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HomeMy WebLinkAboutMiscellaneous - 59 MILK STREET 4/30/2018 59 MILK STREET��-� 210/059.0-0038-0000.0 ' '1 E Npgpy e NORTH ANDOVER BUILDING DEPARTMENT ssaim.in..c. �� oR,TEo y 1600 Osgood Street � cwus�� . . North Andover Tel: 978-688-9545 Fax: 978-688-9542 BUSINESS FORM FOR TOWN CLERK DATE: 3 l a g zv 13 NAME: Co 1)ems, A, W,�s� ^ COPE � ✓a �1(•s ADDRESS: J" ZONINGDISTRICT: r TYPE OF BUSINESS: CIO S I't 7 BUILDING LAYOUT PROVIDED: YES NO AVAILABLE PARKING SPACES: ZONING BYLAW USAGE: YES NO BUILDING INSPECTGR SIGNATURE BUSINESS FORM FORTOWN CLERK ' r 2.40 Home Occupation(1989132) An accessory use conducted within a dwelling by a resident who resides in the dwelling as his principal address, which is clearly Secondary to the use-of the-building.for Hiring purposes. Home occupations shall ` 'include,"but not'limited to the following uses; personal services such as fun fished by an artist or instructor, but not occupation involved with motor vehicle repairs, beauty parlors, animal kennels, or the conduct of retail business,or the manufacturing of goods,which impacts the residential nature of the neighborhood. 4. For use of a dwelling in any residential district or multi family district for a home occupation, the following conditions shall apply: a. Not more than a total of three (3) people may be employed in the home occupation, one of whom shall be the owner of the hbme occupation and residing in said divel ing; 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 existing gross floor area of the dwelling unit. so used, not to exceed one thousand (1000) square feet, is devoted to'such use. In connection with such use, there is to be kept no stock in trade, commodities or products which occupy space beyond these limits; e. There will be no display of goods 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 exterior appearance, emission of odor, gas, smoke, dust, noise, disturbance, or in any other way become objectionable or detrimental to any residential use within the neighborhood; g. Any such building shall include no features of design not customary in buildings for residential use. Signature Date Date. !.'. . N2 NORT: TOWN OF NORTH ANDOVER 3?O•,_�`•o � OOL PERMIT FOR PLUMBING �ssgCMUSE� This certifies that . . . . . . . . . . . . . : . . . . . . . . :.-.? . . . . . . . . . . . has permission to perform . . . . . . . . . . . . . . . : t c . . . . . . . . . . . . . . . plumbing in the buildings of . . . .. . "W- . . • .. . . . . . . . . . . . . . . . . . . . at . . ... . . .. .',!. .. {:`. . . . . . . . . . . . . . North Andover, Mass. Fee., '' . . . . . .Lic. No_-._ . . . . . . . . . . . . . ...r•. frr,.�_.cr. . . . . . . PIUMBINIVINSPECTOR 71 WHITE. Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO 00 PLUMBING ° ftnt w Type) A A J-,,) . Mass. Date—L240 "? 10 PefmR#t eutid' location 5 `� �M / k S 7-� oMma's Nameju ;�—Ty"of occupancy�t �S,_�o�-✓► �U2 N New ❑ Renovation ❑ Repkcement G?-' Mans Sulxn ed: Yes❑ No ❑ FWURES z Z M — d z z .. w at + a > u < = W W O = N < C I cl _ ~at O Z h 4 u s m a W > < > �+ _ d o < — < W = ow ; o o >i , — o a � o 0: iY or W Q .� � 0- V 1s- O = o. Z „ �. at e. O z < 1M W t0 =O O N W *" O i7 z < < O < J 1 < R a: C < O t �- sua—sastT. aAiEMEKT IST FLOOR afro FLOOR 3RD FLOOR 4TH FLOOR sTlt FLOOR dTM FLOOR TTM FLOOR ' RTMFLOOR IntURInQ Company Name AQ,'SEQT ,.; S&MM.4T4e.® owaone: C.ettlticate Add ❑ o f porathn ►ora i)t T ❑ Business Telephone l - 4-r --� Nome at UcwuwI Plumber '��r.3,:-e r 4- _!5A n�►�rc4 INSURANCE COVERAGE: f hove s c urertt Oft Inlumm pOlky Or b subartsntlal aqulvdw t whkh moats the re"bernents Of MGL Ch. 142. Yes Q' No ❑ If you have checked yjW oWe ktdictRe the type eoveape by dteck q the apprOWlde boot A 1WAlty humane*Poky Vol, Cthw type Of Indemnity ❑ 8ortd ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee gms nol IM the humane covergp requl W by Chapter 142 Of the Mass. Gonad Laws, and that my si wwU ne on thts permR apptleation waives this requirement. Check one: Owner or 's Owner ❑ AVmt C3t I herby=*that d of the ddads Md in==tion I lea.a nniWd for entered)in bow apptiation an taw and aowrabe to tM gest of my Ipiowladps and Odd pkgrkq work and nWa�tliorw ~Brier fah' for this appk&bon wdl be in coffwbv oe wAh aN pwbm*pramww of the MaNd""am Aw*F0400 and of the Law& IY Title Type of tioanse: M"* O %aa (OFFICE USE CREW— t;oa+,., a« �l�3 Y L 89LOW FOR OFFICE uSE ONLY FINAL INSPECTIONS $KETCH$ frit[ PROGRESS INSPECTIONS No. APPLICATION FOR PERMIT TO DO PLUMBING NAME a TYPE OF BUILDING LOCATION OF BUILDING PLUMBER PERWT GRANTED DATE _10 PWNBINOINSPECTR Location - � No. Date rf 140117" TOWN OF NORTH ANDOVER ►�.?O•tt`•o .•,Moos • Certificate of Occupancy $ Building/Frame Permit Fee $ s�cMus Foundation Permit Fee $ Other Permit Fee $ TOTAL Check # i ♦ 1 1 0 J U Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING n&S"An for Qwdd use frit BUILDING PERMIT NUMBER: �� DATE ISSUED: / Z _ �� � M fJ SIGNATURE: �r1X� �/,, Builan—g Commissioner/Inspector of Buildings Date Z SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: dd Map Number Parcel Number CA,) 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Wo-posed Use Lot Area(so Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private 0 Zone Outside Flood Zone 0 Municipal ❑ On Site Disposal System 0 SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT rn 2.1 Owner of Record 6aeA�A" - /�� " ,, - ,,� Name(Print) Address for Service: N ��6kL ZZ 7 Signature Telephone 2.2 Owner of Record: Name Print Address for Service: O Z M Signature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ aaja4yW_4A1 Licensed Constru t Supervisor: �1i{i o S� License Number Mn Address G c 5F7,f 737 �° Expiration ate Signature Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ 0 / M Compan are / t�3�� m "A � Registration Number r Address � � r n G 9 6 - 3 7 Expirationate ^Z Signature Telephone 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.......L No.......❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) 11Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of m9 Construction 3 Plumbing Building Permit fee(a) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owner/Authorized Agent of subject property Herebv authorize to act on , My be f,in 11 m relati e ork authorized by this building pennit application. Signature of Owzier IfDate SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name Si ature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB RD SILE OF FLOOR TINMERS 1 2 3 SPAN DDAENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS IIF.IGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE x40RTH LED ONM Of 1 Andover No. 3a3 C� COC..C/1 O * over, Mass., A a'2 DRA T E D iP"" �5 SS 4 BOARD OF HEALTH Food/Kitchen PEIiMIT T D Septic System BUILDING INSPECTOR THISCERTIFIES THAT.......... ..................... ........ ..... .... . ........ .. .............................................................. ................. Foundation • has permission to erect........................................ buildings on ...`�.............................. ................... .... .................... Rough to be occupied a .... Chimney provided that the person acceptin is permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions o he Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR Rough ................................................ .....,�Yl .. Service �G 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 Street No. SEE REVERSE SIDE Smoke Det. A.J. Walsh & Sons Inc. 55 11Icasan( Sires( Nurlll Andover, MA 01845 LICENSE # 022690 Mass. IlLGISTItATION n 103.359 RESIDENTIAL CONTRACTING AGREEMENT Read this agreement and make sure you understand it before signing it. This agreement has legal force and effect and binds those who sign it. Notice: All home Improvement contractors and subcontractors engaged In home improvement contracting,unless specifically exempt from registration by provislonsof Chapter 142a of the general laws,must be registered with the Commonwealth of Massachusetts. Inquiries about registration and status should be made to the Director, Home Improvement Contract Registration,One Ashburton Place,Room 1301,Boston,MA 02108. Designated Registrant's Name: Registration Number: Salesperson's Name. This agreement is made on a3 d-)— be (DATE) tween ��er (CONTRACTOR) _ of rl= —C 167,,7 (ADDRESS) (PIIONF.NUMBER) called"Contractor"and j�U(�,s� nc ' (OWNER) of ADDRESS) (P)tONE NUMBER) hereinafter called"Owner 11 DETAILED DESCRIPTION OF WORD TO BE PERFORMED Co ctor a ree:s to perform in a good and workmanlike manner all work detai d below. Such work consists of the following: DETAILED DESCRIPTION OF ATERIALS TO BE USED MaterialsJO be used' forming the bov4.descnbed wor consist of the folio ' g, 11. PRICE c� Contractor agrees to do all work described in Section I for the total price of S_ 00 Ill. PAYMENT Payment will be made as follows: f331/-11%(S dQ= )upon signing Contract; rxo(� 9,100.00 )upon completion of to) (S 4 10Q )upon completion of and the remaining %(S )upon verification of the work by Owner and Contractor as having been su6sfactorily completed,which verification shall take place promptly after completion. Notice: No agreement for home Improvement contracting work shall require a down payment(advance deposit)of more than one-third of the total contract price or the total amount of all depositor payments which the contractor must make, in advance,to order and/or otherwise obtain delivery of special order materials and equipment,whichever amount is treater. IV. COMMENCEMENT AND COMPLETION OF WORT: Contractor will not begin the work or order the materiAls before the third day following the signing of this Agreement,unless specified here in writing. Contractor will begin the work on or about [o`Z.- ©oZ/(date). Barring delay caused by circumstances beyond Contractor's control,the work will be completed by "-Z 1^ 02fdate). The Owner hereby acknowledges and agrees that the scheduling dates are approximate and that such delays that ire not avoidable by the Contractor shall not be considered as violations of this Agreement. V. NO ACC:E'LLRATTO.NOF PAYMENTS III:] LSCROWI.NG ALLOWED Thr Conuaetor may not require payments to ler myte uo wlvan­of talc times spxxIfaed to See tion iII(Payment)above for the reason that hr deems himself or the payments to be insecure. If,however,IIc du-ms himself tut tw insecure,he may require,i s a prerequisite to continuing the work described herein, that ilae balance of the payments utulrr thio contract That air tit tltr•c outrod of IIIc f)wnrr.shall I Ili'1►Incrrl to It joutl rscro%*account that requires the signaturc of both the Contractor and the Owner for withdrawal. VI. INSURANCE Contractor will be.responsible to Owner or any third party fur any property damage or Ikoclily injury catased by himself,his employees or his sutx:onuactors in the performance of,or as a result of,the work under this Agreement. Contractor agrees to carry insurance to cover such damage or injury. V11. SUBCONTRACTING Contractor agrees that,notwithstandu►g any agreement for materials aand/or labor between Contractor and a third pang,Contractor is resporuible to Owner for completion of all work described in a limcly and workmanlike manner. VIII. CONSTRUCTION-RELATED PERMITS The following cons permits will N-necessary in order to complete the scope of work included in this Agreement: The Contractor tinder provisions of Chapter 142A of the General Laws is required to apply for and obtain all construction-rel aced permits. The Contractor shall not be deemed responsible for delays in the work described in this Agreement caused by regulatory, permit granting or inspectional agencies, authorities or individuals. Notice: If the homeowner obtains his own construction-related permits for the work described under thlos agreement, the homeowner is hereby advised that in the event of a dispute, Judgment and nonpayment or the contractor, the homeowner will not be entitled to make a claim to or collect from the guaranty fund established by Chapter 142A, M.C.L. IX. MODIFICATION This Agreement,including Elie provisions relating to price(Section 11)and payment schedule(Section 111)cannot be changed except by a written statement signed by both Contractor and Owner. However,cancellation by Owner is allowed in accordance with the Notice of Cancellation(annexed). X. WARRANTIES The Contractor warrants drat die wort,furnished hcrcwtder shall be It cc flout defects tit meals'(pals and workmanship for a period of following completion and shall comply with the requirements of this Agreement. In the event any defect in workmanship or materials,or damage caused by the Conuactur,his subcontractors,employees or agents,is discovered wtdtin one year after completion of any job,including cleanup,the Contractor shall, at hie own expensr,forthwith rerne dy,repair,cnrrec't replace,or caste to he remedial,renairceL or replaced.such damage or such defect in materials or workmanship. 'IIIc foteroinp warranties shall survive anv tnsp•cnor,—formed in cor•nrc•tinn with Utp a�r�r 1 u(wor wn-k. All warranties for equipment supplied by the Contractor under this Agreement shall hr those given by the manufacturers of such equipment,which shall be auud arc heIr.hy pav%rcl through directly to tile-(►wort. t mare-,it,h nc,tnulacIII,r.t..'wet t,uuic the Owner may Ix required to register or mail in a watTtutly card or other evidence of ownership and use of such equipment in order to activate such warranties. The Owner's failure to mail in or register such documentation, which failure voids the manufacturer's wananty,shall not create any responsibility for the Contractor to warranty such equipment. This warranty gives the owner specific legal rights,and owner may also have other rights which vary from st.•tte to state. Under Massachtuetu law,sales of goods carr),an implied warranty of merchantability and fitness for a 1,uticulm purpsc. XI. CONIPLFTENF.SS OF AGREEMENT FOR EXECUTION The Owner is hereby advised that he should not sign this Agreement unless and unul all bhutk sections have been filled in or marked as void,deleted or not applicable,AaS until all exhibits and related or referenc•cd documents that are incorpourawd herein are attached hereto. XII. COPY OF AGREEMENT TO BE GIVEN TO OWNER '11us Agreement is govemed by the Laws of Massachusens. it trust be executed in duplicate,and art original signed copy hereof given to the Owner at thr,time of execution. No work under the Agreement shall begin prior to the signing of the Agreement and transmittal to the owner of a copy thereof. ----- --- RIGiITS TO CANCEI. -- The mvner may cancel this agreement if it has been signed by the owner at a place other than an address of the contractor which may be his main office or branch thereof', provided that the owner notifies the contractor in writing at his main office or branch by ordinary nail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing of this agreement. See attached Notice of Cancellation. HOMEOWNER: DO NOT SIGN TINS CONTRACT IF THEREARE ANY BLANK/SPACES. Owns• 's Signature D//ate Signed g/4z, Contractor's Signa c — D Signed 11 ( t,2s'vt"2 s /Y� The Commonwealth of Massachusetts Department of Industrial Accidents = Office ofinyestiff ons 600 Washington Street ��,•' Boston,Mass. 02111 Workers' Compensation Insurance Affidavit TPTE1559 11111!111 d city �/' / =t[/�G.G � ''L� ' j pine# I am a homeowner performing all work myself. F1 I am a sole proprietor and have no one working in any capacity ❑ I am an employer providing workers' compensation for my employees working on this job. m an n me• ' 9 Uc�1S� Il"c�LJtJ[l 1 t2 address: phone in C] I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: comoanv name• address: city- phone#• insurance co. policy# ;J company name• address- city: ddress-city phone# insurance co policy# Failure to secure coverage as required under Section 25A of NIGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER anda fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certo snider the pains and penalties of perjury that the information provided above is true and correct Signature L� ��c ?: L Date l•x _ Z..-- 7 � Print name /���� �! , �� �' "��� i ':/��� Phone# � / > official use only do not write in this area to be completed by city or town official city or town: permit/license# OBuilding Department ❑Licensing Board check if im■mtdiate response is required oSelectmen's Office oHealth Department contact person- phone#; 00ther (revised 3/95 PJA) Location No. Date i "d .00 i G� MORT.,� TOWN OF NORTH ANDOVER 3? o .� O 0 w :'o ;a Certificate of Occupancy $ s�cNuSEt� Building/Frame Permit Fee $ r' Foundation Permit Fee $ Other Permit Fee $ TOTAL Check#14194 l Building Inspect A Y TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING IS ' BUILDING PERMIT NUMBER. v -) DATE ISSUED: _ c� , X SIGNATURE: Building Commissioner/Inspector of Buildings Date -C;;k` - G'e SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: /! / t17ap Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: n Zoning District Proposed Use Lot Area(so Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.5. Flood Zone Information: 1.8 Sew 1 �-SP� 1.7 Water Supply M.GL.C.40. Iftie 54) �8 System: Public 0 Private ❑ Zone Outside Flood Zone ❑ Municipal 0 On Site Disposal System 0 J SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of Record A, on Name(Print) Address for Service: Signature Telephone { 2.2 Owner of Recor : R Name Print Address for Service: z M Signature Tele hone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor:) Not Applicable ❑ v t� Licensed Construction Supervisor: o (, - ����-- License Number Address Expira on Dat Signa Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiralion Date Si ure Telephone 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.......❑ SECTION 5 Description of Proposed Work(check all applicable) New Construction ❑ Existing Building Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OMCIAL USE ONLY Completed by permit applicant 1. Building r? (a) Building Permit Fee S� Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, as Owner/Authorized Agent of subject property Hereby declare'ih'at the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief lt"��IeI4 - Print Name Signature of Owner/A ent Date W�aef '1111@I IMPOSE= NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 ST 2ND 3PD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 62111 Workers'Compensation Insurance Affidavit Please Print Name: Location: City Phone aam a homeowner performing all work myself. �I am a sole proprietor and have no one working in any capacity am an employer providing workers'compensation for my employees working on this job. Company name: Address 7d ������l�f�/ City: J:z ,��- Phone# 7 JtU Insurance Co. �/ Policy# 67go,"Zo jeC 6 77 6 Company name: Address City: Phone#: Insurance Co. Policy# Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of($100.00)a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify under the pains and penalties of perjury that the information provided above is true and correct Signature Date Print name Phone# Official use only do not write in this area to be completed by city or town official' ❑ Building Dept []Check if immediate response is required Building Dept ❑ Licensing Board ❑ Selectman's Office Contact person:_ Phone#: ❑ Health Department ❑ Other FORM WORKMAN'S COMPENSATION Town of North Andoverof Na DTH � 6, o Building Department 0 27 Charles Street North Andover, Massachusetts 01845 (978) 688-9545 Fax (978) 688-9542 °4 �9SSgcHus���� DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and a condition of Building permit# the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL cl 1, s150a. The debris will be disposed of in/at: Facility location Signature Applicant Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. NORTH Town of AndoverUftoo A h Zc�vo -y-= o dover, Mass. COCHIC HE w IcK V A0RATEO P'le, C:) S H BOARD OF HEALTH PERMIT T Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT....... ... ................... ............................... ....... Foundation has permission to or buildings on�7 .............. Rough �.... ............ ............. .� to be occupied as .. ............. .......4...#. .• Chimney . . . . . . .. .. . ... ... ............................................................................... provided that the person accept! this permit shall in every res ct conform to the terms of the application on file in Final this office, and to the provisions f the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STIT 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.