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® MAPFRE
Commerce
INSURANCE'
February 25, 2015
The Commerce Insurance Company1m
Citation Insurance Companysm
11 Gore Road, Webster, Massachusetts 01570
508.949.15001 www.commerceinsurance.com
BUILDING COMMISSIONER or
INSPECTOR OF BUILDINGS
TOWN/CITY HALL
NORTH ANDOVER MA 01845
RE: Our Insured: JOAN BETTY
Property Address: 67 WHITE BIRCH LANE
Policyk T44573
Date of Loss: 01/26/2015
Filek JWTX46-HNNNA3
Board of Health or
Board of Selectmen
Town/City Hall
Claim has been made involving loss, damage, or destruction of the above captioned
property which may exceed $1,000, 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 my attention. Please reference the above captioned insured, location,
policy number, date of loss, and file number on any correspondence.
ELIZABETH BOTTIERI Telephone: (508)949-1500 Ext: 15284
Sr Claim Representative, Property Toll Free: 1-800-221-1605, Ext: 15284
On this date, I cause copies of this notice to be sent to the persons indicated above, at the
address above, by first class mail.
February 25, 2015
CIC 254 (Rev. 4/95) MAIL M39
Commonwealth of Massachusetts Re11,
i
F City/Town of No.AndoverF at
u° System Pumping Record
M , t-11
,M Form 4 TOWN OF NORTH ANDOAR
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
5. Condition of System:
( C--,:, C>
6.y Pumped By:
Stewart's Septic Service
Company
7. Location where contents were disposed:
Vehicle License Number
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hau r Date 1
� z
Signature of Reqei—v_gFaAlity Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1
A. Facility Information
Important:
When filling out
forms on the
1. System Location:
computer, use
only the tab key
Address
to move your
cursor - do not
No.Andover _
Ma
01845
use the return
City/Town
State
Zip Code
key.
'I Q
2. System Owner: p
Name
Address (if different from location)
City/Town
State
Zip Code
Telephone Number
B. Pumping Record
1
1. Date of Pumping Dat
2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s)
Septic Tank ❑ Tight Tank
❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yesx No If yes, was it cleaned?
❑ Yes ❑ No
5. Condition of System:
( C--,:, C>
6.y Pumped By:
Stewart's Septic Service
Company
7. Location where contents were disposed:
Vehicle License Number
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hau r Date 1
� z
Signature of Reqei—v_gFaAlity Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1
46
N2 I> j 0 Date ..................................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
s�cwusE�
This certifies that ........ ......................................................
has permission to perform V::7. ......................
M ***'****'* ................... P ........
"��Llorth Andover, Mass.
g of (I- !�� .....
...... ... ............ ...
wiring in the buffifin ... ir .
b 01T
V
at .........
..... -
.... . ........ ......................................... ..............
3-� Lic.No.-2//// ........Fee ...................... ............. ....... ... 1 S.S3 ........
U ELECTRICAL INSPECTOR
NUniiis
14:10 15.00 PAID TREASURE R -Cc," :CrJOr
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
rrf£ 057 %45-5,4e4"45,577.5
55r4e415,5775
D 4 ;1-ia S144
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00
Office Use Only
Permit NcL / /',3
Occupancy & Fee Checked _
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Cade 527 CMR 12:00
(Please Print in ink or type all information)
Town of North Andover
The undersigned applies for a permit to perform the elecUical work described below.
Location (Street & Number i "" /'
Owner or Tenant �f
Owner's Address
Date
To the Inspector of Wires:
Is this permit in conjunction with a building permit Yes L� No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
E:asbng Service Amps Voits
New Service Amps Volts
Number of Feeders and
Overhead ❑ Undgmd ❑ No. of Meters
Overhead ❑ Undgmd ❑ No. of Meters
Location and Nature of Proposed Electrical WorkSiE�// �� t
I/e 4/ S'G d -e Ce /G 61 s�
OTHER:
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 youohecked YESpleap indicate the typ/ f �jby checking the appropriate box
�
INSURANCE = BOND = OTHER = (Please Specify) Ir 1-7t � jj�j T
—�— (Expiration Date►
Estimated Value of EI I W)rk$
Work to Start ' Inspection Date Resquested / /Rough Final
Signed under the Penalties of perjury:
FIRM NAME LIC. NO.
Llcansee /�����/✓ �(,' ' ' �/ �� SignatureL? �] GG 7- LIC. NO.
Bus. Tel No. / �f
Address Aft Tel. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licenses 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. PERMIT FEE 5 ---
(Signature of Owner or Agent)
Total
No. of Light8ng Outlets
No. of Hot fuse
No. of Transformers KVA
Above ❑
In ❑
No. of Lighting Fixtures
Swimminq Pool gmd ❑
gmd ❑
Generators KVA
No. of Emergency Lighting
No. of Receptacles Outlets
No. of Oil Burners
Battery Units
No. of Svnfch Outlets
No of Gas Bumers
FIRE ALARMS No. of Zone
No. of Detection and
Total
No. of Ran es
No of Air Cond
Tons
Initiating Devices
No. of Sounding Devices
No./ of Self Contained
A
No. of Oioosal
Heat Total Total
No. Pumps Tons KW
No. of Dishwashers
Soace/Area Heating
KW
DetectiontSounding Devices
❑ Municipal ❑ Other
No. of Dryers
Heabnq Devices
KW
Local Connection
No. of
No. of
Low Voltage
No. of Water Heaters KW
Signs
Bailases
Wiring
No. Hydro Massage Tuds
No. of Motors
Total HP
OTHER:
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 youohecked YESpleap indicate the typ/ f �jby checking the appropriate box
�
INSURANCE = BOND = OTHER = (Please Specify) Ir 1-7t � jj�j T
—�— (Expiration Date►
Estimated Value of EI I W)rk$
Work to Start ' Inspection Date Resquested / /Rough Final
Signed under the Penalties of perjury:
FIRM NAME LIC. NO.
Llcansee /�����/✓ �(,' ' ' �/ �� SignatureL? �] GG 7- LIC. NO.
Bus. Tel No. / �f
Address Aft Tel. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licenses 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. PERMIT FEE 5 ---
(Signature of Owner or Agent)
Location`6,7
No. S Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy
$
pl-:)
Building/Frame Permit Fee
$
2S�, 0
Foundation Permit Fee
$ V°
Other Permit Fee
$
Sewer Connection Fee
$—
Water Connection Fee
$
TOTAL
$
1A
Building Inspec or ,-
- - ill1 �, 1 � 1,128.5 PAID 71 3
Div. Public Works
Location 4114&f...� %_
No. Date
7136
TOWN OF NORTH ANDOVER
Certificate of Occupancy $ • d d
Building/Frame Permit Fee $ —�
Foundation Permit Fee $
Other Permit Fee $
Sewer Connection Fee $
Water Connection Fee $
TOTAL _ $ Q• d C'
Building Inspector
04/15/94 11:02 15'0.00 PAID
Div. Public Works
cation
-�
0 % ,r1 Date
rr-1 f
it
f NOR, TOWN OF NORTH ANDOVER
Certificate of Occupancy $
M
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
Sewer Connection Fee
Y
?3tWater Connection Fee
6951
TOTAL
I&MME
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FORM U - IAT 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 local or state law,
regulations or requirements.
****************Applicant fills out this section******************
APPLICANT: cak s- 2T/ ` C Phone z/ 001,
LOCATION: Assessor's Map Number
Subdivisionl/✓1 4 -i—/—
Street Z/M
************************Official
RECO NDATIONS OF TOWN AGENTS:
Conservation A"ministrator
Comments
►�.WN a�
Town Planner
Comments
Food Inspector -Health
zd
Sep is Inspector -Health
Comments
Parcel
Lots)
St. Number �
Use Only************************
Date Approved
Date Rejected
Date Approved Ly
Date Rejected
Date Approved
Date Rejected l
Date Approved 4/
Date Rejected
Public Works - -&e-�-e water connections Af l IScpQ Q MW
- driveway permit /55uo' (
Fire Departme t
Received by Building Inspector
n Date
$' OR - 61994
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1MMONWULTN DEPARTMENT OF PUBLIC SAFETY AT ONE ASNBORTON PLACE �� L I C
0SACNUS�TTS. BOSTON, MA 02108 '
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I1;.1 /2yI 19 ).� l'i Ihd., I'I )L11 I I1'J I r.�OR EOR PROTECTION AGAINST.`.
EFFECTIVE DATE LIC -N0.
THEFT, PUT RIGHT THUMB
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LOCATION: NORTH ANDOVER,MA.
SCALE. -I"=40' DAT£:6/7/94
CHRISTIANSEN &SERGI
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160 SUMMER Sr. HAV£RHILL.MA. 01830 TEL 108-373-0310
01994 BY CHRISTUNSEN B SERGI INC. l
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I CERTIFY THAT THE PRIMARY STRUCTURE SHOWN CONFORMS TO
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(THIS CERTIFICATION DOES NOT CONSIDER ANY OTHER
RESTRICTIONS SUCH AS COVENANTS.WERANDS.EASEMEVM
ORDERS OF CONDITIONS.ETC.)
THIS DRAWING SHALL NOT BE USED BY THE CLIENT FOR ANY
PURPOSE OTHER THAN THAT OUTLINED A80VE.UCEPT WITH THE
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FURTHERMORE THIS DRAWING IS THE COPYJAICNTED PROPERTY
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MR THE UNAUTHORIZED USE OF THIS DRAWING OR ANY INFOR-
MATION CONTAINED HEREON.
BASED ON SCALED DATA ONLY THE PRWARY STRUCTURE SHOWN
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COMMUNITY NO.: 250098 OOOISC DA Yr.
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ADDENDUM TO PURCHASE AND SALE
BUYER: Joan Betty
SELLER: JDP Development
PROPERTY: 67 White Birch Lane, North Andover, MA
DOCUMENT DATED: February 6, 1995
Joan Betty has agreed to accept the property without carpets on the second floor.
SELLER
COMMONWEALTH OF MASSACHUSETTS
Esses, SS: Febraury 9, 1995
Personally appeared the abo7111
n med Joan Bet acknowledged the foregoing to be her
free act and deed. l /I
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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 �Ch�v1 "t PHONE
LOCATION: Assessor's Map Number PARCEL
SUBDIVISION WAi It ?,,,e� LOT (S)
STREET ;1 /[% ST. NUMBER
USE ONLY******** *,********,rk******,►******
RECOMM NDATIONS OF TOWN AGENTS: -
CONSERVATION ADMINI§TRA
DATE APPROVED
DATE REJECTED_
COMMENTS I �(r) I-1-�-��
TOWN PLANNER
•I�
COMMENTS
FOOD INS
DATE APPROVED
DATE REJECTED_
R -HEALTH DATE APPROVED
DATE REJECTED
IC 114SPECTOR-HEAL
DATE APPROVED 6: /S / !?—«
DATE REJECTED
COMMENTSra
7' C✓ / 5e,��/ c- 57 ',-S .
PUBLIC WORKS - SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE
62•0
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AREA=35452 S.F.
ti
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Q 70.8'
Zt
TOP OF
FOUNDA ]ION
ELEV. = 730.9'
I
181.5'
L. 0 / )
I
RADIAL LINE
56.9,
UCTURE
FOUNDATION L OCA TION PLAN THE HORIZONTAL SETBACK EORTIFY THAT THE PRIMARY U R£XENTS OFOWN TH£ LOCALRXS TO
APPLICABLE ZONING BY—LAWS IN EFFECT WHEN CONSTRUCTED.
(THIS CERTIFICATION DOES NOT CONSIDER ANY OTHER
scorT CONSTRUCTION RCSTRIC77ONS SUCH AS CO ENANTS,W£TLANOS, £AS£M£NTS,
CLIENT: ORDERS OF CONDITIONS,ETC.
THIS DRAWING SHALL NOT BE USED BY THE CLIENT FOR ANY
THIS CERTIFICATION IS MADE AND LIMITED PURPOSE OTHER THAN THAT OUTLINED ABOVE,EXCEPT WITH THE
WRITTEN PERMISSION Of CHRISTLWSEN & SERGI INC.
TO THE ABOVE CLIENT. FURTHERMORE THIS DRAWING IS THE COPYRIGHTED PROPERTY
OF CHR/STUNSEN & SERGI INC. AND ANY UNAUTHORIZED USE
IS PROHISITED.CHRI57UNS£N & SERGI TAKES NO RESPONSIBILITY
FOR THE UNAUTHORIZED USE OF THIS DRAWING OR ANY INFOR—
MATION CONTAINED HEREON.
BASED ON SCALED DATA ONLY THE PRIMARY STRUCTURE SHOWN
LOCATION: NORTH ANDOVER,MA. IS NOT LOCATED IN A FLOOD HAZARD ZONE AS SHOWN ON FEAR
FLOOD INSURANCE RATE MAP.
COMMUNITY NO.: 250098 0005C DA TE: 6/1/93
SCALE. 1 "=40' DA TE. 617 �� AF \=�
,j J
No 33
CHRISTIA NSEN & SERGI
PROFESSIONALAND VEYORs`E7 �
C IANU�e+�
160 SUMMER Sr HAV£RHILL,MA. OIBSO TCL 5OB-373-0310
Q 1994 BY CHRISTIANSEN & SERGI INC.
�OWG. NO.: 93067016
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TOWN OF NORTH ANDOVER
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
MGL c. 142 A requires that the "reconstruction, alteration, renovation, repair, modernization,
conversion, improvement, removal, demolition, or construction of an addition to any pre-existing
owner occupied building containing at least one but not more than four dwelling units ... or to
structures which are adjacent to such residence or building" be done by registered contractors,
with certain exception, along with other requirements.
Type of Work:
Address of Work
Owner Name:
Date of Permit Application: �� K
I hereby certify that:
Est. Cost
Registration is not required for the following reason(s): For office Use Only
Work excluded by law Pemit No.
Job under $1,000 Date
Building not owner -occupied
L --`Owner pulling own permit
Other (specify)
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS
FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION
PROGRAM OR GUARANTY FIND UNER MGL c. 142A.
Signed under penalties of perjury:
I hereby apply for a permit as the agent of the owner:
� b
Date Contractor Name
Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a permit as the owner of the above
property:
/�-4,7
DatW 01wner Name
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From: Joan Betty To: ken Date: 5118198 Time: 2:10:40 PM Page 1 of 2
To: ken
From: Joan Betty
Pages including cover page: 2
Subject: Frame Plan 67 White Birch....
Message: Date : 511S198
Ken:
Company :
Phone: (978) 683-0778, Fax#: (978) 683-9953
Fax Number : 68S-9556
Time: 2:09:30 PM
Here is the Frame Plan. Let me know if you need anything else.
05/18/98 14:13 TX/RX N0.9376 P.001
From: Joan Betty To: ken Date: 5118198 Time: 2:10:40 PM Page 2 of 2
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05/18/98 14:13 TX/RX N0.9376 P.002
From: Joan Betty To: Ken Date: 5/18/98 Time: 12:04:28 PM Page 3 of 3
05/18/98 12:07 TX/RX N0.9363 P.003
From: Joan Betty To: Ken Date: 5!18198 Time: 12:04:28 PM Page 2 of 3
05/18/98 12:07 TX/RX N0.9363 P.002