: pp V Policy#or Self-ins. Lic. #: Expiration Date: Job Site Address:47/)S--,5 q'�(d�j�r.Vk ci(Q Vim. City/State/Zip:�J.PM",('(`{� vs 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 Cine 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 tett' under 1/t airs andpenalties ofperjury that the information provide above is true and correct Signa4411ZDate: Phon Oficial use only. Do not write in this area,to be completed by city or town offtciaL City or Town: Permit/License Issuing Authority (circle one). 1. Board of Health Z. Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: BOARD OF BU OF REGULATIONS License: CONSTRUCTION SUPERVISOR Number. CS 085085 h w a Birthdate:07!2311979 r Expires:07/2312007 Tr.no: 85086 " = Reslrlcted: 00 STEPHEN H OBRIEN _ 56 FITCHBURG RD#531 TOWNSEND, MA 01469 Administrator ✓�e�omvmwnuiea�i o�./l�aaaac�zuaeCf Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 133895 Board of Building Regulations and Standards One Ashburton Place Rm 1301 Expirations 8/22/2009 Tr# 133005 Boston,Ma.02108 Type: Public Corporation , MC CONTRACTING INC:. LEONARD MARTELL JR' i ••� 62 CONSTANTINE OR TYNGSBORO,MA 01879' Administrator Not valid without signature i NORTH Town of No. / � 8 _ � K o dower, Mass., 9 * 5 � I� COCHICHEWICK y1. %ADRATED S ` BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THISCERTIFIES THAT............egir...... ................................................... .......... ....................... ...... ............. Foundation 7 has permission to erect... buil in s on .....5.1. ....../►.. �.�. .... ........ ..!......... Rough P 9 � g to be occupied as , ir Chimney 1� provided that the person accepting this permit shaiUws ery respect conform to the terms of the application on file in Final and this office, and to the provisions of the Codes 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 Final PERMIT EXPIRES IN. 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRU ARTS Rough .......... ....... .................. Service BUILD Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. thoRTN 4.3 ••�+ �`••° Zoning Bylaw Denial Town Of North Andover Building Department �` ' 27 Charles St. North Andover, MA. 01845 s"CNpS` Phone 978=688-9545 Fax 978-688-9542 Street: . i Ma /Lot: 154 a 8 Applicant: E tJ q rVPaN a.20 _. Request: Date: Please be advised that after review of your Application and Plans that your Application is DENIED for the followingZoning Bylaw-reasons: Zoning G 3 Item Notes Item Notes A Lot Area F Frontage 1 Lot area Insufficient 1 Frontage Insufficient 2 Lot Area Preexisting e 5 2 Frontage Complies 3 Lot Area Complies 3 Preexisting frontage ,e 5 4 Insufficient Information 4 Insufficient Information B Use 5 No access over Frontage 1 Allowed yc g G Contiguous Building Area 2 Not Allowed 1 I Insufficient Area 3 Use Preexisting 2 Complies 4 1 Special Permit Required 3 Preexisting CBA y 5 5 Insufficient Information 4 Insufficient Information C Setback H Building Height 1 All setbacks comply 1 Height Exceeds Maximum 2 Front Insufficient 2 Co" plies 3 Left Side Insufficient 3 Preexisting Height e S 4 Right Side Insufficient 4 Insufficient Information 5 Rear Insufficient I Building Coverage 6 Preexisting setback(s) y,c 5 1 Coverage exceeds maximum 7 Insufficient Information 2 Coverage Complies D Watershed 3 Coverage Preexisting y s 1 Not in Watershed c 5 4 Insufficient Information 2 In Watershed j Sign 3 Lot prior to 10/24/94 1 Sign not allowed `1 c 5 4 Zone to be Determined 2 Sign Complies 5 Insufficient Information 3 Insufficient Information E Historic District K Parking 1 In District review required 1 More Parking Required 2 Not in district y c,5 2 Parking Complies 3 Insufficient Information 3 Insufficient Information 4 Pre-existing Parkin y s Remedy for the above is checked below. Item # I Special Permits Planning Board Item # Variance Site Plan Review Special Permit Setback Variance Access other than Fronta e S ecial Permit Parkinq Variance Frontage Exception Lot Special Permit Lot Area Variance Common Driveway Special Permit Height Variance Congregate Housing Special Permit Variance for Si n Continuing Care Retirement Special Permit Special Permits Zoning Board Independent Elderly Housinq Special Permit Special Permit Non-Conforming Use ZBA Lar a Estate Condo Special Permit Earth RemovalSpecial ecial Permit ZBA Planned Development District Special Permit Special Permit Use not Listed but Similar Planned Residential Special Permit Special Permit for Sign R-6 Density Special Permit Special Permit preexisting nonconforming Watershed Special Permit 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 rile.You must file a new building permit application form and begin the permitting process. �BuildinZg D o''Departm Official Signature Application Received Application enied Denial Sent:` If Faxed Phone Number/Date: ( rf Y + .F 1. _ '..Y�•(] �• Plan Review Narrative Fy The following narrative is provided to further 6xpla'in the reasons for denial for.the application)'`; permit for the property indicated on the reverse side: WMIWII f As " ONe C �e/'.N74A.-e•J-A ro OI- S! nj 0.70 A.7&4- In 0 P le- .7D4- more: A N —7 `-JlCiule CaV) S qvaRLa J-e S ' C' 80 "ed d. !`sem/ti S Gv C- // �S Oho .d-c Aim cc"W ✓ ole /N C..) U Referred To: Fire Health Police Zoning Board Conservation Department of Public Works Planning Historical Commission Other �B111LD11�Il�.nFnr TOWN OF NORTH ANDOVER SIGN PERMIT APPLICATION Site Owner L_'Z,/AA,) ?_1ky7A -F , Applicant c�'VAAJ Site Address ��G�S C'/4 1C e ���l�V�' �'_�}� l7 Size of Proposed Sign '/'� tu k 12_S_ How attached: a) Against the wall ' �) Illumination: a) Not illuminated bS Roof ( ) b) Internally illuminated ( ) c) Ground c) Externally illuminated ( ) d) Other ( ) Proposed Colors: Background Gt�Hii�=' Materials: ,��U�� i,�U�1 Lettering Border Required Attachments: Note: No permanent/temporary sign shall be erected, or enlarged until Photographs of building an application on the appropriate form furnished by the Sign Officer has /Gitvlaterial sample been filed with the Sign Officer containing such information including Color sample photographs, plans and scale drawings, as he may require, and a permit for such erection, alteration, or enlargement has been issued by him. L_ --Site or Plot Plan (Required for all free-standing signs) Such permit shall be issued only if the Sign Officer determines that the I.,-Drawings of proposed sign sign complies or will comply with all applicable provisions of the By-Law. Other, specify Will sign overhang any public road or walkway Yes ( ) No If Yes, Name of Agency who will provide liability insurance: ''lJ r AN INCOMPLETE APPLICATION WILL NOT BE ACCEPTED DATE FILED: ` � "OZ l L� revised:jm- 8/98 . SIGNATURE OF APPLICANT 0 0 a--a-- � � 0 144" I 18 " 1 T 12" 1 a `o• 125" 1 t 12" N' t' UJr 9 � S f T 3" Vie, it £ ^y 74 �x p3I5 �.. s r a t � ,4t, . @ » ... . \ �f» m 4 b� L t yzv O 1 r I I i i +I I I i 1 I IIII 1 1 f 4 r i 551' "� 1' 9 J% Town of North Andover QF OO oT� g� Office of the Building Department . �a,�`,,_ . .6.6X. Community Development and Services Division a�a E William J. Scott, Division Director 27 Charles Street 9SSacausE4� �' D. Robert 1�Ticetta North Andover, Massachusetts 01845 Telephone(978)688-9545 Building Commissioner. Fax (978) 688-9542 CONTROL CONSTRUCTION -SECTION 116.0 M.S.B.C. CERTIFICATE OF ENGINEERING/ARCHITECTURE BUILDING INSPECTOR TOWN OF NORTH ANDOVER 27 CHARLES STREET NORTH ANDOVER MA 01845 GENTLEMEN: —, HEREBY CERTIFY THAT THE BUILDING CONSTRUCTED AT DOES CONFORM IN ALL RESPECTS TOTHE MASSACHUSETTS STATE BUILDING CODE AND APPLICABLE FEDERAL REGUALTIONS FOR THE FOLLOWING: ����p A sh/T I✓ (ZG t-E l'"TCCrr P-Acl. 7� � �L O� i N 5125 W �-z�, h1BRlOGE os fI'zE ' NATURE: ��qt TH OF DAT � ' A'._ REGISTRATION: 114 NOTE: ENGINEER "WET STAMP" MUST BE AFFIXED TO THIS FORM r Control ConsWction.doc revised 200160e/ MY COMMISSION EXPIRES SEPTEMBER 3,2004 BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTI-1688-9540 PLANNING 688-9535 TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING ITI OTHER THAN A ONE OR TWO FAMILY DWELLING .7''i '$ This Section for Official Use Only BUILDING PERNUT NUMBER: t f DATE ISSUED: Z SIGNATURE: (6O Building Commissioner/I or of Buildings Date �G�'���� yam`• ���`�}�;.. 1.1 Property Address 1.2 Assessors Map and Parcel Number: � Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: v Zoning District Pr osed Use Lot Area Frontage(R) m 1.6 BUILDING SETBACKS(ft) Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided S2� 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: i Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal On Site Disposal System ❑ kJj 2.1 Owner of Record Name(Print) Address for Service: Signature Telephone 2.2 Authorized Agent 1 Qddres!�Name Print for Service: Z p Signature Telephone Z M " Sri F ' Qp 3.1 Licensed Construction Supervisor Not Applicable ❑ Cel 01 ( � Address License Number O Licensed Co ti Su 'sor: t �a/a (Q)?7) Expiration Date ic_ -70 Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ < Company Name„ Registration Number ' m s Address Expiration Date /Z Signature Telephone Q sEIM6 4 WIJ( KElRs 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 urnit. Signed affidavit Attached Yea.......❑ No.......❑ SECTION S:-PRUF$SSiQIYFA L ri>�srG>�r AI�iD,C41�STTtUCTIt�N sExVICEs F(�B1�I�QIl�t� AND 5�U�'I��� �'�? CONS TRI7CTIaN C�3�s?L PT A 1`TCi" G 16 3I TAl f i Mf E AND36; GF OF> TCII ED, 5'ACE) 5.1 Registered Architect. Name: Address f j Signature Telephone S.2 R�isEe�,et 1PrsYessza»sa�;, ��3" <.=_ Name: C ) Area of Responsibility Address. i --t �4 cam 1 � Registration Number I Signature Total Expiration Date Not applicable ❑ Name: Address Registration Number i{ Signature Telephone I Expiration Date t FN _ i Area of Responsibility i Address Registration Number Signature Telephone Expiration Date i Name Area of Responsibility I I Address I Registration Number Signature Telephone Expiration Date Company Name. Not Applicable ❑ C�tnr� Responsible In Charge of Construction x New Construction ❑ Existing Building C�, Repair(s) ❑ Alterations(s) B.— Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: �.A USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ IA ❑ A4 ❑ A-5 ❑ IB ❑ B Business ❑ 2A ❑ C Educational ❑ 2B 0 F Factory ❑ F-I ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ IInstitutional ❑ I-1 ❑ I-2 ❑ I-3 ❑ 3B ❑ M Mercantile ❑ 4 R residential ❑ 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: Proposed Use Group: I ExistingHazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34: otw, t BUILDING AREA EXISTING if applicable) PROPOSED Number of Floors or Stories Include Basement levels Floor Area per Floor s Total Area s Total Height ft 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 I, as Owner of the subject property Hereby authorize to act on My behalf,in all matters relative two work authorized by this building permit application Signature of Owner Date i X as Owner/Authorized Agent 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 1I CM•� " Print Name Signature of"r/Agt Date Item Estimated Cost(Dollars)to be Completed bY Pernat aPPVlica0nt 1. Building (a`.)� Building �P.e. rn.�.n: t Fe.e 2 Electrical Multiplier h (b) Estimated Total Cost of Construction from(6) r 3 Plumbing Building Permit fee (a) x(e) 4 Mechanical(HVAC) 5 Fire Protection 6 Total (1+2+3+4+5) CJS Check Number }r ' .�.�`.r:�++1 S P�a .,. � ti ..-.. # S .S:kr ...,ems..'�'� .�._�'::2A#� n�'�,�',,.°�sl,:� ���`„ � �7¢v..;:tri `�[ .��f���5��,..t�'"h n, ..f,�4��� r•�l'�� � M,.—; f sP�a nR' NO.OF STORIES SIZE I i BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1sT 2ND 3tw j SPAN DEMENSIONS OF SILLS DEMENSIONS OF POSTS DM ENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY I IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Zr- Y % n�„s-yS, t �. `�;F- s,<"i -,::5 s d £"e#Y�x "� s*e:cy r. 1 Location 5 CAC krl"INIT No. / Date &OWT►1 TOWN OF NORTH ANDOVER � a + Certificate of Occupancy $ c"us`� Building/Frame Permit Fee $ g Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 3 J Building Inspector NORTfy Town o f 4Andover* 0 No. 91 0 LA COCHIC "'Cqdover, Mass., /40 t- 0RATED H BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT......C 60 A NPA A-04 a -A I i ......................................................................................................................................................... Foundation has permission to erect...D PtW!!Y.._ b"'Id'" on ..... ..... Rough to be occupied as.......... 'r'.v+ 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. 8 -A/ /0? 1; '1 *3 do', PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHSFinal UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR Rough 640 J A............................................. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. 3 22!2003 10:07 9786833147 ROBERTS INSURANCE PAGE 01 T►' ISSUE DATE DATE MMIDD S .: T. a.fi.Yid' f 10/22/03 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED RY THE POLICIES BELOW. p R R'"S INS AGCY INC COMPANIES AFFORDING COVERAGE ( ' CS-00D, ST a . Ati;DOVER MA 01845 COMPANY ALETTER S STERN WORLD INS CO Y t 3 1 ......... .... ... .. .... .. ........... .... „• COMPANY LETTER.... . ... . HANOVER INSURANCE CID COMPANY gC CONSTRUCTION CO INC LErrER U.S.L. I . ^ MA 01810 ASSOCIATED EMPLOYERS INS CO c, M COMPANY D - a - LETTER COMPANY E r LETTER THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS " 7`1 A T ",4Ar BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED 8Y THE`POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, :;TUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. r -YfT�Or INSURANCE POLICY NUMBER POUCY EFFECTIVE :POLICY EXPIRATION; LIMITS(MM/DD/YY) DATE(MMIOD/YY) a• GENERAL LIABUTY NF F 8 3 2 8 3 9 4/01/03 4/01/04 GENERAL AGGREGATE s2, 000, 000 ... ............................................ 11 .7t .03cBRERC!a_GENERAL LIABILITY PRODUCTS4OMP/OP AGG. $], .................... WorOCCUR. PERSONAL k ADV.INJURY. !$],, Q Q r,•�0..0..' 7A,`,'ZF o b CONTRACTOR'S PROT. EACH OCCURRENCE :$1, 000, 000 FIRE DAMAGE(Any onp(Irq)..., 1.Q 0, Q 0........... . ........ MED.EXPENSE(Any arta person) $5 0 0 0 AHN6 4 2 4 0 2 7 01 4/01/03 4 01 04 COMBINED SINGLE $ LIMIT 1.,..000,.000 . f �' TO SODILY INJURY J SClYl:D'JLEO AUTOS (Per pemon) y :HIRED AUTOS BODILY INJURY AUTOS (Per aoclaeni) $ I i .............................................. ........................ GARAGE LIABILITY PROPERTY DAMAGE s Ij 1 CUF1006048 4 10/03; 4/10/04 : 6ACHOCCURRENCE y _.. ............ ; lim AGGREGATE 61, 0 0 0, 0 00 _;H=,-rlrtN Uh2REW1 FORM _ CCM mtN8AT1pN WCC 5 0 0 4 3 7 0 01 4/01/03 4 01 0 4 X STATUTORY LIMITS I t .. ......... 1 0 EACH ACCIOENT 11, 000 i QQQ E-PO .................. ..... . ... .....: .......... __..._•.,_r_..,. DISEAB LICY LIMIT.......:.$1!.O O 0, ..O O P DISEASE--EACH EMPLOYEE $1, 0 0 0, 0 0 0 ! f OESCFIPTION OF OPERATIONWLOCATIONSNEM=SISPECM ITEMS `_A—N SCHOOL OF KARATE IS LISTED AS AN ADDITIONAL INSURED IN RESPECTS T T 4^�AB T.LZ TX:..;COVERA..E..:.FOR..:WORK PERFORMED BY..THE INSURED. ....:.....:.::.;.::.. :.::.........,.:::..:.:...:.. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO <`. MAIL 1.P,-DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE Arr.4CAN SCHOOL OF LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR ° f F' ; LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR Rk"PRESENTATIVES, 5c5 CHICKERING ROAD AMMO P N^ _u ANDOVER MA 01845 TIYE 1 ! I I. Z R 1' I. t r. �_ ._ _ ✓/ze'-C�amvmo�.z+ueaf,�� o��/li/aaaac�ucae�a:'� BOARD OF BUILDING.REGULATIONS License: CONSTRUCTION SUPERVISOR I! Number. CS', 049518 Birthdate.`12/25/i947 'r fi j Exp►res 1 212 5/2 0 03 Tr.no. •]2050. Restricted X00 F 99 GARY A BELANGER i 4?MAYFIELDAVE ] METHUEN, MA 01844 - Administrator i ,• i ANDOVER CONSTRUCTION COMPANY, INC. * P.O. BOX 125 ANDOVER. MASS. 01810 Telephone X88'476-6100 Fax 18='470-2560 �7b 97� � 3 Fax Transmission To: Fax Number:: CoO3 - 1 ,;�U a From: �C" CONTENTS: Total Pages transmuted including Cover Sheet. NOTE: if message is not received completely. please contact sender. Subject: n� 1 CSI-�C�L,e, CIA-+C. IEc _,%A .,�.�z� CG,, 1 O V� (o LIS C��C k��11�t S �e,r �C U A'o—c", QE, Cs^C-("L . vv\ctiS c�v\—� , vvEu- ,� i" c( V-E-.r C I N eC.Uc,"n,�CC I C"r �LbCiCoD 70)0 4 G i f NORTp 1 O ta° s "dsul 6u!pllne � 0951 O # DATE: O = $ IV-LO1 aad 3!wJad Ja430 PERMIT $ aaj 3lwJad uo!lepunoi &9=1 m—led aweJd/6u!Pun8 y snm3b, THIS CE �-- r $ Aouedno3o !o aleo!3!;jaO has perm' N3AOUNd NINON .4O N o , - - . _. 565 Chic MOl "�•,1�,;N ►� 4 respectlions of the Codes and By-Laws �2 � 'ON relating ✓ J ! �1 uo!leoo� Violation of the Zoning of Sign Keguiauv.,,, Inspector of Buildings N*A*Rq,L7A S/GNA*RAMA® FRED NASH General Sales Manager 575 Chickering RoaO 978-688-3777 Route 125 Fax 978-688-3993 N.Andover,MA 01845 thesignstore@aol.com "Independently Owned and Operated" American School Of Karate Inside Measurements 78' C/qa a�� 1 1 14' r�'Vic": s ,.�:1►.,y.:1` � �'� ��`'y�Kf:.;. ,�1y'}a�� '3t��Z�@�:+. "'�: .-'i•JF S�• �, �°,` �`�� .,_ ,yam s � w . .• ,.,...,..� �- - -- lro_, . ,- -t+�:7'r�� •�r 7� � t i ;:Y. - Y.a�z Y:�,S.x,T� ...-x2_��.. ,..�.::�¢...2:'` �� r VI "1"'., ,x "", � _ ;, t , .T.€jT.� ��..�....Y. �3. k. � �r `T rsT I � Y �' r•w�,'S! t r - ,. X . s .._a x ;. r ': r' -ri r�.. 1.£ t •r _'z.. rx_x ," M�`�-x x �r r�.x, »xj T ' � a...� x d`r) •`^ `r.�2..°' _ --`� r,L..-i-. -z..-�.z�,T'.�.. ,_�:,..t,.._,.a..-r.,..• � i. c��r1:��i t.' .,c r ��' .x x f 1 A 1 1 ` - r �a 3{ 1 ) i TOWN OF NORTH ANDOVER SIGN PERMIT APPLICATION Site Owner zf/ &_ r Applicant_ r n I Site Address 5-c. ��-� < <�` �' � i� 3 �a = 7c� �"' 7 f� Size of Proposed Sign_ 7 t How attached: a) Against the wall Illumination: a) Not illuminated bS Roof b) Internally illuminated ( ) c) Ground ( ) c) Externally illuminated ( ) d) Other_ O ; c— Proposed Colors: Background Materials: Lettering Border Required Attachments: Note: No permanent/temporary sign shall be erected, or enlarged until Photographs of building an application on the appropriate form furnished by the Sign Officer has Material sample been filed with the Sign Officer containing such information including Color sample photographs, plans and scale drawings, as he may require, and a permit for such erection, alteration, or enlargement has been issued by him. Site or Plot Plan (Required for all free-standing signs) Such permit shall be issued only if the Sign Officer determines that the Drawings of proposed sign sign complies or will comply with all applicable provisions of the By-Law. Other, specify Will sign overhang any public road or walkway Yes ( ) No If Yes, Name of Agency who will provide liability insurance: AN INCOMPLETE APPLICATION WILL NOT BE ACCEPTED DATE FILED: revised:jm- 8/98 SI NATURE OF APPLICANT b I 3�0' 25 r o t ss. 5 LA v 4 OVAT C SU RM-errs*)N Colors -J:M efla� RAID keTl 8\ve SIGN PERMIT WORKSHEET Property Owner Business Name M",;,/1104-0 Sc A06 bra._ Property Owner Address Sign Location Address V Zoning District C Allowed Area �/L'P�, p� S" Proposed Area Allowed Height Proposed Height Allowed Setback Proposed Setback Map Lot Estimated Cost$ Fee$ Permit Application Received 10A /0 -2-- Permit Permit Apposmd/Denied / — 0 ` O Z- Inspector Z" S c -t4 /C/ 's 6 1 3 h AU-v �t/�p n.��a t� p !� 1 Y` e CX A'0--' CJ IC /Y J�./ F Y e s_• 3 _ ...g 1 a rt •�.. a Yep" wo r t iFry N PER111IT NO. APPLICATION FOR PERMIT TO BUILD — NUKIM Nlwuuvkk, Pr►Nal. 9MAP IJO;, LOT NO. 2 RECORD OF OWNERSHIP - DATE (BOOK iPAGE ZC�ivIE I SUB DIV. LOT NO. LOCATION PURPOSE OF &UILDING Z t G �e �� 0 46 OWNER'S NAME Ale to / NO. OF STORIES f SIZE OWNER'S ADDR Efi C .G - &A&EMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMOERS IST 2ND !RD ■UILDER'f NAME FU p &PAN - DISTANCE TO NEAREST BUILDIN-G r _V DIMENSIONS OF BILLS DISTANCE FROM STREET POSTL DISTANCE FROM LOT LINES -SIDES REAR GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS 16 BUILDING NEW - - SIZE OF FOOTING x It BUILDING ADDITION MATER:AL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND I� WILL BUILDING CONFORM TO REQUIREMENTS OF CODE l +S IS BUILDING CONNECTED TO TOWN WATER 7 ' BOARD OF APPEALS ACTION. IF ANY If BUILDING CONNECTED TO TOWN SEWER i to BUILDING CONNECTED TO NATURAL GAS LINE 3 PROPERTY INFORMATION INSTRUCTIONS LAND COOT T 7' SEE BOTH SIDES EST. BLDG. COST EST. BLDG. COST MR SQ. FT- PAGE I FILL OUT SECTIONS I - 7 -- [ST. BLDG. COST PER ROOM � PAGE 2 FILL OUT SECTIONS 1 - 12 SEPTIC PERMIT NO. ' ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING A APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INOPECTOR DATE FI S3JILDINO INtPRCTOR SIGNATURE OF cp4jrm OR AUT IZED AGENT Owners Tel # Contrac, Tel# r[RMIT SRANT[D U l it --- Contra. Lic # U 0 v HIC # (Z t Olt ` _ _ i� To: 00 713 7 7 DEPARTHEN0 0" Pl'5i iC SnFETf' CONSTRUCTION SUPERVISOR i a'E.iSi r 1i �zv Nu&be!'• E:ir'.res: Firt1daCc: i', HdSU^ry I CS 05 " _C 9086 5.',x::!'_9;8 ; _ ' Family c 2 flJlCaS . Restricted To, rt• Farlurr to possess a current edition of the r Hassa_h-Gsetrs State euiildinq Code HENRY E SHr P s cause r � ase for revocation of this license. 99, RTdJ RSI9E DR METHUEN, RA 0:fi4= I fete�io/mnaxu/ea(!�i o�✓tlaw(u.�ivaeCla HOME IMPROVEMENT CONTRACTOR Registration 111257 Type - INDIVIDUAL i Expiration 09/14/98 i HENRY E SHARP { Y E. SHARP ADMINISTPATOR 45 RIVERSIDE DR 20-8 METHUEN MA 01844 V 1 LfOR T/y Town of over No.49 I m °o LAI(E A dover, Mass., �P� 19 9� w 9A_cocNICHEwfcx iY1• /� 9� OAq E Df`►pP`y ,�J `G BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System on BUILDING INSPECTOR THIS CERTIFIES THAT........:.. ..�s.1.......1% ►. .�s�,�acl.. ...T' 41tills...s............................................................... Foundation has permission to erect..... buildings on.......... � ...�.,J�.��....... .................................... Rough tobe occupied as......... '4,P..�c ... 1.� �l�WS............................................................................................................... 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. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRU ON TARTS ELECTRICAL INSPECTOR y� Rough Y.. . .......... ................ Service ... .... . .. .... ........ BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RouFinagh No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner 11-7 Street No. /` k 1 '7 0 Smoke Det. Official Use Only r�7 Permit No. cl a a3t^ t°r(;%W.S4ro Occupancy&ree Checked p� 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 55227 CMR 12:00 (Please Print in ink or type all information) Le Date 811Y10;2- 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 S6 5- Cir,° et %h Ll Owner or Tenant �(/o A & Z I Owner's Address / Quar r y T r r c,,.bo Is th' 0 Pur, n tion No. • 020U 0 1 ❑ No.of Meters Exi Date. .. ....... . e I N ❑ No.of Meters J HORT" Nu o'<•.•. -•.'"o TOWN OF NORTH ANDOVER Loci .• oc misoft. p PERMIT FOR WIRING - ,3 • Total � x -formers KVA -� SSACMuS� No.a a KVA �/ (° F ! G gency Lighting No.a This certifies that . ........ ............(.�.....�f........... .....y1..7�........................... No.o has permission to perform ........ IIS No.of Zone tion and .� wiring in the building of........ q........f �, z 1........................................... rices No.o <� 5 c, ":�:.:.1.�.......,�` orth Andover, ass. s 1 at...Y, .......,�............................ ,-J ilontainede No.oI ' �( / ) //� unding Devices y�if S Llc.No..l.T—?-/* ,--?1.......... �K��,_,. .....11ll..... .. . ...... unicipal ❑ Other Fee. .,:........ No.O. ELECTRICAL INSrECT onnection No.o° Check # _ No. — 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 t�e�oc3 rage by checking the appropriate box INS RAN = BOND = OTHER = (Please Specify) / (Expiration Date) Estimated Value of Electrical Work$ Work to Start Inspection Date Resquested Rough Final Signed underte Pe (ties of p rjury: FIRM NAME//}} /�k+/-�K, SeF�t ��e J`.' !'A LIC.NO. 3/83C7'C Lkensee As A K. S,'ey j;;r- Signature ( LIC.NO. Bus.Tel No. 9 78'8/ 60-70 Address (�J V 3o f GS Na,tO CJh i� 40/86 Aft Tel No. 97-8- 66g/- 66VO - OWNER'S INSURANCE WAIVER: I am aware that the LiQ4hses 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 $ I'"q(✓5w`� (Signature of Owner or Agent) j I I I COMMOI�wEALTH`-6FgSSACHoSETTS ; , , A OF ELECTRF,.:'IANS - REG JOURNEYMAN ELECTRICIA ISSUES THIS LICENSE TO ASA K SEELEy T:I BOX 312 READING ` �,. �16 MA C.xF3f4�03 .?830 c 07/31/ ��. J4 363277 MmulI - mem". _ Fold,Then Detach Along All Perforations • 0 TOWN OF NORTH ANDOVER BUI LDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING _.:.. x7ggz nThis Section for Official Use Onl BUILDING PERMIT NUMBER: Z DATE ISSUED: 1-7^3 Z SIGNATURE: /(/L Buildin Commissioner/I or of Buildin Date 1 _ 565 C Location .�/ No. 1 Date d v 1.3 Zon' pORTp, TOWN OF NORTH ANDOVER � Zonin District 3 pyoo� 1.6 BUE DIN .° ; - p m Fr + Certificate of Occupancy $ Regtur( �vided Ex 'Ss��Mustt� Building/Frame Permit Fee $ 70 1.7 water Suply h Foundation Permit Fee $ Public ❑ Pr isposal System ❑ Other Permit Fee $ 2.1 owner of R TOTAL _ $ 9D Evan �� r� MA 0 Na mt) Check # rn Signature 2.2 Authorized 1 5 7411 ' Building Inspector Pris 01880 D Name Print Z 781-246-1900 0 Signa re Telephone /m 3.1 Licensed Construction Supervisor Not Applicable ❑ 107 Audubon Road, Bldg. 1 - Suite 19 CS 078126 Address License Number O Matthew Genzale Licensed Construction Supervisor: 1 3 05 781-246-1900 Expiration Date Signa Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ 0 Company Name r Registration Number m ' r Address r Expiration Date ^Z P1 Signature Telephone 1, Matthew Genzale / Prism Builders, Inc. asOwner/Authorized Agent 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 Matthew Renzale Print Name 7/11/02 Signature o er/Agent #4 Date Item Estimated Cost(Dollars)to be x' 75 (► Completed by permit applicant 1. Building .50000 $60,000 (a) Building Permit Fee Multiplier 2 Electrical '1.000 (b) Estimated Total Cost of $12,000 Construction from(6) 3 Plumbing 6Ooo Building Permit fee (a)X(b) $6,000 4 Mechanical(HVAC) 600 600 5 Fire Protection N/A 6 Total (1+2+3+4+5) $78,600 Check Number a`x.±bk 'N '�t,. �• ark n�z�;.'��.��1k��iS 4- }+.:'� .i,.�"n,zr ��r���,.r,:ti 5t�:.,���r� s�, r i s a�.,t� � s * -��1 f��lu��zt"+ -_r r � r � ��,ix s1 a4•s_ — 1.�r{ a: ,,.u., cc'•:. +,r„ � _ tt +s "' x.� � �! x, .;�' NO.OF STORIES Existing SIZE BASEMENT OR SLAB Existing SIZE OF FLOOR TRVIBERS Existing 1ST 2ND 3RD SPAN Existing DEMENSIONS OF SILLS Existing DEMENSIONS OF POSTS Existing DIMENSIONS OF GIRDERS Existing HEIGHT OF FOUNDATION Existing THICKNESS SIZE OF FOOTING X Exsiting = MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND Existing IS BUILDING CONNECTED TO NATURAL GAS LINE Exisintg r ,r v�Y hs ` -` Af�. cv,�Vde m F t9S� rr FORM U - LOT RELEASE 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 or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT-AM !A SA ppl 3(-� PHONE � 64- Io8y LOCATION: Assessor's Map Number PARCEL SUBDIVISIONLOT(S) STREET Ck t c.V*AVN q -0 ST. NUMBER N05 ************************************OFFICIAL USE ONLY *********************************** RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS ANN lzE u, 2 ch 5� DATE APPROVED ' - ` DATE REJECTED COMMENTS �y FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT a FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9\97 jm OFFICE OF BUILDING INSPECTOR TOWN OF NORTH ANDOVER ...�.. CONSTRUCTION CONTROL PROJECT NUMBER: PROJECT TITLE: 221AC661114 A07 NE WoSdFACM PROJECT LOCATION: C-t"C-4L NAME OF BUILDING: NATURE OF PROJECT: IN AC20RDANCE tTH1AR1A_TlCl EF THE MASSACHUSETTS STATE BUtLD� I, ��� PREGISTRATION NO. 4F 441 BEING A REGISTERED PROFESSIONAL ENGINEERJARCHITECH HEREBY CERTIFY THAT I HAVE PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS, COMPUTATIONS AND SPECIFICATIONS CONCERNING- ENTIRE PROJECT 0 ARCHITECTURAL9 MECHANICAL FIRE PROTECTION ELECTRICAL OTHER(SPECIFY) FOR THE ABOVE NAMED PROJECT ANU THAT, TO THE BEST OF.WY KhiM1,EGE,SUCV PLANS, COMPUTATIONS AND SPECIFICATIONS MEET THE APPLICABLE PROVISION OF THE MASSACHUSETTS STATE BUILDING CODE,ALL ACCEPTABLE ENGINEERING PRATICES. AND APPLICABI-8 LAWS AND ORDINANCES FOR THE PROPOSED USE AND OCCUPANCY, I FURTHER CERTIFY THAT I SHALL.PERFORM THE NECESSARY PROFESSIONAL SERVICES AND B EPRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND PERIODIC BASIS TO DETERMINE THAT THE WORK IS PROCEEEDING IN ACCORDANCE WITH THE DOCUMENTS APPROVED FOR THE BUILDING PERMIT AND SHALL BE RESPONSIBLE FOR THE FOLLOWING AS SPECIFIED IN SECTION 116.0 1. Review, for conformance to the design concept,shop drawings, samples and other submittals which are submitted by the contractor in accordance with the requirements of the construction documents_ 2. Review and approval of the quality control procedures for all code-required controlled materials. 3. Be present at intervals appropriate to the stage of const ru e, generally familiar withSthe progress and quality of the work and to date a work Is being performed in a manner consistent with the constn.Cti Cy0 PURSUANT TO SECTION 116.2 .2 1 SHALL SUBMIT Y, O REPORT TOGETHER WITH PERTINENT COMMENTS TO THE NG I ECTOR. �h g5• UPON COMPLETION OF THE WORK, I SHALL SUBMI T E r SATISFACTORY COMPLETION AND READINESS OF T r NCY SUBSCRIB ANDS M TO BEFORE ME THIS DAY OF v 20002. NOTARY PUBLIC MY COMMISSION EXPIRES =November /INCENT lic assachusetts Expires ,2007 Date: 7/2/2002 03:57 PM Senders Fax ID:McLaughlin Insurance Page 2 of 2 R� CERTIFICATE OF LIABILITY INSURANCE CSR EX DAT6iNL4,DD" PRIS14-1 07/02/02 iR000CER I THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE McLaughlin Insurance Agency HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 828 Lynn Fells Parkway 1 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Melrose MA 02176 Phone: 781-665-2775 Fax: 781-E65-0295 INSURERS AFFORDING COVERAGE INSURio -- -- — INSUDERA Ohio Casualty Group Prism Builders, Inc. n5•Ie'_P H Attn: Susan Veno — 107 Audubon Road, Bldg 1 s''CEc Suite 19 ':n.SVPE Wakefield MA 01BEO IN;)FE= COVERAGES =COVERAGES THE POLICIES OF INSURANCE:IS7ED 8ELO11J-AVE EEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICYPERICD IND'CATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONOIT:ON OF ANY CONTRACT OR OTHER DOCUMENT w TH RESPECT TO NM,CH THIS CERTIFICATE MAY BE ISSUED OR MA'/PERTAIN,THE INSURANCE AFFCRDEC BY THE POLICIES OESC"ED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID C'_AIMS. INlR� FCLICY EFFECTIVE F LTR TYPE OF INSURANCE POLICY NUMBE0. QUCY!%FIRATIOr.' CATS MMTO"! DATE RAPAM0,7YI I LIMITS GENERAL LIABILITY 17Ec=0=UP.RE;:CE 1,000,000 A COANEROSL;EYE;f; A31L!Tr' =E:hMACc(Av cna f'.-e 13 100,000 E U r.+E _ arn�;roes:on• I i 5,000 AL., P.' 1,000,000 L—� R/O BKA0252504031 06/30/02 06/30/03 1 GENERAL E >2,000,000 w3GPE•i .Ir.;r:: L.Ei pco j PPC,. 2,000,sP.�F.-• 2,000,000 I �TOMOEIILI LIABI_- nrr .I, I :CME:hEu91+•aLELVIr (`1,000,000 (Ea acanxa; i �ALL CT,Y!lED.:J':S j �� i i I SCGVI^IJUC•v I 'EC,NEDI.LrJ�_'.•: FmC'::C^; �' A E' ^'Eo::' _'_ R/O CBZB15790 1 06/30/02 05/30/03 ~— �— A $ r•nN.I=r.a!E^.,. /.r,L'tl i. . i GARAGE UABIUTY _ E%CEE6 LVBIL'TY 5,000,000 A 'I% I:''-'•'P _ ==-:u •� j HKA0252504031 06/30/02 06/30/03 s 5,000,000 I I` 1 �i !WORKERS COMPENSATION AND ' - EMPLOYERS'UASILITY j I g A 500,000 R,!O %P00152509031 06/30/02 06/30/03 __ : 500,000 •;OTXGR e.F•LY:Y r„T 1<500'000 I I A Install Floater IAny Job $25,000 _ R/O BKA0252504031 1 06/30/02 06/30/03 DGSCR�P 11UN OF OPERATIONS T.S LOCATICNS.VEHICLGS:E%:L_SI ONS ACOED BY ENDORSERIENPECIAL FRCYISIONS — CERTIFICATE HOLDER Y ACOITIONAL!NSURED:INSURER LETTER: CANCELLATION S14OULDANN OF THE ASCSE DGSCRIBED POLICIES BE CANCEL-ED BEFCRE THE E%FIRATION DATE THEREOF,7HE I990NO INSURER LMILL ENDEAVOR TO MNL 30 DAYS WRITTEN NO–..CIG TO THE CIiIZM-.ATE HCLCSR NATUEC TO THE LETT.BUT FAI W RG TC DO SO GRALL IMPOSE NO OSL OATION OR LIABILITY OF ANY KIND WON THE INSURER.NB AOlNTS GR _ REPRiSENTATIVi:. iAUTHOR-01, ESEN NG ACORD 25-S(7/97) t ACORD CORPORATION 1988 BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 078126 Birthdate: 01/03/1978 Expires: 01/03/2005 Tr.no: 78126 Restricted To: 00 MATTHEW R GENZALE 46 CRESCENT AVE SAUGUS, MA 01906 Administrator The Commonwealth of Massachusetts JDepartment of Industrial Accidents Office oflnvestigations Boston, Mass. 02111 r _ WorKers'Compensation Insurance Affidavit Please Print Name: American School of Karate Location: 565 Chickering Road {ty North Andover, MA Phone am a homeowner performing all work myself. �I am a.sole proprietor and have no one working in any capacity l am an employer providing workers'compensation for rry employees working on this job. Company name-: Prism Builders, Inc. Address 107 Audubon Road, Building 1, Suite 19 Cid Wakefield, MA phone# 7.81-246-1900 Inautance Co. Ohio Casualty. Insurance Co. po"CV. XGIO 52504031 MEOW Address Cllr: Phone* .n 4r�anoe Go. Poll►# __ l=aifilre hi ase cuf6 caverage as"Wired under Section 25A car!GL IS-- and/or one years•impris&nmwt as'well as chn7 penalties in:th i form,of a SToP WORK OtZ!>! and a tine of 31affles f day against 1.5ne. 1 understand that a copy of this statement may be forwarded to the Office of Invr stigatkm of the DIA for coverage verification_ l do herby certify under the pains and pen Ofpeduty that the Wxmatkn provkfed above:is true anis coff"t: Signature Date 7/11/02 ' Matthew Genzale Print name Phone# 781-246-1900 Official use only do not write in this area to be completed by city or town offic:iar Building Dept ' D.Oireck if immediate response is regrud Building Deft © Licensing Board electrrian's Office Contact person: Phone# D S 0 Health Department 0 offer :4;°WORKMAN'S COMPENSATION �etegnu�w r 09010 IA+T 'AO06Vai NI 3N+d a1N01 C NVA-VVM "alio b 00 -loop"ov tL99i dti'•J HWAM D;wgdsl 1901180M AgpNual IM90 to :ggwnN VOSIANidneNOjL3 WjgN07 :•*ue0ljj INO1LVV03V OMIa?In9 dp amrov vfl'd 1��09b�, istt TA6A '4bZ 't9d ' T Ley iz: tfl ZO-©8-'lftr —.... . _ ,iUL-3e-0.. 07�2� t�M 1. T83 . 246.0903 17812�6990Y P.01 i ---- TOWN of rOltTH AlNDOVM BIUMDMG DErARTMENT ' .rxk cic►�to axr�ivtum.v.n� nv�r�VRAWAnslift a, or IbL%Nx BO WT SM—oln EiL1LD F ye; DA . t SUM � _SIGNATI V PIMA taws. a 1.4 PAPE"wowmim. .#its . nq+/se lAr 1ks Alw7r� Mw�(1q Side Y ltnr Yard p pprid� !Mod Ptorided fWA.' M'N�+Y�r 741 r eyrrArleir IM—f0d 084baYMmtG7r- 3W 1 UrrOh of!roof r 3.1 l.thlr0 l'A '�f11�'�M► 1iq f _. . .IKON - AB jpAM N�nfMl LDNE Pt E LNV MMD 1.2 •- ar7nrl Mww[eN�.wiain!Cwin�crw . . . ._ ��,� r,. 1pyv Nam iir, KYt711rr %woo'• .�..�.�.'...�._...` -- 1.7s�lwoe r�� •--• .. IdRao0e - NORTH Town . of - over �- N= 0 No. —7- o dover Mass. ` 3o daa 1Q COC HICK WICK\y 1 1 �•9 °RATED S � BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System THIS CERTIFIESTHAT 4Vit N ��N �1Z/ �f�r` Ih����A V S I�J UILDING INSPECTOR ......................................................................................... ........... .......................................... Foundation 00 4'! N 1 v.rbuildings on .....S C k1 `x�N 1 A� — Rough has permission to erect.....�.. ......................... ......................................... ....................�................. to be occu occupied as ik� rr r" r 1► .. r„I........... 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 y-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. 8 y a S � 170/106 i PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARS ELECTRICAL INSPECTOR Rough ............................ Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det.