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Miscellaneous - 73 CARLTON LANE 4/30/2018
a `C� 0 �/ Date ..... �` f TOWN OF NORTH ANDOVER AMU This certifies that—,-:/.���.: -rr has permission to perform plumbing in thpbuildings of at . ..—............ bra ' Fee d�.,. ' .. Lic. No.It?13 Check # '�''L 6287 PERMIT FOR PLUMBING .. -: . . . ----I I . . . . . . . . . . . . . . . . North Andover, Mass. PL"fVI81NG N�� CTOR" MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBIN, (Type or print) NORTH ANDOVER, Building Location 172 New Renovation Owners Name Type AcCupancy Replacement FIXTURES Date -2-2 Permit # Amount I Plans Submitted Yes No ❑ (Print or type) Check one: Certificate Installing Company Name Corp. ddress rel Partner. Business Telephone _ ` El Firm/Co. Name of Licensed Plumber: //'/ Insurance Coverage: Indicteth pe of ' nce coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent I hereby certify that all of the details and info ation I have s bmitted�ented) above ication are true and accurate to the best of my knowledge and that all plumbing ,ork and install ons pee d for this application will be in compliance with all pertinent provisions of t e Massac , tts St d p r 142 of the General Laws. BY igna ure o icense umbe Type of Plumb g License Title z d z Q l City/Town License INUMDer Master Journeyman ❑ APPROVED (OFFICE USE ONLY Date ..... ...... L/ .............. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that."/rz_Ie-.a/ ..... A 4 .......... ...... has permission for gas installation ..... T ................................ inthe buildings of ................................................................................................................... at......7 ........................ ...,....,,, NorthAn. It ..dover, Mass. FeoziVo .. �P... Lic. No. JOY) ........ .................. GAIINSPEC R Check # 9674 w-,n�P MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY l O--C�� � MA DATE I1� GI PERMIT # lP7�l lT JOBSITE ADDRESS - � 1A.��C1II� OWNER'S NAME GOWNER ADDRESS TEIFAX-J p�T OCCUPANCYTYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAUX CLEARLY NEW:A RENOVATION: ® REPLACEMENT: PLANS SUBMITTED: YES 0 N43 APPLIANCES 7 FLOORS- BSM 1 2 3 1 4 5 6 7 8 9 10 11 12 13 14 BOILER - BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER 4. FIREPLACE FRYOLATOR- FURNACE _ _. J (_I �_...-J ti �T �.._.__ , GENERATOR= GRILLE1- INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNITh- OVEN POOL HEATER�.I. DOOM ( SPACE HEATER ROOFTOP UNIT TEST_ J I�� ..�_.__J_- - = -- — JL UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER ._—.... x- - - .- y - f - _ J _ is_ � J I�J = — _zl (-T� --L—Jil I __ I I 1 = —_ - INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY /Y OTHER TYPE INDEMNITY © BOND 0I OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT El SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true a ac urate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complia h all ovision ofxhe Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAMELICENSE #F15141 Ir SIGNATURE MPI MGF El JP 0 JGF © LPGI © CORPORATION Ej# = PARTNERSHIP®#= LLC ®#= COMPANY NAME: �yJc,� li�DDRESS�— CITY STATEZIP� TEL FAXJEMAIL l�m�., Y itl CELL �---:.�.!! LL�--�.---m-•— w-,n�P H O z 0 F U W a rA w 0 El z O to W a Z U w * U) W 55W a W O> w w w C a z a d g a a U J F a M �. a c w s w H LL Un F O z 0 F U W a + kq c7 a .The Commonwealth of tllassachusetts Department of-fndusttial.4ccid%nts Office of Invesfigations 600 Washington Street Boston, MA 02111 www.mass gov1d1a 'W'orkexs' Compensation insurance Affidavit: BuildersfContractor> IFIectrxexans]Pliinber,s Applicant Information Please PrntLegibXy Name(Business/Organi'zationl.Cn(Hvidual):� � Nsk Q 0R QS -P, , Q`��p/JSI Address: a�s City/State/Zip: PN�- 6k U Phone Are you an employer? Check the appropriate box: L ❑ I am. a employer with 4. ❑ I am a general contractor and I employees (fall and/or part-time).* 2 I am a sole proprietor or partner- ship and'haveno. employees. working for mo in any capacity. [No workers' comp. insurance required.] 3.E1 I am a homeowner doing all work myself. [No workers' comp. insurancerequired.J i have hired the sub -contractors listed on the attached sheet. t These sub -contractors have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised.their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New c6nstraction 7. ❑ R.emodeag 8. ❑ Demolition t 9. [❑ Building addition 10. El Electrical repairs or additions I1A. Plumbing repairs or additions 12.❑ Roofrepairs 13.❑ Other I1Ary applicautthat checks box4f must also fill outthe scogon bel6wshowingtheir workers' compensation policy information. T'Homeownerswho submit ihis affidavit indlca&jthqy Aire. dping all work and then hire outside contraotors must submit anew affidavit iadleatiftg SUA 1Contractors that cheskthis box must attached as additional sheet showingthe name ofthe sub -contractors andtheir workers' comp. policy infonnation. lam an employer that is providing workers' compensation insurance for my employees Beloty is the policy anti job site information. Insurance Company Name% Policy # or S elf -ins. Lic. Job Site Address; ExpirationDate: City/State/Zip:. Attach a copy of the workers' compensationpolley declaration page (showing the policy number and expiration date). Failure to secure ooverage as requiredmder Section 25A ofMGL o.152 can lead to the imposition of criminal penalties of a :Cute up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK. ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hareby that the in, formation provided above is true and correct. Phone#. —A — � L 0 � Mc) c) - Official use only. Do not write in this area, to be completed by city or town official. City or Town: PermitlLicense # TssuingAuthority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. EIectrical Inspector 5. Plumbing bspector 6. Other - - - Contact Pers on: Phone #: j Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person hi the service of another under any contract Ofhire,• express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or anyiwo ormore of the foregoing engaged in a joint enterprise, and including the legal representatives of a•deceased employer, or the receiver ortrdstee of an individual, partnership, association or other legal entity, employing employees. Iiowevertha owner of a dweiiing house having not more than. three apartments and who resides therein, or the occupant of tine dwelling house of another who employs persons to do maintenance, construction orrepair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employes." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shalt withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant vvho has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of pnblic work until acceptable evidence of compliance with the insurance requirements of this chapter have, been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking tfie boxes that apply to your situation and, if :necessary, supply sub-contractor(s) name(s), addresses) andphononumber(s) alongwiththeir certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are notrequired to carry workers' compensation insurance. If an LLC orLLP does have ernployees,apolicyisrequired. Be advised that thisaffidavit may besubmitted tothe Department of Industrial Accidents far confirmation of insurance coverage. Also be sure to sign and date the affidavit. 'Tho affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a Workexs' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill. in the permitAicense number which will be used as a reference number. Ill addition, an applicant thatmust submitmultiple permit/license applications in, any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town): ' A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit fs on file for future permits or licenses..A, new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license orpermit to burn leaves etc.) said person is NOTregami d to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Covamonmft ofMquarkwats De.p.axinmit o£I.dustdal .Accxdeats qi tco ofIuvestiga-bin 600 Washhom Sixoet J3QA0.121; , 02111. Tel. # 61.7.72.' -4900 et 406 ox X-����;W SSAFl3 Revised 5-26-05 Fax # 617-727-7749 -WWmMass,g0v1cl7.a GENERATOR APPLICATION DATE: I I I lot Ia6N LOCATION: I � Oat- 1,'hOAv Lcv\a OWNERS NAME: �CvCe �%i I�IQwIS GENERATOR kw NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR: PHONE NUMBER: 781- i I� °-G-7 6-0 ELECTRICA GAS RESIDENTIAL COMMERCIAL TEMPORARY LOCATION OF GENERATOR:(`cr��' tN *ZONING DISTRICT: TPLANNING APPROVAL (IF IN WATERSHED) *CONSERVATION APPROVAL Y� ,� ,4Y t PP A � f'f eg J� fist , i y ✓/ 5 A T I � / ^'�•�� .fit +yy aH �,� ��� Pn, 454- Notth Andover MIMAP November 19, 2014 106.0-0017 r" s� 106.0-0086: 106.0=0.0.37 95,' CA'gjjQR LNq 1060 008x' 106:0-(1096 j a 00 106.0-0033 'J t fl�f 66'S- RLINGQLN 106C=0(195 106:0-0_,0.88' '106;C-0022 W C#RLLTOR LR 106C-0036" ;t r R2,. 106.0-0020 106:C-0094: ,? 73 CA`RL'-TON LN a 10,&q-0093 106,C-0089, Ii GA'ROTQN;LR 106 0.0120 106 C=0091 106:C=0127' Rail Line "-;u Wetlands Zoning Interstates 12 Exempt Land. iv Busine Q Busine s 1 Dist s 2 District Horizontal Datum: MA Stateplane Coordinate System, Datum NAD83, — — Roads Busine ■ Businei Genera s 3 District s 4 District Business Distdct®f NORTI� tato r•�• Meters Daly Sources: The dale for this map was produced by Merrimack Valley Planning Commission (MVPC) using data provided by the Town of North Andover. Additional data provided by the E eculive Oflce of C. Easements O Planne Commercial De - ? •� 00 •- Environmental AHainalMassGIS. The information depicted on this map is Q MVPC Boundary 0 Municipal Boundary 12 C—d. d Corridc Q Comdc S.: Intlustn Developmenl Dist Developmenl Dist Developmenl Dist 1 DisMct 3 - - O .-- t' p >f for planning purposes only. It may not be adequate for legal boundary detrition or regulatory interpretation. THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY Zoning Ovartay BAdull Entertainment D Induald 2 District • i ^ OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT 0 Downtown Overlay District 0 Historic District Q lirdustri Q Industri 3 District S District - # e : .r 41 • ° " "" "0e s �,, ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION ®Water Protection Ras Is O Reside cel District ce 2 Distdct •+sig �°�,�•(g `sSAONUSe ❑ Parcels O Rec:de ce 3 District O Hydrographic Features de de ode ice 4 UistnU ce 5 District -- Streams 1" = 84 ft ice 6 Districta a sidential District . ................... Datelil 1.1 TOWN OF NORTH ANDOVER PERMIT FOR WIRING ri 1{o Sim This certifies that ................ ..... ................... Com has permission to perform .............................................................................. wiring in the building of ................. .. ........ at AQ ............ North Andover, Mass. Fee .... ........ Lic. No. ..... . ... ...... iEECTIICAL INSPECT Check #ao�* `1 1 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Usly Permit No. � poi Occupancy and Fee Checked [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 12712.00 (PLEASE PRINT W INK OR TYPE ALL INFORMA OA9 Date: / � / City or Town of. NORTH ANDOVER To the Inspecto of res: By this application the undersigned gives notice of *her intention to perform the electrical work described below. Location (Street & Number) V �° d�G% Owner or Tenant 16!rVjt — 5 Telephone No. Owner's Address Sri` k,- t m at o 51c) f �, Is this permit in conjunction witha bpilding permit? Yes ❑ No P (Check Appropriate Box) Purpose of Building �11 = Ce Utility Authorization No. - Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Undgrd ❑ No. of Meters Completion of'the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Cell.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- Elo. rnd. rnd. o mergency tg ting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No, of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Dis posers p HeatPump Totals: Number Tons " ' ' KW I-., ........... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW SecurNo.itySystems:* st lees or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Eg uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications No. of Devices or Equivalent OTHER: Q- V Attach additional detail if desired, oras requiredby the Inspector of YYires. Estimated Value Value of Electrical Work: �� (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. - INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such covers a is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:) I certify, under thepains /and penalties q fpperJUX"<- that the information on this application is true and complete. FIRM NAME: / pC[ r/ L �-PC LIC. NO.: Licensee: ` QN Yi �Le Z Signature'A LIC. NO.: t,?Cpl (If applicable, enter "exempt" in the license n her line) Bus. Tel. No.: d Z V? Address: P, & /.30lt' 25U &/4 K ;tJ4 630(o) Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires'Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chanter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses conceming the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8—Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass n Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: PassV, Failed 0 Re- Inspection Required ($.) ❑ Inspectors Com ts: IT Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com ' i The Commonwealth of Massachusetts Department oflndustrlglAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl� Name (Business/Organization/Individual): -- / , 'r�-. Address: �� p�JnX^� 4 /X`1' -i \ �d i City/State/Zip: Phone #: r04 Jam) Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction oyees (full and/or part-time) * have hired the sub -contractors listed on the attached sheet. 7• ❑Remodeling 2. I am a sole proprietor or partner- ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. g, E]Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10 ❑ Electrical repairs or additions required.] 3. ❑ I am ahomeowner doing allwork officers have exercised their right of exemption per MGL 11.[] Plumbingrepairs or additions myself. [No workers' comp. c. 152, §1(4), and wehave no 12.QRoofrepairs insurance required.] t employees. [No workers' 13.0 Other comp. insurance required.] !Any applicant that checks box#1 must also fill outthe section below showingtheir workers' compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. TContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. . I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. 11 1 r- Insurance Company v7es5 Policy # or Self -ins. Lic. #: Expiration Date; Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). 0Ziailure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1.,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP. WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the AIA for insurance coverage verification. I do iereby cero under the pains flad penalties ofperjury that tiie information provided above iso true an�l correct. Offacial use only. Do not write in iltis area, to he completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - ('nn4arf•PPrcnn� Phone #: ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed Y on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shalL.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8—Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act—Permit/Date Closed: Trench Inspection Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass I] Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com Town of North Andover Office of the Building Department Community Development and Services Division 27 Charles Street North Andover, Massachusetts 01845 D. Robert Nicetta Building Commissioner Re: 73 Carlton Lane North Andover Ma 01845 To Whom it May Concern �yORrf4 Ottttan rbRM .��• °t ° �, ss ooG lo- A • i, e s �RATQY p�`y4h �4SSACHUSEt Telephone (978) 688-9545 Fax(978)688-9542 August 2, 2001 Upon review of existing Town records it appears that the replacement of the deck as the same size as the original constructed from 1983 would be grand fathered. The 8x13 infill deck would pose no additional violations. Respectfu , Michael McGuire Building Inspector BOARD OF APPEALS 688-9541 BLTILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Commonwealth of Massachusetts Department of Fire Serv! s BOARD OF FIRE PREVENTION RE ULATIONS M. APPLICATION FOR All work to be performed in (PLEASE PRINTIN INK OR TYPE ALL City or Town of.. By this application the undersigned gives not Location (Street &Number) 7 7 _� Owner or Tenant �T Owner's Address Official Use Only Permit No. Map & Parcel RMIT TO PERFORM ELECTRICAL WORK the Massachusetts Electrical Code (MBC), 527 CMR 12.00 iATIOM Date: / Z — .20 —o f .� 'i,' o1/F2 To the Inspector of Fres: � or her intention to perform the electrical work descnbeti-lie�ow.f Telephone N Is this permit in conjunction with a building permit? Yes JS_ No ❑ Building Permit tr Purpose of Building SI,N��E Z!�� Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service ABPs •- / Volta Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders amid Amp'acltY" Location and Nature of Proposed Electrical Work: (Zo w 1 a L z ,XP4y7>,5D ['enrnletton al the following table may be waived the Ins ector o Wires No. of Recessed Fixtures - No. of Ceil.susp. (Paddle) Fans Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators.. KVA No. of Lighting Fixtures Above n- Swimming Pool nd. ❑ red. ❑ o. of Emergency Lighting Battery Units No. of Receptacle Outlets 8 No. of OR Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. o e on an Initiating Devices No. of Ranies Ttal No. of Air Cond. -Tuna No. of Alerting Devices No. of Waste Disposers Ht eaTotW a um IAN_ Lr ons "--�- Wned No of Self-Conts. Det ction/Alertin Devices . No. of Dishwashers Space/Area Heating KW Local ❑ Connection [] Other Heating Appliance KW SecuritySystems: -Devices Equivalent No. of Dryers Na of or No. o atero. Heaters dIy i! W o o. o Signs Ballasts Data Wiring: Na of Devices or Equivalent No. Hydromage Bathtubs ass No. of Motors Total HP a ecommu ca ons g: . Na of Devi or Equivalent OTHER: S7'�,4A'( /`1 / Wires Attach addutonal detail q desired, or as required by the Inspector of INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the.licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE Q BOND ❑ OTHER ❑ (Specify:)9/1 7 (Expiration Date) Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start; Inspections to be requested in accordance with MEC Rule 10, and upon completion Icon*, under the poles andpen of perjury, that the information on this appUcatlon Is true and completes FIRM NAME: LIC. NO.: A l 1983 Licensee: LOUIS CONT INO Signature- LIC. NO.: E 2 8 7 8 8 (rapplicable, applicable,. enter "exempt " in the lkense number /mita) Bus. Tel. NO3 7& - 3 6 3 — 5_4 2 0 Address: 1 nnNnvnN nP-TAjFQT mpwguRy; MA 985 Alt. Tel. No.; OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insmaance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) 0 owner C1 owner's agent Owner/Agent _ . __ AFAXLfrT FFV- .t 2�, R (")- o 9 q — 0 k 1- 06— Pr ry� No 2321 Date..c.6 .... ... Q 140 T 4 0 TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING ,SSAr9D CHUS This certifies that e,e-elAm ........... OO Imo`.. .......................................... has permission to...:.:::.:.:.--Zr...................................... wiring in the building of ................................................. at ...................... . North Andover, Mass. Fee -4-5 .............. Lic. No . ............ . ......................... ......... ....................... - ELECTRICAL INSPECTOR Check # 11Z, - WHITE: Applicant CANARY: Building Dept. PINK: Treasurer V Office Use only THECOMMONWEALTHUFA CHUSEM DEPART &WOFPUBLICS9FETY Permit No. CZ9 BOARDOFMEPREVF.1VTIONRWUL4TIOASSraffl ix00 Occupancy &Fees Checked U4,APPUCATIONFORPERWTOPMFORMELE=CAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00Q O (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Da Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) cA r I-- Q N Owner or Tenant v4C� •4�S .., Owner's Address Is this permit in conjunction with a building permit: Yes [0 No (Check Appropriate Box) Purpose of Building s'n ��� �^^ Existing Service Amps ! Volts New Service Amps /� Volts Overhead Underground Overhead Underground Utility Authorization No. No. of Meters No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work r�a�:� a.s, i k .S � '; No. of Lighting Outlets No. of Hot Tubs No. of Transfonners Total KVA No. ofLighting Fixtures Swimming Pool Above Below Generators KVA and1:1 ound No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units V No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of flanges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices LocalMunicipal a Other No. of Dryers Heating Devices KW Connections No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP 0 IFR . htstltm=Cmeage Rasuatttbthetegmatt��C�alaallaws j Iha aartartLiabtldyhstratoeR�titymchdntgCar>pl�e a ess�t9atbalt�}nvalat � �t NO Ihawsulxrl�dvatidpttxfofsametodteOlgoe YES Leif W)mtavedWodYES,P=asertdi *tltetMxofwmp� Fbydukingthe INSURANCE BOND ORER L -, I( C4 Waktoslat Z ht mDa> Recgttsted Signedtexi3�ieP�>altsofpajta� FIRMNAME cY Lignm�1 ' t �� _ Signan ftwe) E4'sn&dvakeafflwlidW0& $ Rough Final LiOWNTa IS— 3 7 ?' 4 BusinwTdNa 7 z s—I I qTf 3 ?S Vo 7,7 C"- It ddrmi- AkTfiNa OWNER'SINSURANCEWANER;Iamawatetha ftLioawdomnsthvmettteirsrawammFa-#sab at de*naiet asm*zedbyMasmdws&G=rAlmvs and#sa mysigi aril isp=dWpk-,6anw,lisestlrismgtm not (Please check one) Owner Agent E Telephone No. PERMIT FEE $ i Location No. Date NaRT� TOWN OF NORTH ANDOVER Certificate Occupancy $ of s�cMus Building/Frame Permit Fee $� Foundation Permit Fee $ Other Permit Fee $ �l TOTAL $ Check #� 1 Z 7 [ �.r 3 / J ._ Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING $.t '?✓?�@��°5&b .',P. �S� 4fi�-M BUILDING PERMIT NUMBER: DATE ISSUED: 40 ® ram G SIGNATURE: 0A Building Com oner for of Buildings;Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: /06 c a Map Number Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area (so Frontage ft 1.6 WELDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Re red Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public 0 Private 0 Zone Outside Flood Zone 0 1.6 Sewerage Disposal System: Municipal 0 On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record if; NJN ta�.i �'� ss ; N S 3 �r4o� 1�t� .✓ lnl Name (Print) Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: 57V7-41 Is Licensed Construction Supervisor: 4 4. N RC1 Addresg n i W t L' {"T fIt G N'%Vf� Signature Telephone zivz #��' / 7 Not Applicable ❑ License Number 3 _ ?. O Expiration Date egiste Ho a mprovemcnt Contractor L ac - Not Applicable ❑ 3 p Company Name /\ Registration Number Addre 7 P b Za Expirat o Date re Telephone At s ic r M r !d SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 6 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 .......0 No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building R Repair(s) 0 Alterations(s) )Id Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant ` v` x OFFICut; U,SE ©ma y �.... .. 1. Building p B d (a) Building Permit Fee Multi lier Q • 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 1, ; 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 OWNERIAUTHORIZED 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 N sigatKrovvner/ ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS iST 2 No 3 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 i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print Name: Location: ZI City 41V ilia Phone 5� am a homeowner performing all work myself. 01 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. Company name: Address City Phone #: Insurance Co. Policy # 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 certifyynder the Signature. penalties of perjury that the information provided above is true and correct. -6b Print name 6 /7 gid {'t le- (FPhone # �7 -S 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 m m m C/) 0 m C) 'O C � CA Cl) 10 0 n Z co) O O'v a r c. CU =c a =' CO) v CD CD CLQ •< CD CD o C O H' a v cm CD co CD dy C m N NMa m C09 CD C] � H sn•+a m CD CD am o > > m N co �Oi. C !* •�► O N C)CD ca :_ V A- m !` tc < ? ? :T� � O m N m om m N „�,•: O I N . N W: CS o�W-i a NO C CO) -. X 'Q. 03Got col 03 Go, CD so C.,. 0 lb mot n o CD ..m.M alhe 00 0 C o� A o c� :.S C, CD: :� 1 O 0 y 0 0 c p �' r� n aq 00 wC �•- n n 9Q 1 O 0 y 0 0 c Location CrxMi C- 7 -OA) No. %� Date/y�-- f TOWN OF NORTH ANDOVER Certificate of Occupancy $ ,Buuiill�ing/Frame Permit Fee $ k-,(�ndation Permit Fee $ $ Leo, Ot�er Permit Fee 0 2wer Connection Fee �p *nection Fee NO.P�aQVet TAL — ' Building Inspector 67 Div. Public Works PEWMIT'NO. JFy APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 0. LOT NO. 2 RECORD OF OWNERSHIP IDATE BOOK 'PAGE ZONE SUB DIV. LOT NO. II LOCATION PURPOSE OF BUILDING ft;� `rh / OWNER'S NAME c5 (+_50, �+ 11 d NO. OF STORIES " SIZES�;� OWNER'S ADDRESS 'i •�� 1 j — BASEMENT OR SLAB ARCHITECT'S NAME "`fit 4,S/ l7CT"7 SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME If � SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS , DISTANCE FROM STREET IJ POSTS , DISTANCE FROM LOT LINES - SIDES REAR GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATIONg THICKNESS toil IS BUILDING NEW �� - SIZE OF FOOTING / l `i X IS BUILDING ADDITION �,e JGJw !`. % MATERIAL OF CHIMNEY IS BUILDING ALTERATION eiF7>�- IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TOO REQUIREMENTS OF CODE //��'� IS IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION, IF ANY a AO IS BUILDING CONNECTED TO TOWN SEWER Q IS BUILDING CONNECTED TO NATURAL GAS LIN { i MAP d,4 INSTRUCTIONS SEE BOTH SIDES PAGE I FILL OUT SECTIONS 1 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED rF FEE 9'1 rjl PERMIT GRANTED Z V 19 9 MAY 2 1 1992 c s OWNER iTEL. k k r *- 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST®�7s EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BOARD OF HEALTH PLANNING BOARD BOARD OF 1 OCCUPA CY 12 i k i� e` SINGLE FAA" MULTI. FAMILY i0 IE ES APARTMENTS CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE .d 1 2 13 CONCRETE BL K. BRICK OR STONE HARDW D PIERS PLASTER DRY VJAII _ UNFIN. 3 BASEMENT'. AREA FULL FIN. BM'T' AREA 1/4 1/2 1/1 FIN. ATTIC AREA NO BMT _ FIRE PLACES HEAD ROOM MODERN KITCHEN 4 WALLS - I 9 FLOORS CLAPBOARDS - DROP SIDING _ .. CONCRETE B _ 1 2 �_ 3 _ _ WOOD SHINGLES ASPHALT SIDING ASBESTOS SIDING VERT. SIDING EARTH HARDW'D COMMON ASPH. TILE 4' STUCCO ON MASONRY STUCCO OM"FRAME _ BRICK ON MASONRY BRICK ON FRAME 'ATTIC STRS. & FLOOR I_ " CONC. OR CINDER BLK. WIRING STONE ON MASONRY STONE ON FRAME SUPERIOR I� POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE HIP BATH 13 FIX.) _ GAMBREL MANSARD TOILET RM. (2 FIX.) FLAT I SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER ROLL ROOFING MODERN FIXTURES _ _ TILE FLOOR q TILE DADO MING I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. & COLS. 'i.. STEAM STEEL BMS. & COLS. - HOT W T'R OR VAPOR WOOD RAFTERS AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ 1st 13rd ELECTRIC NO HEATING BUILDING RECORD THIS SECTION MUST SHOW EXACT -DIMENSIONS OF LOT AND DISTANCE FROM LOT LINES AND EXACT DIMENSIONS OF 'BUILDINGS. WITH PORCHES. GA- RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT? PLAN; ; 2 -ly Am far Free Estimates Fully Insured Remodeling - Decks —Additions ;,Windows Kitchens DAN BERGSTROM (508) 686-3389 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 local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: Sdrvrd�S C) SCI kl Phone- LOCATION: Assessor's Map Number Parcel SubdivisionLots) treet 73 ` CA k A LIV. --Sf-. Number ************************Official Use Only************************ R�ECQOMMENDATIONS OF TOWN AGENTS: "� � • ��(,� Date Approved Conservation Administrator Date Rejected Comments Date Approved Town Planner Date Rejected Comments Date Approved Health Agent Date Rejected Comments Public Works - sewer/water connections - driveway permit Fire Department E ji ,F MAY 2 1 1992 t Received by Building Inspector Date t (Please print) DATE 6//WZ JOB LOCATION Number Town of North Andover BUILDING DEPARTMENT Homeowner License Exemption treet Address ection of town "HOMEOWNER" n*q �-Soew 1'1%it 6:8Z- JYo Name Home Phone Work Phone PRESENT MAILING ADDRESS��� City Town State Zip code The current exemption for "homeowners" was extended to include owner occupied dwellings of six units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. (State Building Code, Section 109.1.1) DEFINITION OF HOMEOWNER: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one to six family dwell- ing, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable to the Bulding Official, that he/she shall be responsible for all such work performed under the `;building permit. (Section 109.1.1) The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of ..North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. ,EH0MEOWNER' S SIGNATURE' , APPROVAL OF BUILDING OFFICI 'Note: Three family dwellings 35,000 cubic feet, or rger, will be required to comply with State Building Code Section 127.0, Construction Control.. r. MAY 2 1 1992 I �' r N z r- rrm O Z �q N Z T 31 0 T1 Cl) T m 1 n 21 3 $. 5 C s 5 v o M Vart �• v � 0 0 v m n CL �• MO = oC. O V. I� fA 3 y t O P* m o fl) a a -,o a v � �v Z y o CL 47 N z r- rrm O Z �q N W T 31 T1 Cl) T m 1 n 21 3 $. 5 C 5 CD o o o v m n MO fA m v � Z O 4M _ ,-moi "' r1 D t1 O O O -� _ 70 70 x z 0 co 34d Location -'D �e� ` No. Date TOWN OF NORTH ANDOVER 9 o ; ; Certificate of Occupancy $ J4CNU5 Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $}• TOTAL Check # (a� 17721 Building Inspece 9 TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: .2 DATE ISSUED: �� l (/��t/ SIGNATURE: Building CommissionefflnsLxnlor of Buildings Date SECTION 1 -SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 1 3 Lam �-RN bT uhi\)kq-S r.� & la l 1 ^ Map Number/Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: ` 1 ` X1 i4C2 r 01 d` Zoning District Prop6se&se Lot Area (so Fronts 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. 34) 1.3. Flood Information: Zone Z Outside Flood Zone 0 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal Syst Public Private ❑ 1 SECT ON 2 -PROPERTY OWNERSIIIPIAUTIiORIZEDRGENT „Torlc: District: Ye's —Na AD 2.1 Owner of Record k' t s T� N-yz (--J-T,A; (Print) Address for Service: on ignature _ Telephone 2.20wner of Record: Name Print Address for Service: Signature Tele hone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ ,AT S<✓ �s ``lord - 63- 0 /'d. Z/,f 7 Licensed Construction Supervisor: License Number fT -Al d'4 1l�yCi` Address 97f - 44f r -"l`J' 3'% Expiration Date tgnature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number ,0 [/Pc �.v9 J t" �t/a /IdDQ✓�%G 1sr1�- - Address Expiration Date —14 Signature Telephone IN z M 90 0 M r z Q SECTION 4 - WORKERS COMPENSATION (M.G_L C 152 s 25r(61 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 buildinj permit. Signed affidavit Attached Yes .......0 No ....... 0 SECTION 5 Description of Proposed Work check sll applicable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ ddition T Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: / ly ,k /)0 i t /e / pis dc� �'?r 1' ' G � r� t a.•t SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed b ermit a licant �FFICIAi:USE`t)NLY - . 1. Building a Da (a) Building Permit Fee Multiplier 2 Electrical 71/000 (b) Estimated Total Cost of Construction 3 Plumbing D Building Permit fee (a) x tb>� SCS 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 '7, 1 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, RT iZt c tIN as Owner/Authorized Agent of subject property Here uthonze /44 1 i'�xdti r1%Ffa/td.✓? to act on Myeh - in all matters relative �to_work authorized by this building permit application./ \ = 1-1 .ti AV� /L Si iature of Owner Date SE ON 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 P ne- It) `0-Q%� Signature of Owner/Agent - Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TUVIBEIkS 1' 2ND' n 3RD SPAN DD,4ENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION _ THICKNESS SIZE OF FOOTING V X MATERIAL OF CHIT L Y IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE it d 5 • 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 AX We -5 '12/1PY"-5 PHONE V2,T LOCATION: Assessor's Map Number N:Ve.-,rl i PARCEL lo6 c 1:2 o SUBDIVISION LOT (S) STREET ST. NUMBER_ USE ONLY ***� CONSERVATION ADMINISTRATOF� DATE APPROVED a� DAT{EI REJECTED COMMENTS�_V� TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD IN OR -HEALTH DATE APPROVED l/ �/ DATE REJECTED �EF�I PECTOH DATE APPROVED - f r,> /! Z / D"Y DATE REJECTED COMMENTS f h r r ea C-- PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm 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: (Location of Facility) igna Lure 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: I.1Afr1Ydw 290,,yo,�✓ Location: /9 City A/D, .1-M. I Phone # ?,F - e k 71 1 am a homeowner performing all work myself. ® 1 am a sole proprietor and have no one working in any capacity F-1 I am an employer providing workers' compensation for my employees working on this job. Company name: Address City: Phone # Insurance Co. Policv # Company name: ` Address City: Phone # Insurance Co. Policv # 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 _vinCas_civil.penaltiesin]he lam dfa STOP WDRK.ORDER.,aid_a flee of (.$1L10.0J]) allay agair>st.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,#d penalties of perjury that the information provided above is true and correct. Print name_,"ALr'& 'A 9 Phone# Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing 0 Building Dept (]Check if immediate response is required Licensing Board ffice Contact person: Phone #: CD Health Department r7 Other w LWINJ H C d O a) 'C O C7 z CO) CDD O CL03 0 =a. y aCo -0 �CD so -, CD o p CDCL o Q d CD CDo C CD N Q, v y to CD I 0 N CD Z CD � o CD O CCD C C O — di < Cl)Q N ca 0 2-L 110 'a0 o m �c o y�3 Z =F -o w CL 0 CD -4O m y C y 6 �mm;� o D () ' � oi co c Z �• o y m: mW R r COO o -- 7 r, m m lfn .� b CD 1 „ ; ell,z d �0.� C ll��n n CCD :b CD L:,. o :� O O m ' o o N W 0 o H a W t cn CD CLI o= � w ro oly � x r. ow5 � �• o � Com" a � o °a. 'U r. S �' � a a- o a GJ � � b CA � � Ll`J y 0 9 0 c