HomeMy WebLinkAboutMiscellaneous - 68 JEFFERSON STREET 4/30/2018 68 JEFFERSON STREET
210/023.0 0004 0057.H
J
4
Location �E-
No. Date �f
�o�TM TOWN OF NORTH ANDOVER
Certificate of Occupancy $
sACMUs<� Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL
Check #- -1-1-),7
/i'--Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER. DATE ISSUED: D43
SIGNATURE: 1#94f Zf�A�,
Building Commissioner/I for of Buildings Date z
SECTION 1-SITE INFORMATION O
1.1 Property Address: 1.2 Assessors Map and Parcel Number:
Map Number Parcel Number O
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Areas Frontage(ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard Rear Yard
Required Provide R 'red Provided Required Provided
v
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System:
Public 0 Private ❑ Zone Outside Flood Zone 0 Municipal ❑ On Site Disposal System ❑
S)✓`CTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes NO rn
2.1 Owner of Record
A.
14tn /'r &,- 44-u .6m vier - t --ttJkn
Name(Print) Address for Service:
Signature Telephone
2.2 Owner of Record:
O
Name Print Address for Service:
rn
Signature Telephone 90
SECTION 3-CONSTRUCTION SERVICES
3o1 Licensed Construction Supervisor: Not Applicable ❑
. C
Ltt Sft2C, /tf /� r
Licensed Construction Supervisor: O
,n �J License Number
Address
Q_ Z_7LC!
�l Expiration Date `f-
Signa rem Telephone r
f
3.2 Registered Home Improvement Contractor Not Applicable ❑ v
Company Name
Registration Number
�3�C-r,� 12a� ����5 � dV� • r
Address j( r
°3��I� Z
Expiration Date
Signature Telephone v'
w
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 Pro osed Work check all applicable)
New Construction ❑ s Exitig Buffing ❑ Repair(s) Alterations(s) ❑ Addition ❑
Vi
Accessory Bldg. ❑ '`Demali ion +I ❑ Other ❑ Specify
Brief Description of Proposed Work: // /' -- •
/4
SECTION 6-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollar)to be bFFICIAL:USE ONLY ,
Completed by permit applicant
1. Building (a) Building Permit Fee
Multiplier
2 Electrical (b) Estimated Total Cost of
Construction
3 Plumbing Building Permit fee tel X tbl
4 Mechanical(HVAC) 11205 Fire Protection
6 Total 1+2+3+4+5 - •° �j Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BURDING PERMIT r
r 1 `—Z'G 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
1, L iW2 tL _-C e7 5 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 caner/A ent Date
NO.OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TDvIBERS 1 2ND 3RD
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
1-IEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
----------------
F P A. omznaaourrPa�l/ o�✓�aaaacLuiaetta
r
BOARD'OF BUILDING'':REGULATIONS
71-cense: CONSTRUGTION'SUPERVISOR
s Number =.CS. 069951
i
i f Birthdate"�08127/.1955
+ � E".P".!`s 08/27x2004 Tr'no: 288
- i � g � " •Y � I TI i 5
LEE G SJ
EPHENS
r
81 CHESTER RD#2 p je�i
RAYMOND NH 03b7� .:r Adm�rnstPator
t a.
Board of Building RegulAtions:and St3>sdards
a HOME IMPROVEMENT CONTRACT.O:R.
Registration 1,08985
,Expiration 8x1,8/2004.,
TYPe D8A
SYLVAIN CONTRACTING/-
J
Marc Sylvain.
9 0LAISTOW RD;
PLAISTOW NH:- "SAdmmisfrafr
I
r
I
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers'Compensation Insurance Affidavit
Name Please Print
Name: -f--(14-,7 f r
Location:
city Al- Phone # -7 f
I arra 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.
ComyaLiy name: Jr-4<! m C1,7
Address c w
c
City: AaeJ-YLC-(-- Phone# b OG
fnsurance:Co. rr("r- SfG/An<-� Policy
Company name:
Address
City: Phone#-
Insurance Co. Policy#
Faiture to secure coverage as required under Section 25A or MGL 452 can lead tofihe imposition of criminal penat6es of a fine
up'to$t.S00:0Q
and/or one years'imprisonment_as well-as_c aM4xmakies-o-thelmn-dA STOPYAMMI)FU)ERand_afinejc€_(,$IMM)aAwAgaiost me I
understand that a copy of this statement may be forwarded to the Office of Investiga ions of the MA for image verification.
I do hereby cw fy under the pains and penalties of perjury that the inf nnabon providad above is bile and correct
signature
Print name L t' f Ef-efge-?2 -71 Phone.#
Official use only do not write in this area to be completed by city or town officiar
City or Town PermM icemina
E! Building Dept
[]Check I immediate response is required Licensing Board
El Selectman's Office
Contact person: Phone# E] Health Department
Ei Other
AC/!C�nD 1 i DATE(MrMIDD)YY)
OR f , y: � '' { 5 i �� r� +�U. I ' ') r 'j y 71LL/20o3
.I.,•.:'v. �,.. ,�'.:,. 0 r.
.OD UCER Serial# A16442 THIS CERTIFICATE 13 ISSUED AS A MATTER OF INFORMATION
AON RISK SERVICES, INC,OF FLORIDA ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
1001 BRICKELL BAY DRIVE,SUITE#1100 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
MIAMI, FL 33131-0937
800-743-8130 COMPANIES AFFORDING COVERAGE
80
COMPANY
A AMERICAN HOME ASSURANCE COMPANY
COMPANY
ADP TOTALSOURCE,INC. B
10200 SUNSET DRIVE --- ----------- ----------
MIAMI,FL 33173 COMPANY
"ALTERNATE EMPLOYER C
SYLVAIN CONTRACTING LLC COMPANY
D
9VtAGS
t A
y ri1i r )i r r t1
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
_r-- - —
TYPE OF INSURANCE POLICY NUMBER POLICYEFFECTIYE POLICY EXPIRATION LIMITS
2 DATE(MMfDDfYYj DATE WMDYY)
GENERAL LIABILITY GENERAL AGGREGATE $
r—C'C+&EPCALGENERAL LIABILITY IPRODUCTS-('OMPfUFAGG $ —
CLAIMS MADE 71 OCCUR SPERSONA'&ADV INJ.PY $ ----
OWNERS&CONTRACTOR'S PROT EACH OCCJRP.ENCE $
FiRF DAhtAGC-(Arty one fire) $
�—� ---- ------------- MEDE)F(Any rneperson) $ -----------
AUTOIJIOBILE LIABILITY
I ANY AUTO
cornsl� NED aNC+._E Lllrltr $
ALL OWNED AUTOS
IF oaILYIW'RY
SCHEDULEDAUTOS Per erson
HIRED AUTOS
I-1 LY INLIURY
NON-OWNED AUTOS Per�PI�EITY[DkAAGF
`Otl�j g
----------- -- $
I
GARAGE LIABILITY AUTO ONLY•EA ACCIDENT $
ANY AUTO OTHER THAN AUTO ONLY
------ -- ------EACH ACCOENNTT—}$--
AGGREGATE $ ---'--—
EXCESS LIABILITY EACH OCCURRENCE $
UMBRELLA FORM AGGREGATE
OTHER THAN UMBRELLA FORM $
WORKER'S COMPENSATION AND RMWC 3476330 06/30/2003 06/30/2004 X -° "Ll",+l" ER
EMPLOYERS'LIABILITY
EL EACH ACCiDEPI? $ 1,000,000
THE PROPRIETOPI INCL EL DISEASE-POLICY LIME $ 1,000,000
PARTPER&EXECUTNE L
OFFICERS ARE: EXCL rEL DISEASE•EA EMPLOYEE $ 1,000,00
OTHER
.L EMPLOYEES WORKING FOR THE ABOVE NAMED CLIENT COMPANY,PAID UNDER ADP TOTALSOURCE,INC.'S PAYROLL,WILL BE COVERED
ZER THE ABOVE STATED POLICY."THE ABOVE NAMED CLIENT IS AN ALTERNATE EMPLOYER UNDER THIS POLICY.
£14T)fi�ATE tlCft�D ��, i ! Cl��
SHOULD ANY OF THE ABOVE DESCRIBED PCUCIES BE CANCELLED BEFORE THE
SYLVAIN CONTRACTING LLC EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
9 PLAISTOW ROADSQ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
PLAISTOW, NH 03865 BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
0 REPRESENTATIVE
I
Q1iD�d !1l9.9j r t i r ti i t` ¢a
trfr.;.....
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 properly
licensed solid waste disposal facility as defined by MGL Chapter 111, S 150 A.
The debris will be disposed of in:
(Location of Facility)
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 .
i
NORTH
ONM Of AndoverE
Ow.w' ti�•l' .�j{i
No. /J0
o� ���y dower, Mass., •
ADRATED PPq\ tC;�
'9S H BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT
� . ... .................................... .... .............. ... .......................................... Foundation
has permission to erect.... ................................. buildings on .....� .......
... Rough
to be occupied as...:...... .... ..... ...... .... ..................... . ......... ... ... .......
.................................. Chimney
provided that the person accepting s permit shall in every resp ct conform to the terms of the application on file in Final
this office, and to the provisions of a 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 CONSTRUCTION T T 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.
2749 Date\ !3?-�^ .. • . �( ,�,
s
r10RTH TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
NO � 9
a
a i �� • (� �
• o� .� a l(7 I
'!f .O+..ao '(h N
9SSCHUSEt �^
O••
vJ /— t� ftp i
This certifies that _ • • ..
has permission for gas installation ::'. . . ' . ... .. ' ``•
in the buildings of . . . . ... : . . . . . . . . . .
` r ( , North Andover Mass.
at .��`.'�`. . .`�.:�'� -dry-:�. . .�. . . . . . ,
Fei:4. . .. . . Lic. No.?7c�/. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
G GASINSPECTOR
f WHITE:Applicant CANARY:Building Dept. PINK:Treasurer
E
----7��0
t,vASSACHUSETTS UNIFORM AP ON FOR P IT TO 00 GASFITTING
r (Print or Type)
C NORTH ANDOVER Mass. Date 2-
building Location /p fj Permit #
(L i
dyke o U 40N dd i Owners Name
• New '—! Renovation D Replacement Plans Submitted D
F1 -r U P E S
N
_ . z cc v�
cc
d
N
2 3 d }' z o F tz C
us
Z 47 N t' < a U1 CCO 7 O W !-
cc W d W W O f. N A. Cr q
N N t3 U W C7 '- 4 Q O Q > W
W W Q7 x Q X a W d Cts W ~ W
t7 {- Z f' x H N d ? k F � .1
2 Q W G tr h W
Q yr y C W 2 a cc d Q O O Wcc O W F-
Cc x o O Y ti > E a f- O
BASEMENT 2
IST FLOOR
G1
2ND FLOOR
3RD FLOOR
4TH FLOOR
5TH FLOOR
6TH FLOOR
y� 7TH FLOOR _
i{11 STH FLOOR
(Print or Type) - Check one: Certificate
Installing Company Name S )Co PIS Corp. 7
Address �� 5 j�o� ( 4 { Partner.
Mo . 0-219-0 [D Firm/Co.
i
Business Telephone: 9 ,K — L/3�Z S
Naffie of Licensed riUMber or Gas t=itter -pa (,/ j2
r / 6
rr
Insurance Coverage: Indicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy ther type of indemnity 0 Bond
Insurance Waiver: I , t e undersigned, have been made aware that the licensee of
this application does of have any one of the above three insurance coverages.
Signature of owner/agent.of property Owner I--] Agent '^b
I hereby certify that all of the details and information 1 have submitted(or entered)in above application are true and accurate to thebesty
knowledge and tlut all plumbing work and insaallations performed under'Permit iuued for this application will-be in compliance with ent
provisions of tho hLssachusetts State Cas Code and chapter 142 of the Genual Laws.
By - TYPE LICENSE:
A 7
1urriber
Title Gasfitter Signature of Licensed
City/Town: ster Plumber or
APPROVED (OFFICE USE ONLY) License Gasfitter