HomeMy WebLinkAboutMiscellaneous - 73 FOREST STREET 4/30/2018 (2)a
77
'Location,/.%�`` ? =�
No. vim? J Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
ACMUS
Foundation Permit Fee $
Other Permit Fee
TOTAL
Check # Yji
/ Building Inspector �,
v TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER: �f--� S'_ DATE ISSUED: / D
A//�ff
SIGNATURE: --
Building Commissioner/I for of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
A d�C�
Map Number Parcel Number
1.3 Zoning Information:
1.4 Property Dimensions:
Zoning District Proposed Use
Lot Area Fronts ft
1.6 BUILDING SETBACKS 00
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 Zone Information:
Zone Outside Flood Zone ❑
1.8 Sewerage Disposal System:
Municipal ❑ On Site Disposal System ❑
Public ❑ Private ❑
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
ist(!i f; Y?s
2.1 Owneer1of Record /, ,. l` I
Name,(Print) Address for Service
Signature Telephone
2.2 Owner of Record::
1 4I4 1A l gdS "*l /k,I4X `77—� HoC=S�
Address for Service:
Name P:217
(y n
, z4y
Si re Telephone
SECTION 3 - CONSTRUCTI SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable ❑
'Licensed Construction Supe or:
(DS 8
License Number
� � } / '' t►�C // �( � + f� t � ,(4 �
Address
0 S—
Expiratio Date
SignatureILI,
Telephone
3.2 Registered Home Improvement Contractor
GQ h211 9a C
Not Applicable ❑
c
5,! L
Company Name
b S
Registration Number
Address
Expiration ate
,nature _ Telephone
SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit
in the denial of the issuance of the building rmit.
Signed affidavit Attached Yes ..... No ....... 0
SECTION 5 Description of Proposed Work check a4 applicable
New Construction 0 Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑
Accessory Bldg. ❑ Demolition 0 Other ❑ Specify
Brief Description of Proposed Work:
I SECTION 6 - F.STIMATFn rnNCTRiTrT1nN rnCTQ I
�
result
Item
Estimated Cost (Dollar) to be
Completed b pennit applicant
OFFICIAL USE ONLY
1. Building
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
�� �� �-
3 Plumbing
Building Permit fee (a) x (b)
4 Mechanical HVAC
5 Fire Protection
—et
6 Total 1+2+3+4+5
G -0
Check Number
OWNERS AGENT OR CONTRACTOR FOR BUILDING PERMIT I
Hereby authorize_
My behalf in all matters
as Owner/Authorized Agent of subject property 11
ve to work authorized by this building permit application.. /
to act on
91' iature of Owner Date
SECTION 7b OW(NE AUTHORIZED AGENT DECLARATION
1, 6 k, " " 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
of
NO. OF STORIES
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 1'
SPAN
DIMENSIONS OF SILLS
D1tyIENSIONS OF POSTS
DB/IENSIONS OF GIRDERS
HEIGHT OF FOUNDATION
SIZE OF FOOTING
MATERIAL OF CHRANEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
'2 -d,/ -o -s"
Date
SIZE
2
X
3
M
I
L!
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Afltidevit
Nor n Please Print
Locatlan:
City p
I am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
I am an empiw providing workers' compensation for my employees working on this job.
Company Irm,l bVNI
16-13
city: L Ausre n
7oio y 2.301 zoo
CornRM name:
Address
C ft Phone 0
Poky a
Fdk" to some coverage • required under section 25A or MOL 152 can lead to on imposition d aknind parwWas d.a fine up to $1,500.00
andfor one yeers' Imprisomient_ae_anal.n.cbA peomonjnlnhmd A STAP.w.11DRK ORDER.anda.flmd.(,:1tb.OMAAW palod-ma 1
understand that a copy d this staternerd may be forwarded to the Office d Investigation of the DIA for coverage vsrtflcaum.
I db hereby certify under ft pains andrmffiw o/ perjury Mai the Mlbrmedon provided above is trus and collect.
Print narne
official use only do not write in this area to be completed by city or town offider
Ctiy or Town F i
2 Y/o.<
[]Check IF Immediate response la rsquied 13 Building Dept❑ L kGfAS#V Bo"
[j Selectmen's Office
Contact person: Phone #f~ ❑ Health Department
❑ Other
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- A A e.,o Cho I ,S�M m e -r-
LOCATION: Assessor's Map Number q 4
SUBDIVISION
STREET i3 :cr ei I
OFFICIAL USE ONL
RECOMMENDATIONS OF TOWN AGENTS:
CONSERVATION ADMINISTRATOR DATE APPROVED
DATE REJECTED
COMMENTS
TOWN PLANNER DATE APPROVED
DATE REJECTED
COMMENTS
FO D INSPECTOR -HEATH DATE APPROVED
DATE REJECTED
COMMENTS
PHONE9 7,_ F!3 -S/ 13
PARCEL 6 — /_'� � �) -
LOT (S) 171
ST. NUMBER
DATE APPROVED(,-/
DATE REJECTED
PUBLIC WORKS - SEWERIWATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE
RevlsW 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:
r
(Location of Facility)
Signature o ermit Applicant
2 0�
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
1 . _
�f3L�
TA
MONS?
1
NO RSAT ?
26.0
TA
No RAT -
2�•0
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TA
No RAT -
2�•0
✓/ie -Viominauaea�i o�'✓1�acicaetia
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
tr Number. CS 058238
Birthdate: 09/15/1964
Expires: 09/15/2005 Tr. no: 2869
Restricted: 00
GLENN M GARY
507 W IOWELL AVE Z2"
HAVERHILL, MA 01832 Administrator
lie a
�!oktloas and 9taadsrds -'
Board of 11180ift ift
jjq HOME VAPROVEMENT CONTR CTDR
RegistrsttoA: 10496
,..
fExoratian 112i/2006
'
Type -
GLENN GARY GENERAL CONTRACTORS
02125/2005 11:29
FROM t MODA
b .
9785575439 GLENN GARY GEN CONTR PAGE 02
FAX NO. I. 978663521"3 Feb. 25 2W5 11:43W PI
02/25/2005 11:29 9785575439 GLENN GARY GEN CONTR PAGE 01
FROM : MODA FRX NO• : 9786835113 Feb. 25 20 5 11:43AM P2
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Date ...: <<`..... .
No
"•OR7:��o TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
�O•. r, o 'A �qy SSACMUS�
This certifies that ......................................
A .
has permission to perform ............. , . _ ..::..< .........
plumbingin the buildings of.....................................
.
at . !-....�'...::�.... ............... . Nooh Andover, Mass.
Fee......... Lic. No.. ................. ........ .
PLUMBING INSPECTOR
Check #
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING 20,
(Print or Type
Mass. Date 1i� )c41 Permit # /101, 2�
i
Building Location Owner's Nam ! %py�je r
Type of Occupancy _� 1 D E ti ft v-1 I_
New ❑ Renovation ❑ Replacement Tr Plans Submitted: Yes,®' No ❑
sue—BSMT,
BASEMENT
IST FLOOR
2ND FLOOR
3RD FLOOR
4TH FLOOR
STH FLOOR
6TH
FLOOR
7TH FLOOR
8T8THFLOOR
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FIXTURES
Installing. Company Name P(rMATAeCO. Check one: Certificate
Address 7-)o C0 �4 C /4 mt4k) 'A PJ ❑ Corporation
/Y) E % 4 o E/1 YO (4 • y t,���1 ❑ Partnership
Business Telephone / ' -c/'77 1 l�rm/Co. j
Name of Licensed Plumber 21,3 r=,F_' T fri SArumlq rrCl c�
INSURANCE COVERAGE:
I have a currentflability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No ❑ '
If you have checked Yes, please
/indicate the type coverage by checking the appropriate box
A liability insurance policy Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Owner ❑ Agent ❑
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that all plumbing work and installabonspe0ormed under the permit issu for this application will be in compliance with all
pertinent provisions of the Massachusetts State Plumoft g e and apter of the eral Laws.
By tiL L
VW're of Licensed Plumber
Title
City/Town Type of License: Master % Journeymah C3
APPROVED (OFFICE USE ONL License Number G�3.3 5 _
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INSURANCE COVERAGE:
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Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Owner ❑ Agent ❑
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that all plumbing work and installabonspe0ormed under the permit issu for this application will be in compliance with all
pertinent provisions of the Massachusetts State Plumoft g e and apter of the eral Laws.
By tiL L
VW're of Licensed Plumber
Title
City/Town Type of License: Master % Journeymah C3
APPROVED (OFFICE USE ONL License Number G�3.3 5 _
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Location rGIi c3 7
No. -%
4S 1
Date %if
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
` Other Permit Fee
RECEIVED Fr"i�'bonnection Fee
$ [ L
$
Water Connection Fee $
APR , NOTAL
No. Andover Collector
Building Inspector
Div. Public Works
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MORTGAGE INSPECTION PLAN
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THIS PLAN IS BASED ON A TAPE SURVEY AND IS TO BE USED FOR MORTAGE PURPOSES ONLY.
THIS IS NOT PREPARED FROM THE RESULTS OF AN INSTRUMENT SURVEY AND THE OFFSETS
AS SHOWN SHOULD NOT BE USED IN THE ESTABLISHMENT OF PROPERTY LINES.
E !�- �z E >C COUNTY
DEED REFERENCE:
8KIZ21 PG. 3 �7
PLAN REFERENCE:
PKcc 9&17
PL.BK. PL.
I hereby certify that the existing building is located
approximately as shown and was not in violation of the
zoning bylaws at the time of construction. This building
is not located in a flood hazard area.
FLOOD HAZARD COMMUNITY NO. L!5 0 0
y �:
BOUNDARY MAP NO.001 Cf EFFECTIVE 15,j
JOHN �a
N
EGIS�nED LAND SURVEYOR
McDONNELL w
DATE -./,2 - - % / No 33601
PLAN OF LAND
IN
NDR-7H Ahl D av�CfZ.
PREPARED FOR:
SCALE: I IN.= 4 C FEET
BAILLIE & COMPANY
CIVIL ENGINEERS & LAND SURVEYORS
89 VINE STREET
READING, MA 01867
(617) 944-2767
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LARSEN ENTERPRISES
HOMES • F�EMOC1Fi �!NO • ��T� �S-r�
174 INGALLS STREET • NO. ANDOVER, MASS. 01845 9 686-0528
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LARSEN ENTERPRISES
HOMES • REMODELING • ADDITIONS • PORCHES
174 INGALLS STREET • NO. ANDOVER, MASS. 01845 0 686-0528
LARSEN ENTERPRISES
HOMES • REMODELING • ADDITIONS • PORCHES
screens
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deck area
174 INGALLS STREET • NO. ANDOVER, MASS. 01845 • 686-0528
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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 local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
/APPLICANT:
w 2 ' �' L ?S ' C1P,BECC) Phone
LOCATION: Assessor's Map Number
Subdivision
Parcel
Lot (s)
t 73 -/--/ t c'I S t . Number -'73
************************Official Use Only************************
RECOMMENDATIONS OF TOWN AGENTS:
/conservation Administrator
Date Approved
Date Rejected
Date Approved
Town Planner Date Rejected
Comments
Comments
Public Works - sewer/water connections
- driveway permit
Fire Department
Date Approved
Date Rejected
Received by Building Inspector Date
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Date.. ........:� — va
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
C'
This certifies that .....................�...' -a' ....!.........S......n..
`....................%......r...�.....t.
...............
has permission to perform
wiring in the building of . / �� `"�� S `... v.�c✓.
............................................. ..........
at....................................................................... ........ . North Andover, Mass.
Fee..ar.-r Lic. No.
ELECTRICAL INSPECTOR `fi
Check #
.T :l
IrmLUIVILylU[vrrrr 17 yr tr1t1A30n%1"U01.:f11J
DF.PAHI1bIDV1'OF SF1FEl1' permit No. _� Z
BOAMOFFMPREM NRF,GUT4T70NS527(W12W
Occupancy & Fees Checked
APPLICATTONFOR PERMIT' O PERFORMELEC'FRICAL WO
ALL WORK TO BE PERFORMED IN ACCORDANCE THE MASSACHUSSTS ELECTRICAL CODE, S27 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dat r
Town of North Andover
The undersigned applies for a permit to perform the t
Location (Street & Number) �t
Owner or Tenant
work described below.
S 1
To the Inspector of Wires:
Owner's Address
Is this permit in conjunction with a building permit: Yes M No a (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps�Volts Overhead Underground No. of Meters
New Service Amps �Volts Overhead Underground No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work PSEM 2777 1 =77 777
No. of Lighting Outlets
No. of Hot Tubs
No. of Transformers
at
KVA
No. of Lighting Fixtures / „
Swimming Pool Above
Below
Generators
KVA
round
round
No. of Receptacle Outlets
No. of Oil Burners
No. of Emergency Lighting Battery Units
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS
No. of Zones
No. of Ranges
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
Local � Municipal
17
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
O't1'HER-
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Ihaveaatt o tIia *yhts><atoeRiGCymdu frlgCcnVI le�*=Cora',ecrltakamwe9rAmt YES NO
IhavesubrriWdvafidptoof s=1Od e0ffi= YES r M IfyouhaNedrekdYFS,pleasenic*the"xofornmWby
L.; -J
NSLRANCE BOND p OHiER p >
71/ Estkr*d VArofElacbieal Wade $
W�ID&rt �4sio� °D*�"e*`l Ib1 Fmal
SigneduiePtr>altjesofpetjt=y�"(zsy C.il r UUk
FIRMNAXV.AMF.
IJLIT=��� � S1gi�
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OWNER'S MJRANCEWAIVER; lamawmdgdrL=
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OWNER'SMJRANCEWAIVER;IamawarethattheLiowdoesriothavetheinsutmecot"aageoritss16Aaria1egllivalattasnjgtritadby Galeal Laws
and lhat rrry sigrtat<ue m dris pearrt appliabotl waives t)zs lec}mtlna�t
(Please check one) Owner Agent
Telephone No. PERMIT FEE $Wr
..
signature of Owner or Agen
I rm LluimN1VLv rrcru.i n yr inrs.La %_12 VJLM I L3
DEpAR7mENToFf uBUCSIFETY Permit No. �? Z—
BOARDOFF=P ONREGULMT70NM5VCM12'00 Occupancy & Fees Checked
.� APPLICARONFOR PERMIT
ALL WORK TO BE PERFORMED IN ACCORDANCE Wrr
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION)
Town of North Andover
PERFORMELECTIZICAL WO _
MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 ) os
Dat2.
To the Inspector of Wires:
The undersigned applies for a permit to perform the a ectric work described below.
Location (Street & Number)
Owner or Tenantes�
Owner's AddressI
Is this permit in conjunction with a building permit: Yes No (Check Appropriate Box)
Utility Authorization No. .........,�„
purpose of Building
Existing Service �� J AmpsVoid Overhead a Underground C:3No.. of Meter's —�
New S ice �� Ampg�..Volts Overhead Underground 1:3No. of Meters
Number of Feeders and Ainpacity'
Location and Nature of Proposed Electrical Work /JSt✓/� Q ✓L p- � f '
No. of Hot Tubs No. of Transformers Total
No. of Lighting Outlets KVA
Swimming Pool Above Below Generators KVA
groNo. of Lighting Fixtures anti ground
No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units
No. of Switch Outlets No. of Gas Bumers
'No. of Ranges No. of Air Cond. Total FIRE ALARMS No. of Zones
Tons
No. of Disposals No. of Heat Total Total No. of Detection and
Pumps Tons KW Initiating Devices
No. of Dishwashers Space Area Heating KW No. of Sounding Devices
No. of Self Contained
Detection/Sounding Devices
No. of Dryers Heating Devices KW Local Municipal El Other
Connections
of Water Neaten KW No. of No. of
signs Bailasis
Hydro Massage Tuba No. of Motors Total HP
ER•
CowraW R>suattbdletagtmanalsdMassed>�sC�ataalLaws
aaataiLiab�tyheuatoel�Gc7,inc]txflgCanple>e YES NO
orltsst>b�rltialegtuvaia*
subtnkledwfidptoaf samelDftOMMYES j/ lfycuWedniWYFS,plea9 nic*drtypeofwvmWby
kg the VPTA�
RANCE FV] BOND - Dai
f/6s E
%VailedEbcWWWdk $
oos>atc SAS `fkgWionDaleReWe*d Rough Fmd
under IUmkiesafpmjtxy:c '-�4- ' �Ce4 V, SV
NAME Goati9eNa
S - - Boats
M=TdNo.
1qaU
AIL Td No.
SNSURANCEWAIVER;Ianawmdatthel�o wdoesrlottlaaetheimsuaroeo m*critsstka3tralepvalmtasmgaedbyMass duMCtnmalLaws
my sigttahne on d>is pearls applicatial wares thls tegtmerrlat
e check one) Owner Agent
Telephone No. PERMIT FEE $