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Home My WebLink AboutMiscellaneous - 63 WOODSTOCK STREET 4/30/2018C7 'T1 °' TOWN OF NORTH ANDOVER 0 .... ` 9 • PERMIT FOR GAS INSTALLATION • a 'ISSACMUSE� This certifies that ......... has permission for gas installation, .�1. � f'l ...�..... . in the buildings of at fI�DC..-///� �..... , North Andover, Mass. Fee ��. Lic. No..'77N5 .......................... + GAS INSPECTOR Check # �i 4830 MASSACHUSETTS UNIFORM APPLICATION (Print or Type) M V ` G Building New ❑ Renovation ❑ I PERMIT TO DO GASFITTING ,f Y Permit # 44U Owner's Name J i)f H p --_ Y- Type of Occupancy_ ES 1 n EU i A L 0 Plans Submitted: Yes❑ No ❑ Installing Company Name BAY STATE GAS COMPANY Check one: Certificate # Address 55 MARSTON STREET XO Corporation 1862 LAWRENCE, MA 01840 ❑ Partnership Business Telephone .687-:1105 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Francis X. Corkery ,. INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 9. No ❑ �f you have checked Yes, please Indicate the type coverage by checking the appropriate box. i A liability insurance policy Other type of indemnity ❑ Bon ❑ 4 OWNER'S INSURANCE WAIVER: 1 am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner'sagent Owner❑ Agent ❑ 1 hereby certify that all of the details and information I have submitted (or entered) in abo plication are true and accu�te to the best of my knowledge and that all plumbing work and installations performed under the permit iss f r this application will n mpliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s. (j i T of License: . Title Plumber Signature of license Plumber or Gas Gasfitter � $, Cit /Town Master License Number 31 nr'yPrAOVED (OFFICE US O f�LY�— Journeyman 0 Y • wool NEI ... ■ 0 NEI ■ONEE 0 Mn MEN IN IMMENEMOMEMIRIMMIN on .. ■NINININNEENNIN NoMEMEMEMIROMMMEN �r��rinrf��n■ MR ••, 000000000100010��r�■ Installing Company Name BAY STATE GAS COMPANY Check one: Certificate # Address 55 MARSTON STREET XO Corporation 1862 LAWRENCE, MA 01840 ❑ Partnership Business Telephone .687-:1105 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Francis X. Corkery ,. INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 9. No ❑ �f you have checked Yes, please Indicate the type coverage by checking the appropriate box. i A liability insurance policy Other type of indemnity ❑ Bon ❑ 4 OWNER'S INSURANCE WAIVER: 1 am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner'sagent Owner❑ Agent ❑ 1 hereby certify that all of the details and information I have submitted (or entered) in abo plication are true and accu�te to the best of my knowledge and that all plumbing work and installations performed under the permit iss f r this application will n mpliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s. (j i T of License: . Title Plumber Signature of license Plumber or Gas Gasfitter � $, Cit /Town Master License Number 31 nr'yPrAOVED (OFFICE US O f�LY�— Journeyman 0 Z - O_ H U W a N _z N N W LL 0 O ccCL NI - W z �• W x � � a n i F z tP- a k ol _z z o v o a a LL WO (7 Q O z m z a a Ir z H a u u' a N. O p tL O m a J W U W0. O W C J z O a ui Q W Q : .2J o w a U. z J o :� NI - W z �• W x � � N i z O ' W Z , J Q Z LL s Location 6-3 U.,y0y,5 to c e S No. >70 Date 0/ ;-- Check # '17657 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ 170 Foundation Permit Fee $ Other Permit Fee TOTAL $ 170, ✓ Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMjOLISH A ONE OR TWO FAMILY DWELLING BUELDING PERMIT NUMBER: C9 O DATE ISSUED: SIGNATURE: r //Q Building Commissioner/Inspector of Buildings Date SECTION 1- SITE INFORMATION 1.1 Propetty Address: C rilindoAN. 1.2 Assessors Map and Parcel Number: 1 `{ Map Number Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUII.DING SETBACKS 00 Front Yard Side Yard Rear Yard Recittired ovide Required Provided Re red Provided r54) 1.7 Water Supply M.G.L.G.40. 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSIIIP/AUTHORIZED AGENT r 1S'101!C;District: Yes No 2.1 caner of Record /fie R -ere o 6 lJo�/ e1C' S�./1l % C Name (Print) Address for Service Signature Telephone 2.210wner of Record: 4 Name Print Address for Service: Si nature Tele hone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Not Applicable ❑ License Number _ -/ _ c /Date v� Expiration 3.2 egistered Home Improvement Contractor 7 Company Name C+ f Address � Gj�l693'-5-10--`- 7 Not Applicable ❑ Registration Number Expiration Date Signature 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 ....... 0 SECTION 5 Description of Proposed Work check ali appUcabte New Construction ❑ Existing Building ❑ Repair(s) 0 Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition 0 Other ❑ Specify Brief Description of Proposed Work: n SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be C m leted by permit applicant OFFICIAL USE ONLY. 1. Buildinga -7 060 Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ---,as Owner/Authorized Agent of subject property by authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Signature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB RD SIZE OF FLOOR TIMBERS l5 2' 3 SPAN DM ENSIONS OF SILLS DIN ENSIONS OF POSTS DB/IENSIONS 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 O � W 2 W OAC 4 4 E 4 CLA 9 O a o � a r` C2 ca v; U CJ O� a� O HE U or - A E a Ea a Q o a o n V: E c a �oo U w 4 w w a I w o a w" � w oo o A � o A CLA r, N O O �V E Z O cc LLI LLI U) 19 W W C9 W U) z Eo o � r` C2 ca v; U CJ O� a� or - A o� 0 Ea Q o o n V: E c �oo co '. m c �► CL E y M r lo:_ m �' �.: � C y C C N.V. E m e td : �0 CLL) O D cm v, r:Soo M � olm 'moo - 1 I Z Cl � m o` cm �r o s CL. r.. mom~ Z H W w Z o O o'r C_„ •� M=Wc Z ca 0 0.00 1 = ws a�m210 O r, N O O �V E Z O cc LLI LLI U) 19 W W C9 W U) z North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: t Z--Sk)a5J@wo®d llz� 43Gr (Location of Faci ` Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print Name: Location: City Phone # I am a homeowner performing all work myself. F-1 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. Kt Comaanv name: Address City: Phone # Insurance Co. Policy # M Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a tine up to $1,500.0 and/or one years' imprisonment -as va kas_civil.,penaltiesinlhefnrm nfa.STOP WORK ORDER..and..a.fine of ($100.OD)-ar1ay against.me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature 1�irl✓��,r� �� Date�� Print nameA / a_ /'19 ,( e 0/ - Phone # Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensin ❑ Building Dept []Check if immediate response is required ❑ Licensing Board ❑ Selectman's Office Contact person: Phone #.• ❑ Health Department ❑ Other @ k \ J § o f � z k SCD 2 �ZG)\k /U�kt ) wo ) o CL j a. w CL.� 0LU @ k \ J