HomeMy WebLinkAboutMiscellaneous - 71 WAVERLY ROAD 4/30/2018F
Location
No. Date 0,5
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
CHU
Foundation Permit Fee $
Other Permit Fee $
TOTAL - s
Check #
18 3 9 2=1'-'
Building Insp,<b-for
Location
No. Date --2 es j
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
CMu
Foundation Permit Fee $
Other Permit Fee
TOTAL 0-a
Check #
18399 Q-�, "
�/ — Building lnspeePr
1.1 Property Address:
'? 1
1.2 Assessors Map and Parcel
IS
mapNumber
Number:
Parcel Number
n' A
�/ l/� (J
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Areas
Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard
Side Yard
Rear Yard
Required Provide
R red Provided
R
red Provided .
1.7 Water Supply M.G.L.C.40. 54)
Public p Private p Zone
1.5. Flood Zane Information:
Ontside Flood Zone ❑
1.8
Municipal
Sewerage Disposal System:
On Site Disposal System ❑
SECTION 2- PROPERTY OWNERSHIPIAUTHORMEDAGENT historic Ulstrfct: Yes No h
2.1 Owner of Record
Laura D f hoc n Pd N.
Name (Print) r Address for Service:
/-�bj,uA Cry r1 -?6- 9� (/- 014
—signature Telephone
2.2 Owner of Record:
t
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: Not Applicable ❑
U5�
Licensed Construction Supervisor:
� 1 License Number
Address
Expiration Date
Signature Telephone
3.2 Registered Home Improvement Contractor Not Applicable ❑
Company Name
Registration Number
Address
Expiration Date
Signature Telephone
J
0.
z
M
0
v
M
z
0
SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 & 2506)
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 aIl applicable)
New Construction ❑
Existing Building ❑
Repair(s) ❑
Alterations(s) ❑
Addition ❑
Accessory Bldg. ❑
Demolition ❑
Other ❑ Specify "
Brief Description of Proposed Work:
r / 'n ` a 15 -
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
OFT)EC-A ""USE
� ,y
1. Building
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (e) X (b)
, ^ �•
G S� r
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
I, G () ( �� ��—t�,C as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf, in all ma ers relative to work authorized by this building permit application.
Signature of Owner Dat
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
Sikature of Owner/Agent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TLMBERS iST2ND 3
SPAN
DIIvFENSIONS OF SILLS
DINIENSIONS OF POSTS
DM ENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHININEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
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Location
"No. Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
C)
It Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
G c) —
TOTAL $
to 9
'#-heck #
AAC
1 6�45 Building Inspector
t
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of lnv"dgadons
Boston, Mass. 02111
workam' Compensation fnsuvarx a A"vk
n• oaV l r--a-
cily nus -r Q Eu. Lq--z�-cnqq-0(9$
M am 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.
io�►e►o'
Company R M (�'rte_ S L r
wrn�nv
Insurance Co. Poliav # --
Failure b secure coverage as required under SecWn 25A or MGL 152 can lead to the imposition of a8minal penaltlOS of a ane up to $1.500.00
and/or ons understand yaws,t a copy�s s atate+� t may be forwarded an dvN penalties in to the ORios of InvestigationsJbrrn of a STOP WORK Oof theR� DIA far coverage verification against me. i
1 cb herby cerWy unde� the *-,,I and p�n" d perjury that the k armatian p►ovided above is hue and corrsct.
----- - \
Print name
yc� V 2��� Rhone;# `l5 b- 6 6 °�
Offices use only do not write In this area to be completed by city or town official' [] Bui d#V DWt
❑Checkirlmrnediate response is required Buying Dept ❑ Licensing Board
❑ $ejoctman's ice
Contact person: Phone #: ❑ Health Department
FORM WOM MAN'S COMPENSAVON
)r,�,( +
(.06
HOME IMPROVEMENT INSTALLATION CONTRACT
Branch Name: f+t/ Date: �a Sold, Famished & Installed by
The Home Depot Installed Sales
Branch Number: �_ Job #: �`f� % 345A Greenwood Street, Worcester, MA 01607
Toll Free (800) 651-5182; (508)756-6686; Fax: 508-756-29
Federal IDrr 75•?6984(+0 ME LicMAA Home lR� o�ment ('obv ct r Reg. #125522
6x93
)4#4
Installation Address: of
State Zip
9 Home Address: C'dy State zip
(ifditterent bunt Installation Address)
0�
60
Proiect information I/We (-Purchaser"), the owners of the property located at the above installation address, offer to contrac h
materials as described on the attac ed Sprt
I'he Hoene Depot ("Home Depot") to htrnish, deliver and arrange tar the installation of all
-7-r hereof.
S 9` , incorporated herein by reference and
made a part
Home Declot reeves the right to cancel this contract
ir, upon re -inspection of the job, Home Depot determines that 't cannot
its obligations due to a structural problem
with the home or because work required to complete fie Job w s not
perform
included In the contract.
DEPOSIT PAYMENT OPTIONS
(Subject to fund %crilication and or credit appmll 1.1
I. Chcck, C'ashicn Chcck or US I r. at Scnice ki ocy (trdcr
nn:uicp:p;drlcto I?t tharre't t ¢
(,ONTRAST t1NT $
6L,TH2.
Q
're dit
lo
ard' and ur her i, 'mens , tions - Greg One Ikw'
'iL ..'S DEPOSIT S1-_
Vi:
MasterCard Discotrr Anhric;m P.�p+'ess
BALANCE. DUE! OC�
O
n l mmrtemrnt t' Iia
a Depot Credit C'drd
/ i VT F#
ailsbBe Credit: f 7�
(EIIL & 11D(1"ONLY)
*25% of 'ontract punt upon execute n of this
contrnct One -t rd (i/3ri{ o 'ontract Amo nt (s required
"1'ti 'ti
,-fir_..
for R ...' ( tISF: :N ON
Name as, aprxarn on card' (,! . (/ .J.. �.f /
`tit ms our signuttn • helot,, I 'A a agree to allure I he I lame 1",t to c . rec the
Indicate-Ptiv�men't;Miethod For
C'LAN('F. DUk ON COM 7 lON
t (
uus titiard i v t usn indicated.
- '•1
r.(-
-J
/;` t
�w.
dllU dcl':s Si�na".rc .. _.....
t
'rated herein by
if iftl5 is a finance ir''ansacticim-the'agreement torhnanung'ts contmned m astp a -. ucumrnt• w�tttc t
Relrren�> ,and inadtf-a part.hereof. At -Home Services Credit/Loan Apphciititih , L #
Purchaser agrees that, immediately upon satisfactory completitxt of the work. Purchaser w dl tutu a Com ion Certificate and pav any balance
due (unless the job x financed, in which case, apo bmsion of the executed Co
on 'eniticatr, Home ikpot will he paid in full by the
lender).Purchaser also agrees to be jointly and erally obligated and liable her n ec
For plass, Residents Onh': Contractor shq}�procure all permits re uir y law a ing as lie owner's agent. Owners who secure their
own permits.will he excluded from t�l{{e guaranty fund prtsiions MGL C pier 142A. Unless otherwise nuted within this
docutnent, this contraci shall not imply f ila( any fien or other'seeartt,Z in[ est has be' n placed on the residence.
Entire Agreement ; This agreement a d its attachments, nciuding ny fitncing agreement, contain the complete agreement
tween the parties and can not be arae de or modified less in w iting in a separate agreement signed by both parties.
t u,.
NOTIC O PURCHASER
Do not sign this contract before you read it. ou are entitl to o completely filled-in copy of the contract at the time you sign. Keep it to
protect your rights. Do not sign any Complet ate or agreement stating that you are satisfied with the entire project before this
%roject Is complete. Law prohibits home repair contractors from requesting or accepting a Completion Certificate signed by the owner
prior to the actual completion of the work to be performed under the contract.
You may cancel this transaction at any time prior to midnight of the third business day after the date of this contract. See Notice of
C'inceliation for an explanation of'thls right. There will be a service charge equal to 25% of the contract amount if the Job is cancelled by
Purchaser AFT£R the third business day.
rt,
BY MY/OUR SIGNATURE BELOW, I/WE AGREE 1.0 BE BOUND BY THE PERMS OF THIS CONTRACT. 1/Wil ACKNOWL.EME:
RECEIPT OF A (•OPY or nits CONTRACT AND TWO COMPLETED COPIES OF THE NOTICE OF CANCELLATION.
BY MYiOUR SIGNATURE BELOW, VWE UNDERSTAND THAT THE AGREEMENT IS SUBJECT TO.REVIEW Of' MY;OUR CREDIT
HISTORY AND•1'WE AUTHORIZE HOME DEPOT AND RMA HOME SERVICES, INC'.. A HOME DEPOT AUTHORIZED CONTRACTOR.
TO. VERIFY -AND,REV.IEW. MY/OUR CREDIT RECORD WITH AN 'INDF.PENDENT.CRED1f REPORTING AGENCY AND,RELEASE
'T HEMFROMALI.I.I F3ll.l INC• E:DF O INADVEkT-ENTOMISSIONSORERRORS.'4'::`
- •._ - _ ..
Fr i
i~ SUBMITTED BY: ' r Datr: �O
S" es C'unsu onl-
--- ._- . PITIONAL
Il-
,.,., Date:NO rfCF: ATERMS, CONDITION\ AND WAR"A'TIES ARE STATED ON l'HE RL% 9. 6F. Si1DE-AND Aim PART OFT' WS ('0511'RA(`r
5.9-03 ('•SC
IS - lil—h file Y06. - C'u w.n Pink gales l'..n,uhwn
CERTIFICATE OF LIABILITY INSURANCE OATE(MMrDDIYYI
07/02/2003
rRooucER Serial # 82698 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
SHEPARD 6 SCOTT CORP, ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
352 SEVENTH AVENUE, SUITE 301 HOLDER, THIS CERTIFICATS DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
NEW YORK, NY 10001 -----
INSURERS AFFORDING COVERAGE
INMIRED RMA HOME SERVICES, INC. INSURER A: ADMIRAL INSUFBANCE COMPANY
D/B/A THE HOME DEPOT INSTALLED SALES INsuRER s: COMMERCE AND INDUSTRY INSURANCE CO.
3200 COBS GALLERIA PARKWAY. STE 200 INSURER C:
ATLANTA, GEORGIA 30338 INSURER D:
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDfNG
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED NO
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUOR
CH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
`GENERAL LMftITY WFRODUCTS
RENCE { 1,000,
A X COMMERCIAL GENERAL LIABILITY A03AG16362 3/10/03 3/10/04 (AnyoneIts) S _ 50,
CLAIMS MADE ® OCCUR me Pwum) � EXCLUC
ADV W IURY 9 1,000,
REGATE S 2,000,
GEN L AGGREGATE UM IT APPLIES PER OMPIOP AGG S 1.00C).'
.000 i
.. i"1 own ;
000
WORKERS COMPENSATION AND
INFLOYERS'LIAOILMY
OTHER
07101/03 1 07/01/04
DESCRRRION OF OPERATIONS&OCATIOM3NE ICLE#EXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS
DISEASE • EA EMPLOYEE S 1
DISEASE • POLICY LMT S 1
SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED SEFCRI rK W;RATION
DATE THEREOF. THE ISSUING INSURER WILL ENDEAVOR TO MAIL30 DAY$ WRRTE4
NOTICE TO TME CERTIFICATE HOLDE.k NAMED TO TME LEFT, OUT FAX.WtETo DO SO SHALL
IMPOSE NO OYLIDATION OR LIAMI Y OF ANY KIND UPON TWE IriURERTTiAGENTS OR
REPRESENTATIVES,
•�nwonsn suoa/swet�Ta�c
I ,+�•` ,/M�:s. „b . `�.9%!::,yr.,. � ;;,. ter.
'14-6 (7/87) Q A O D CORD Arinu � ee•
AUTOMOBILE
LIABILITY
SINGLE LIMIT
ANY
(I.&COMIeace" S
ALL OWNED AUTOS
LPww►RY
SCHEDULED AUTOS
m =
HIREO AUTO$
_
NON-OWNEO AUTO$
_
PROPERTYDAMAGE
(Pw a dem) S
GARAGE LUNKITY
AUTOONLY • EA ACCIDENT Is
ANY AUTO
OTHER THAN EA ACC S
AUTO ONLY: AGG _
EXCESS LIASR.RY
EAC+9000URRENCE {
OCCUR ❑ CLAIMS MADE
AGGREGATE S
S
DEDUCTIBLE
I
S
RETENTION S
S
WORKERS COMPENSATION AND
INFLOYERS'LIAOILMY
OTHER
07101/03 1 07/01/04
DESCRRRION OF OPERATIONS&OCATIOM3NE ICLE#EXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS
DISEASE • EA EMPLOYEE S 1
DISEASE • POLICY LMT S 1
SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED SEFCRI rK W;RATION
DATE THEREOF. THE ISSUING INSURER WILL ENDEAVOR TO MAIL30 DAY$ WRRTE4
NOTICE TO TME CERTIFICATE HOLDE.k NAMED TO TME LEFT, OUT FAX.WtETo DO SO SHALL
IMPOSE NO OYLIDATION OR LIAMI Y OF ANY KIND UPON TWE IriURERTTiAGENTS OR
REPRESENTATIVES,
•�nwonsn suoa/swet�Ta�c
I ,+�•` ,/M�:s. „b . `�.9%!::,yr.,. � ;;,. ter.
'14-6 (7/87) Q A O D CORD Arinu � ee•
Bonet of 0"96 Resolvelew end MandIrdS
1401M wpxOV5WMT CONTRACTOR
RegWidion: 128893
gavam", 8*2M
Type: GLVPWW4WA CWd
ft"o 099 AS -ft"
PAUL. VENTRE
3200 00" GAUSMA PKWY WA
ALTANTA, GA 3*339
Lkftu or rowm1we Wam ew jamwivi at elkily
bgfom the upblow dreg If haid re/w►® tom:
Bard of owmas xWbow W4 S"44&r*
Ore AIMUACII P120 RM 1301
seem, Ms. 02100
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Date................... .....
,XORT##
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ............................. ? ............ ..........
has permission to perform I I
.................. .....................
winng in the building of ..... . .... . .............. .......................
�7 / -� " -.e_, /, � I /
at .......................................... q ...................................... . North Andover, Mass.
Fee..... \:� . ............. Lic. Noll .... 7.4o� ...... ............................................
ELEemcAL INSPECTOR
Check #
4 8 u 5
^� The Commonwealth of Massachusetts j/ FOR OFFIC�E1U EONLY
f Permit No.
Department of Public Safety Occupancy & Fee Checked��
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 (leave blank)
WIG;
)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work will be performed in accordance with the Massachusetts General Code. 527 CMR 12:00
(PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date /I �J h /o
City or Town of A — tel ) 0r-,:�L%dn oe ✓ To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work described below:
Location (Street and Number)
Owner or Tenant
Owner's Addresses-� _
Is this permit in conjunction with a building permit?
Purpose of Building _ ! cJ n 4 1116 )'
Existing Service 600 Amps (� ! GVy Volts
New Service IM Amps Volts
Map: Lot:
Zone:
Yes ❑ No Z (Check Appropriate Box)
Utility Authorization No. R910/
Overhead` Underground ❑ No. of Meters
Overhead. Underground ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work &KO 4 -la StMLR_ jam I- U,(Q /o�
IVo. of Lighting Outlets
No. of Hot Tubs
No. of Transformers Total KVA
No. of Lighting Fixtures
Swimming Pool Above grnd. ❑ In-grnd. ❑
Generators KVA
No. of Receptacle Outlets
No. of Oil Burners
No. of Emerg. Lighting Battery Units
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS No. of Zones
No. of Detection'and
i i
itatn
Initiating Devices
No. of Sounding Devices
No. of Self -Contained
Detection/Sounding Devices
No. of Ranges
No. of Air Cond. Total Tons
No. of Disposals
No. of Total Total
Heat Lumps Tons KW
No. of Dishwashers
Space/Area Heating KW
Ne). of Dryers
Y
Heating Devices KW
g
No. of Water Heaters KW
No. of Signs No. of Ballasts
Local ❑ Muncipal Connection ❑ Other
No. of Hydro Massage Tubs
No. of Motors Total HP
Low Voltage Wiring
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liability Insurance Policy
including Completed Operations Coverage or its substantial equivalent. YES ❑ NO 111 have submitted valid proof of same to this
office. YES ❑ NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box.
INSURANCE V BOND ❑ OTHER ❑ (Please Specify)
(Expiration Date)
Estimated Value of Electrical Work $
Work to Start Inspection Date Requested: Rough Final
Signed under the penalties of perjury: A
FIRM NAME � LIC. NO. �L�
Licensee Liar.Abap Dir?iS Signature LIC NO.
L0n5 �
Address _ -- �� Bus. Tel. No. g122 / Yy'21
Alt. Tel. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee 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 $
INSPECTION RECORD
Date I Notes — Remarks I Inspector
Location
No. Date
L
A/9;
I if it
40RTN
TOWN OF NORTH ANDOVER
Of
60
Certificate of Occupancy
Building/Frame Permit Fee
$
Foundation Permit Fee
Other Permit Fee
Sewer Connection Fee
re-,
Water Connection Fee
TOTAL
N2 1214.10
Building Inspector
Div. Public Works
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TOWN OF NORTH ANDOVER
Certificate of Occupancy $
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