HomeMy WebLinkAboutMiscellaneous - 57 BOXFORD STREET 4/30/2018 (2) r57BOXFORD STREET \1
/ 1 `
� 210/106.A-0065-0000.0 \\ �
MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION
Two Center Plaza
Boston,Massachusetts 02108-1904
(617)723-3800 Ma Only(800)392-6108,FAX(800)851-8424
1/13/2018
Form of Notice of Casualty Loss to Building
Under Mass.Gen.Laws,Ch.139,Sec.36
NORTH ANDOVER BUILDING COMMOSSIONER
NORTH ANDOVER TOWN HALL
NORTH ANDOVER MA 01845
Re: Insured: ROBIN SAVIGNI
Property Address: 57 BOXFORD ST.NORTH ANDOVER,MA 01845
Policy Number: 1373343
Type Loss: Water Damage:All Other Water Damage
Date of Loss: 01/11/2018
Claim Number: 421571
Claim has been made involving loss,damage or destruction of the above captioned property,which may either
exceed$1000.00 or cause Massachusetts General Laws,Chapter 143,section 6 to be applicable. If any
notice under Massachusetts General Laws,Chapter 139,Section 3B is appropriate,please direct it to the
attention of the writer and include a reference to the captioned insured,location,policy number,date of loss
and claim or.file number.
MPIUA Claims Division
CMA00021
MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION
Two Center Plaza
Boston,Massachusetts 02108-1904
(617)723-3800 Ma Only(800)392-6108,FAX(8001851-8424
10/15/2016
Form of Notice of Casualty Loss to Building
Under Mass.Gen.Laws,Ch.139,Sec.313
NORTH ANDOVER BUILDING COMMOSSIONER
NORTH ANDOVER TOWN HALL
NORTH ANDOVER MA 01845
Re: Insured: ROBIN SAVIGNI
Property Address: 57 BOXFORD ST,NORTH ANDOVER,MA 01845
Policy Number: 1373343
Type Loss: Water Damage:All Other Water Damage
Date of Loss: 10/14/2016
Claim Number: 409667
Claim has been made involving loss,damage or destruction of the above captioned property,which may either
exceed$1000.00 or cause Massachusetts General Laws,Chapter 143,section 6 to be applicable. If any
notice under Massachusetts General Laws,Chapter 139,Section 3B is appropriate,please direct it to the
attention of the writer and include a reference to the captioned insured,location,policy number,date of loss
and claim or file number.
MPIUA Claims Division
CMA00021
J f
Date .l)b 1)/!7
TOWN OF NORTH ANDOVER
«� PERMIT FOR WIRING
This certifies that . . � �G, I!.• . . . . . . . . . . . . . . .
has permission to perform . !/�1 v
. . . . . . . . . . . . . . . . . . . . . . .
wiring in the building of a.✓. /. .!` ! . . . . . . . . . . . . . . . . . . . . . . . .
at . . . .�. .�. . .�� �`.�:{. .Sr:. . . . North Andover Mass.
Fee . . Lic. No. . .
ELE RICAL INSPECTOR
Check# 3 v
11179
Commonwealth of Massachusetts Official U``se Only
Department of Fire Services Permit No.
' p Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leaveblank
v�
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date:
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number)
A u l S' (; ri 1 Telephone No.
Owner or Tenant R n ( �
Owner's Address
Is this permit in conjunction with a building permit? Yes [6""- No ❑ (Check Appropriate Box)
Purpose of Building W « ^+ e- Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: (�,� r YZ l ""t C- �-l'e-0 a�S
Completion of the following table may be waived by the Inspector of Wires.
No.of Total
i No.of Recessed Luminaires � No.of Ceil:Susp.(Paddle)Fans Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
Above
In
o.o Emergency Lighting
No.of Luminaires L4 Swimming Pool rnd. ❑ rnd. ❑ Batter Units
No.of Receptacle Outlets 'Z No.of Oil Burners FIRE ALARMS
P No, of Zones
No.of Switches No.of Gas Burners No.of Detection and
L� Initiating Devices
No.of Ranges No.of Air Cond. TonTots No .of Alerting Devices
No.of Waste Dis osers Heat Pump Num_ber .Tons KW No.of Self-Contained
P Totals: Detection/Alerting Devices
al p
No.of Dishwashers Space/Area Heating KW Local El Mimic'Municiion ElOther
+ Heating Appliances KW Security Systems
No.of Dryers No.of Devices or Equivalent
t No.of WaterKW No.of No.of Data Wiring:
Heaters Signs Ballasts No.of Devices or E uivalent
Bathtubs No.of Motors Total HP Telecommunications Wiring:
No.Hydromassage No.of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: t 6 06. (When required by municipal policy.)
Work to Start: t b -2 9 j z Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE E&If3OND ❑ OTHER ❑ (Specify:)
I certify,ander the ains and penalties ofpee ury,that the information on this application is true and complete.
FIRM NAME: . �CJ�'(� �'I / '�C/ LIC.NO.: 4 S2 z-F
Licensee: Signa tur LTC.NO.:
(If applicable,enter "exempt"in the license number line) Bus.Tel.No.CR 7
3 ?�
Address:
k ese y Q� AIA o3(.s
Alt.Tel.No.
:
Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑ owner's agent.
Owner/AgentPERMIT FEE:
SilInature Telephone No.
�9 I
f •
^ ._ • .+:+JUJ6��l.rl.J.�.L'U�,c�(�'�s/�"�J�l!(1..�.'1,L�fJ-ilJ�'��'Q®��i�i'p�j.�'(�j'J'� ,.'-'•l�JI�UJ+..+.�.4Y J-`aa�JG®�`�•*•� �
_ .U'a r�n'U.�0.'�x.�.C�,.V_f J-.lt9.R.+�/rL.J.f.V'�" .. � — ' ,.�_ • • '
.R017ir P MON,
. asset xaileft•=•[ Ie-znspee ioxtxegtuzacT{ �OAQ)•-�
�uspectpxs'�ozume�.ts: - '
(JCusp oxsy atux'e�3xo�xitiaYs} .- _ date
3.'assec�--[ �'aftec�-•j } � etc-3�ns,�ee�ioxtxe4uixec�(��4.40)--j � .
�StS�ecta�rs'comiuents; '
{JCnsliectozs',ignature• 3z0 7xtztiaTs) /,� % iZ y !/ date
'asser3--Z � �'azIec�•-j � ate-•Snsp eetzo�,xetluixet�{��Q.40)�[ �
as,vectozs,comments;
(�nspectoxs�,�ignatuxe��oin�` aTs} ]ate
OMI C. 1 R-TbW e+OXA:I�`I +Erb11 ; NAME:
y
�sec�--[ ) �'af1e�--j � Re 5nspeci�oxtxequi�e�{�50.4D)�j �
�ectbxs'eo)mutep.�s;
05aspectoxs',fignatuxe-io initials) Pate
r '
'Re-Ins
eetioxt xeguixed{$ 0.4D)• [
actoxs'coznmarits;
• S
(ft
s ectoxa° ignatuxe no xnitiaTs} date '
P
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): �
—r-
Address:�
City/State/Zip: -."A Phone#: k4 1
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
— enip4oyees(full and/or part-time).* have hired the sub-contractors
2. e I am a sole proprietor or partner- listed on the attached sheet.t ?• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
[No workers' comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ I im a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs
insurance required.]i employees. [No workers'
comp.insurance required.] 13.❑ Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Ad',Iress:_ 5 City/State/Zip: N Ayu O ay
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
Pine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
if 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.
l do hereby certify under the pains a d penalties of perjury that the information provided above is true and correct.
3i nature: Date: / 6 _ -3o — /2-
?hone
/2?hone#: 1 V'J y 2a
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
t
Information 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 withhold 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 evidence 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 sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of a'
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 Department 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 }
5
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."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 burn 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 Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax# 617-727-7749
www.mass.2ov/dia
y
N° 9630 Date
i•
4,o TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
• � •"a
SSAcW
This certifies that . . . . . . . . . . . Pesti .... S
u ^^—i�?n.c�
has permission to perform . . . . . . . . . . . . . . . . .
plumbing in the buildings
f' . . . . . . . . . . . . . . . . . . . . . .
at. . . . . . . . . . . . . .. North Andover, Mass.
Fee 6-:x. . . .Lic. No�.7.�7. 9 . . � . . . . . .
PLUMBING INSPECTOR
check #
WHITE: Applicant CANARY: Building Dept. PINK:Treasurer
v
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
' CITY fl _ ---I MA DATE PERMIT#
yo _
JOBSITE ADDRESS OWNER'S NAME
P -
OWNER ADDRESS S TEL ? 7 p FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT:® PLANS SUBMITTED: YES® NO
FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB )
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM I ......I �( �( _,! ,.__.._,_l I ...- _w_J
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER �f .___.-! _ I V f I _ I _--..__...-JII--._..._-J _-__' ._.____I .-___.__I .._..___-! ._ _._! -I _.___.(
FLOOR IAREA DRAIN _? f � 1 1 f ....__1 J .___.._ ._--_-__.F ._._.-__I __.........__
INTERCEPTOR INTERIOR I I I _. J I J J I ( _1 _j
KITCHEN SINK F—! _J _._.._.J --i ____.I _._._.__1 __-__-! _-_� .__ I _.._..._.._( ...-__.._-.I ._._.._...I f t _..__.__J
LAVATORY
ROOF DRAIN
SHOWER STALL �f _ail.----I _.___-___( ... __I .._.__..I _._._.._I __._._J __._J _____l _. __� .--__...J
SERVICE/MOP SINK
TOILET
URINAL _ I ......._..-..1 I i J .._.____.� ._._.._.__ f __-..__._..( J _..___.._i .__._.._( ......__ J _. ._._._..:
I
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING i ; I { [
OTHER L—J
!
I __.-_-._.I ..____-I ( _(
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ] NO �l
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ®'i BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT
SIGNATURE OF OWNER OR AGENT
1; hereby certify that all of the details and information I have submitted or entered regarding this applicati n ar§Arue and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will b in ompliance withal[Pertinent provision of the
IVlassachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE# SIGNATURE
MP _I JP Ej CORPORATION O# PARTNERSHIP O# LLC E
COMPANY NAMEjs� �� ADDRESS
CITY �,{/� fi STATE j ZIP -- ^� TEL �� l
FAX � �J CELL JJEMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
—� � Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT# /44-01
PLAN REVIEW NOTES
y
b
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,NM 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lellibly
Name (Business/Organization/Individual):
(Vt 0 J'A C
Address: 9t/ 14,11
100,
City/State/Zip:J�4,,eJ Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2. I am a sole proprietor or partner- listed on the attached sheet. 1 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers' comp.insurance. 9. ❑Building addition
[No workers' comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their
1011 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself. [No workers'comp. c. 152, §1(4),and we have no 12.❑Roof repairs
insurance required.]t employees. [No workers' 13.❑Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
(Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
F am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
Information.
[assurance Company Name:
?olicy#or Self-ins.Lie.#: Expiration Date:
lob Site Address:__C7 S74'fes/ City/State/Zip:Xk 1
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
nne up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
)f up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
nvestigations of the DIA for insurance coverage verification.
do hereby erti under the pains andpenalties ofperjury that the information provided above is true and correct
ti nature: Date: f
'hone#:
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
,q
Information 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 withhold 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 evidence 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 sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)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 Department 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)and under"Job Site Address"the applicant should write"all locations in (city or
town)."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 Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel.#617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax# 617-727-7749
www.mass.gov/dia
ik
i
COMMONWEALTH OFMA§SACHUSET-TS
PLUMBERS AND GASFITTERS.
LICENSED ASA JOURNEYMAN p.LUMBE
i` ISSUES THE ABOVE LICENSE TO
f ` Luis C -FERNANDES �..i
94 BERKELEY AVE � '
t MA 01852-490
L'OWE L L
?_'P179 05/01/14 1.7646:8
r Fold,Then Detach Along All Perforations
CONTROL# H 3 8 5 012
IMPORTANT
If this license is"lost or destroyed, notify your Board at the: ;
Division of Professional Licensure, 1000 Washington St.,
Suite 710,Boston,MA 02118-6100.
If your name or address shown is changed, notify.your board
of correct name or address to insure proper mailing of next
Renewal Application. Always refer to your license number.
This license is subject to the provisions of the General Laws
as amended. It is a personal privilege,and must not be loaned "
or assigned to any other person. Keep this license on your
person or posted as required by law. K
Fold,Then Detach Along All Perforations J T
Location 52
No. Date �d
„oRT„ TOWN OF NORTH ANDOVEFG.
F , Certificate of Occupancy $
• ' Building/Frame Permit Fee $
SACMUS tom# Foundation Permit Fee $
Other Permit Fee $
Sewer Connection Fee $
0
Water Connection Fee $
TOTAL $
Building Inspector
' x:4433
i" Div. Public Works
PE&\IIT NO. � -- Y —-- - - - L _ _ 1� PAGE 1
APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS.
tMAP 440. LOT NO. 2 RECORD OF OWNERSHIP (DATE BOOK :PAGE
ZONE I SUB DIV. LOT NO.
LOCATION ; _ _ .i�v! *PURPOSE OF BUILDING
OWNER'S NAME NO. OF STORIES SIZE
m . _
OWNER'S ADDRESS BASEMENT OR SLAB
s
ARCHITECT'S NAME - SIZE OF FLOOR TIMBERS IST 2ND 3RD
BUILDER'S NAME SPAN
DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS
DISTANCE FROM STREET POSTS
DISTANCE FROM LOT LINES-SIDES REAR GIRDERS
AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW SIZE OF FOOTING X
IS BUILDING ADDITION MATERIAL OF CHIMNEY
t
IS BUILDING ALTERATION �ryL_% % 1 �/,' �1S BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM TOREQU1REM%N' S OF CODE IS BUILDING CONNECTED TO TOWN WATER
BOARD OF APPEALS ACTION, IF ANY IS BUILDING CONNECTED TO TOWN SEWER
IS BUILDING CONNECTED TO NATURAL GAS LINE
INSTRUCTIONS 3 PROPERTY INFORMATION
LAND COST
SEE BOTH SIDES EST. BLDG. COS. V
fl 16
PAGE I FILL OUT SECTIONS I - 3 EST. BLDG. COSTIPER SQ. FT.
PAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY
t
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
T
DATE FILED
NUILDING INSPKCTOR
SIGNATURE AWNER OR -o-- GEN J e / ''}/��/
l{ C7�.s OWNER TEL.# �/V/���Df1 J -GD•J
FEE
PERMIT GRANTED CONTR.TEL.#
19
•q„ CONTR.LIC.#
H.I.C.#
BUILDING RECORD s f
1 OCCUPANCY 12
SINGLE FAMILY STORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM
MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA-
APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN.
CONSTRUCTION
2 FOUNDATION 8 INTERIOR FINISH
CONCRETE B 1 2 13
CONCRETE BL'K. PINE
BRICK OR STONE HARDW D
PIERS PLASTER
_ DRY WALL _
UNFIN.
3 BASEMENT
AREA FULL FIN. B M'TAREA _
'/. 1/2 3/. FIN. ATTIC AREA _
N_O 8 M FIRE PLACES _
HEAD ROOM MODERN KITCHEN
4 WAILS I 9 FLOORS
CLAPBOARDS B 1 —2 3
DROP SIDING CONCRETE —I_
WOOD SHINGLES EARTH
ASPHALT SIDING HARDVd'D _
ASBESTOS SIDING COMRACN
VERT. SIDING ASPH. TILE _
STUCCO ON MASONRY _
STUCCO ON FRAME
BRICK ON MASONRY ATTIC STRS. 8 FLOOR I_
BRICK ON FRAME
CONC. OR CINDER BLK.
STONE ON MASONRY WIRING
STONE ON FRAME r"
SUPERIOR I__� POOR
ADEQUATE NONE
5 ROOF 10 PLUMBING
GABLE HIP BATH (3 FIX.)
GAMBRELMANSARD TOILET RM. (2 FIX.)
FLAT A SHED WATER CLOSET _
ASPHALT SHINGLES -LAVATORY
WOOD SHINGES KITCHEN SINK
SLATE NO PLUMBING _
TAR 8 GRAVEL STALL SHOWER _
ROLL ROOFING MODERN FIXTURES _
TILE FLOOR
TILE DADO
6 FRAMING ' 11 HEATING '
WOOD JOIST PIPELESS FURNACE
FORCED HOT AIR FURN.
TIMBER BMS. h COLS. STEAM
STEEL BMS. S COLS. HOT W'T'R OR VAPOR
WOOD RAFTERS AIR CONDITIONING 'p
RADIANT H'T'G
UNIT HEATERS
7 NO. OF ROOMS GAS T
L
8M'
' T 2nd _ ELECTRIC
I st 1 OI
3rd NO HEATING
NORTFy
.i, (DNvn- of 4 R over,
No.
*nor dower, Mass., 199
COCHICHEWICK
�AD'gATED
'9S BOARD OF HEALTH
OiT
Food/Kitchen
. Septic System,
BUILDING INSPECTOR
THIS CERTIFIES THAT................................:.
•
;.......V../r'f.4F_............... ...... ........................a """""""` Foundation .
a (Z"�
has permission to erect....... ",l /. .�... buildings on ..... .7...... ..( ......, ............ ......................:........... Rough
to be occupied as.............................:.................. -c.� ..,.... 1.. .1/5 ........ .............I...... .......... Chimney
provided that the person accepting this permit shall in every respect conform.to the terms ofIhe application on file in Final
this office, and to the provisions of the Codes and By-haws 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 CONSTRUCTION STAWS Rough
................:.........:... Service
UILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Rough
°Display in a Conspicuous Place on the Premises ` -- Do Not. Remove Final
f No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector.
Burner
Street No.
,. Smoke Det.
y
b
, y
TOWN of NORTH ANDOVER
Ar'-FIDAVIT
am- 1pcCa,act3r Ia z
aRioimtto.Fe mt An licaroa
MZ_c 142 A tures that,the • �r� ���
ramal;damli.tiarn, or�r tip. of an aim m any pre- eras b nld
irg crntairnzg at lest one b t mt —�n faur,�17-irg torts-..or tD, start � 4ich are a ijweat to
strh L�dH� Cr g'be da by nth n ' atF
Er
Type Of Work: _ ) 1 ? C UC 7! FSt. c6st G/U
Address. ofrk :V F V
`
owner Name: -v2:-f' 4a-
Date
of Permit Application;
i hereby certify that: `
Registration is not req=ed. for the following reason(s): Fr ofsice Use. Qay
Work excluded by law fit'.No:
Job rendez $1,.090. Date
Building not ownr- occupied
Owner, pL l'no own permit
Ether. {specify)
Notice is hereby given that.
OWgS TU _
7 TNc U= OWN PER= OR:.DEAi.!% WITH UNREGISTERED Ct?NIRACTUPLS_
NE
FUR APPLICABLE EICME I RflVEMEYT WCC"-DO Nom::HAVE ACCESS TO UE ARBITRA-
TION PROGRAM;OR GUARANTY FUND II1EFR MGL c. .142A_
:
Si
� of
tert Lnf= I�'a1
_-- .I hereby apply for a permit as the agen t or the owner:
Date Contractor Name Registration oto.
OR:
Notwithstanding the above notice,, I hereby apply for a permit as the
owner of the above prop
Date 'Owner Name