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HomeMy WebLinkAboutMiscellaneous - 79 GRAY STREET 4/30/2018f` PO Box 55098 Boston, MA 022055098 617-951-0600 Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Inspector of Buildings City Hall NORTH ANDOVER, MA 01845 Board of Health or Board of Selectman City Hall NORTH ANDOVER, MA 01845 RE: 'Insured: ERIC E HALBACH and KATHLEEN K HALBACH Property Address: 79 GRAY ST, NORTH ANDOVER, MA Policy Number: HMA 0056171 Claim Number: BOS00052810 Date of Loss: 2/14/2015 Company: Safety Indemnity Insurance Company Claim has been made involving loss, damage or destruction of the above -captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number,, date of loss and claim number. Connor Donovan Claim Examiner 3/4/2015 Safety Insurance Company Homeowners Claims Unit P. 0. Box 55098 Boston, MA 02205-5098 Phone: (617) 951-0600 EXT 3298 Fax: (617) -603-4926 Email:.,Conn,orD,o,n,ov-an@,Safetylnsurance,.com � r + The Commonwealth o, fMassachusetis Depadmentof ndustklAce nts (J�f. face of-Mvestigaibw 600 Washington Street Boston, .AVIA 02111 www.massgov/dia Workers' Compensation insurance Affidavit: BufldiDrs/Contractors/EIectricians/Plwmbers AuDlicant Information Please Priunt Le ibly Name(Businessl0r9anizafion/ifndividud): 1f O: KS ` Cbn�St. n -- l C. Address: aSLi N . Qr00d wqy Phone #: 9 !] 8 (p� �p—�%2�(© I eAnyapplimut that checks box#1 mustalso fill outtheseodon below shownlgtheirworlme compensatioapolicyWonnation. t Homeowners who submitft affidavit indicating thq ere doing all workand then hire outside contractors must submit anew affidavit iudioating suck tContractors that check this box must attached an additional sheet showing the name of thesub-contractors and their workers' comp. policy fnfornistion. Iain an employer thatisproviding workers' compemadon Insurance forany employees .8etow is the policy arulfob $He information. MmanceCompany Name:. Get��`or Y15U`f`Qlf1C�. Policy # or Self -las. He. #. �t�{ e. � (02.� J Expiration Date. s 11101 Job Site Address; � � � �� . Coity/staie/Zip: N - N)A ak ` 5 Attach a copy of the:workers'. coinpensationpolley $eciaration page (showing the policy number and expiration date). Failure to secure coverage as reT&edunder Section 25A of MGL o.152 can lead to to imposition of criminal penalties of a fine up to $1,500.00 and/or oner--year imprisonment, as well as civilpenalties in the form of a STOP'WORK ORDBR and a fine of up to $250.00 a day agamst the violator. Be advised that a copy of this statement may be forwarded to the Ofte of Investigations of the DIA for insurance coverage verification. I do hereby certify wa, i andpenaldes of perjury Aat the fnf hrnWIon provided above fs true and correc4 Signature: Date- 4 �f1►c� Rhone #: Official use only. Do not write in this area, to he eomplefed by clfy or town off elal City or Town: Permit2icense # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical inspector 5. Plumbing Inspector 6. Other - - - Contact .Person: Phone Are you an employer? Check the appropriate box: Type of project (required): I. [TI am a employer with_ 4. Q I am a general contractor and I 6. []Now construction employees (full and/orpart fame).* have Hired the sub -contractors 2. El am a sole proprietor or partner- listed on the attached sheet. I �• [Remodeling ship and have no employees These sub -contractors have 8. ❑ Demolition worldug for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. [1 We are a corporation and its 9. El Building addition required.] officers have exercised their 10.�] Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL 11.[] Plumbingrepairs or additions myself. [No workers' comp. c. 152, §1(4), and wehave no 12.❑ Roofrepairs insurance required.] t employees. [No workers' 13.[] Other comp. nzurancerequued.] eAnyapplimut that checks box#1 mustalso fill outtheseodon below shownlgtheirworlme compensatioapolicyWonnation. t Homeowners who submitft affidavit indicating thq ere doing all workand then hire outside contractors must submit anew affidavit iudioating suck tContractors that check this box must attached an additional sheet showing the name of thesub-contractors and their workers' comp. policy fnfornistion. Iain an employer thatisproviding workers' compemadon Insurance forany employees .8etow is the policy arulfob $He information. MmanceCompany Name:. Get��`or Y15U`f`Qlf1C�. Policy # or Self -las. He. #. �t�{ e. � (02.� J Expiration Date. s 11101 Job Site Address; � � � �� . Coity/staie/Zip: N - N)A ak ` 5 Attach a copy of the:workers'. coinpensationpolley $eciaration page (showing the policy number and expiration date). Failure to secure coverage as reT&edunder Section 25A of MGL o.152 can lead to to imposition of criminal penalties of a fine up to $1,500.00 and/or oner--year imprisonment, as well as civilpenalties in the form of a STOP'WORK ORDBR and a fine of up to $250.00 a day agamst the violator. Be advised that a copy of this statement may be forwarded to the Ofte of Investigations of the DIA for insurance coverage verification. I do hereby certify wa, i andpenaldes of perjury Aat the fnf hrnWIon provided above fs true and correc4 Signature: Date- 4 �f1►c� Rhone #: Official use only. Do not write in this area, to he eomplefed by clfy or town off elal City or Town: Permit2icense # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical inspector 5. Plumbing Inspector 6. Other - - - Contact .Person: Phone 4 A� rte® CERTIFICATE OF LIABILITY INSURANCE Q/8�?017YY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER- THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER, IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s), PRODUCER INSURANCE SOLUTIONS CORPORATION 60 Westville Rd Plaistow NH 03865 CONTACT NAME: Linda Bogdanowicz PHONE ,,(603)382-4600 FAX (603)382-2034 E-MAIL .lindab@isc-insurance.com INSURERS AFFORDING COVERAGE NAIC q INSURERA:Peerless 24198 INSURED Brooks Construction Co. of Lawrence ABA Brooks Vinyl Siding, Doors & Windows Co 254 N. Broadway Salem NH 03079 INSURERa:Excelsior Insurance 11045 INSURER C: INSURERD: INSURER E INSURERF: COVERAGES CERTIFICATE NUMRER:CL1391613110 RFl/ISIAAI MI lmrtFR- 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE 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. ITR TYPE OF INSURANCE J= AIR POLICY NUMBER POLICY EFF POLICY EXP LIMITS A GENERALLIABILITY }{ COM MERCIALGENERAL LIABILITY CLAIMS -MADE 7 OCCUR CBP8945793 /16/2013 /16/2014 EACH OCCURRENCE S T.,onn,non DAMAGE a « ca1 $ 100,000 MED EXP (Any one person) $ 15,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY 0 PRO- LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALL AUTOS�ED AUTOSUI ED NON -OWNED HIRED AUTOS AUTOStp COMBINED SINGLE LIMIT ee d BODILY INJURY (Par person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ $ UMBRELLA LIAR EXCESS LIAR HOCCUR CLAIMS -MADE EACH OCCURRENCE S AGGREGATE $ DED I I RFTGNTION s B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED ® (Mandatory In NH) If yoa, deeedbb undor DESCRIPTION OF OPERATIONS below NIA C8836275 /16/2013 /16/2014 x WC STATU- OTH- E.L. EACH ACCIDENT $ 500 000 E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS f LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, ff more space Is required) Rick-- & Kathy Halbach 79 Gray St N Andover, MA 01845 AGORD 25 (2090/05) INS025 (204005).01 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE Maglia/LJB `- fir- //l__ 61<_— ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD A 14 -.Office of Consumer Affairs & Business Regulation 140ME IMPROVEMENT CONTRACTOR Registration: 101682 type Expiration: 6/2902014 Supplement BROOKS CONST. CO., INC. OF LAW MARK'Di PRIMA 254C N. BROADWAY STE 110 �G -•— — SALEM. NH 03079 Undersecretary 41 Massachusetts -Department of public Safety Board of Building Regulations and Standards Construction Supen icor Specialt} License: CSSL-099730 MARK DIPRIMA 18 HAWK DRIVE SALEM NH 0309 r " Ilk ' Expiration Commissioner 02/2012016 A 14 a @ owner's' Rick Kathy Halbach 978-686-7267 Job Addre 79 Gray St. SIDING -WINDOWS - DOORS North Andover, MA 01845 • r Phone: Family Owned And Operated Vwe the owner(s) of the premises mentioned below hereby contract wlth and authorize you to fumisn a: m.,eseary materials, labor and workmanship, to install, constr ct and place the improvements according to me following specifications, term and conditions. on premises below described: Brand: i !c , . OC ( dr (WINDOW{ SPECIFICATIONS Roof Quantity: Build Tie Into Roof Overhang Low -E Argon Metal PVC New Inside Screens Grids Trim Trim Finish TOTAL $ �r '. oc, O Color: Yes 114t`trAr r1:o✓ No Yes No Yes No YeNo Yes No Yes No Yes No Yes No Fluted Post 5'/e uble Hung I PVC Trim k k' k k x 1/3 Deposit $ Cc, 0 (^S -CC Picture i.ir • t' �: l . � t l Slider X' ( X 1/3 Start of Job $ C C' Ci Co Bow/Say Garden 1/3 Balance Upon Completion $ '9s CaS/Awn NOTES: t�:.•lJt., R-t:v� •' S4trf<lrr-L �' f r�:.../+ G�{" �fJ j'Ci. l ,lit; Apply ItPme not rnvorwt nr inetaltul• V a Mn (SIDING) SPECIFICATIONS body area of house. Type of insulation Vne Mn V- At - Strip off Existing Siding Vinyl Shutters Roof Provide Container and remove all debris Window Mantels New Gutters Cover Fascia & Soffit Door Surrounds Gutter off & on Door Window -Casing Ceiling Fluted Post 5'/e Vinyl Fixture Accessories if needed PVC Trim Traditional Post 51 4' Corners {-n'•y� tr rvfn n r .., �4- is•. �i tJ.ar' i.ir • t' �: l . � t l ON START OF ALL JOBS -HOMEOWNERS MUST REMOVE ALL ITEMS FROM MALLS & SHELVES Consinwfion related permits: It the homeowner obtains his own Conshuetton-related parmtts for the work descrlbod under this agmement,the homeowner is here by advised that M the event of dispute, judgment and nonpayment of tha contractor the homeowner will not be entitled to make a cd: im to or collet from the guaranty fund established by Chapter 142A, M.111. WARRANTY Carla to aTW !s thaths werk Lin had hereunder shat tot ton de avis in m a!s and wado zn7 a t7 s grad :d 1 Year faa., co ,tion and sha!I corWy with the r:q;:mms� a c s Agrearnc^!. N tha e.�.:r:ry defect let wod;manshD a matetk�.o da:.�ga G:usud of dta Co^:ac:-:.` > s�x:c- :�."cs.e"F:a,�s a zn°rs.:s d:s�vered within ate yearaitsrcarp'e- tan d aryj�.x�c:;:d!>a c;zanup.rry<Carha�x c:a!' :' h`s ovm eyrns� `off:c � retcadj,i9Dea.correct,reD!ace.a cz;�, b be remeC:ed.rApw'ztl,a re;'-xa.sa�+ a-^�: : __ o• =xn A` -t m rant^:s a w�iarznshlp. T1e faeganq wartanties shat: surme ant >rpec" Deriar=d n tnr xz x w'1 the agreed-upon Aak, w guramee on gutter back up in roof.no gusran!: a on ice tldk t.;, r r g :;r.,.•:_: m'^d rq e :..,• i 1g. SHOOKS does not do aw pt!ntrg or sea:a'tq. BROOKS is not re.Wtble for the car&= r irwrs!mas beyoril19 ca1a reseq from ordue to pre-ezo ig conal=. 6ROOKS s net rosy t.a'a - T rc.:trc z-,, rt:t-T rmrk 'rc"�d wood is fou^dan addyoral cherye w:1, be incurred 84001,03 w,'! chage rx rep!:m-e^• F,-rts. BROOKS is not reaXZ.4:e for mold or rr::jew. M warram.2sor guama ees relate back-) :`s �_ !=,m ,:e;oder ex-1.�; _':.turas' rnzn':N, the Ow+>,^r may oe regrred to tr"�^ar^'tae�rznt;cwdaa.^rat'Gaeta:^::,th'pa�3msc!s:tcna�rw''<.:fitincxdzrmaca:;a"�ssdtw.anal.�.ObmFne;s`ar.^Jae^-`scw,�*wh.-�.•-+,r%s<-.wr�xfz�-.tteiha;1,er's*a:J^aisata•.nater strh documonu!0n, wh'ch `a .'e tc�rfs da r-,r.!W rr's warranry'S't ' not M= any responsib;9y for the CWJZC;or b w: ao such equ omr^t •'tNVACTMP :xIVMTEf; IAE& A% MATEF At5.NOT BROOKS M*. :'G. A sr sate, r!i^rgo o/Zro dthd ur{n idb:..'�nce p: ma::.+; R 'De zA'IM1 ro b,:h.nce'fratp^'dtt�rdrg to terns dcnntmcYm canFMttrn otconh2Ct A!.;..m-r+•c`dbux ?O`a re:r-:.'„g Cc'�ce alas!pryrnent whzhewramorml &fess adra 2 ; s.^n;� cirardd a ,`ba 4:R"Ed. rt�:,•rs,:'chaya hxarfit'up ren ps sHe r,�t.�rf mask irrls rfranpste+- TOTAL$ Brooks Vinyl Siding • Windows - Doors Name of Contractor / D=.;q ,t -d Reg::aem Payment to be made as to:lows: 254 N. Broadway - Breckenridge Mall 1/3 ($ 1 Upon signing Contract; Sheet Addrea 1/3 (5 1 Start of Job Salem, NH 03079 (603) 894-4488 www.brooksswd.com city / state Prone website 1/3 ($ Balance upon completion 101682 99730 After H!C a / Registration M ltab H !'ed tter 3 Dar,, 5MOf flan!a'nhg P -!-.=!s Non-Rs'untich a. %tte No egreetrent for home i '-wement cont ac!'ng work shat; requ',e a down payment (advance Name of salesn an * ` depoemm of viae than -50%- of bha total contract price or the total amount of a9 deposits or payments - which the contract or must maka,h advance,A order and/or ,:tan iso ootal de:ivary of special order ;511 ' � � . mr'erta!s aid equ,pnent,wh'ctim" ammrt I orc-, AAhortzed Sgnature Acceptance of Proposal - I accept Ti? pr rss spec': aCa s and condtixts sta".ed. i understand that upm s:grtng,fh s propaal becoras a,'sett'* con"r . Yro: era at,'hmzwd io clothe Yak as specif il. Payment x;:1 be made as ou'red Cove, You,the Bummay cencef this transaction at any time prior to midnight of the third business day after the date of this transaction. Cance0adon must be Cone in writing. We reserve the right to Meek yaw erodh. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. G IN WITNESS WHEREOF of the parties ereunto have sig ed their names this / day of /)A; C /, 20 t R Aseryacct:Mj&.?9�ofth-jf--:iib'+r_ParmonfhxitbeaddedtobeLnceifnot Yes, i am the owner X1-4 c0ord'.".g:a:.':'^s ofsn;Ter oa canp'a.';an of contract Maximum N01 back 10% 'q b." -r.. r, • ,rt r:i gym, -"4t Al. VIP_,W: anoint !s less or the 2% seroo Charge Signed w con y ^ :4):.' eq., rq_ Ci as 'v cion -0 s.te related matelis.'s mro dumpster. Yes, t am the owner Hdtlaf��_L n un 5� H LLI = LL oz Q m> v O LL v a N u v (n N z z m ° +� o LL s O K a c E t U LL 0 u LU N Z > a s tw O d' LL 0 u Q v W w s to O o: u pj (n LL D: OU d z Q t to O d' LL z ui W W v 7 CO o zto (A 0 Y In = i O cc Cc 0 V �+ .Q Q. CD m� �a o y V Q d N �+ C O' O ►� o O W :a J m H Oc G CD CLZ U Cl) �� xz o L LJ O 15 U ami Cl) U) Lu W J CL Z_ 0 a� c N d L O Z O O it `IV •ti 4. 4J w 00 0 CL CL CD Q J � O Z CDN C i mpffllzim MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) a t:, N° 4E'A4.0 ,4a1ass. Date Permit #4--614D / Building Location S� Owner's Name �,��IL�4'11` ) _ Type of Occupancy Residential New ❑ Renovation ❑ Replacement Plans Submitted: Yes ❑ Noy❑ FIXTURES i 2 N ' zx r N N O, Z " w O W 'b W Y J N !n z N Q a 2 z N � W z z ` d cc o(n w I- w ¢ r U w N x a J Z - co N 3 O Z O ¢ Q N ¢ a W N z p a 4 c p 3 •� R1 x Rf x rd �'; 7 3 ra xLAI W U a z N r z Q Q N z 2 Q F- Q l'- 2 N WQ a O J J a cc X W�( a Q o Q Q�� ?s^5• a 3 x J to N O O J 3 z F- .. V) LL.. (7 ,� O Q O: N .20 °/ Date s• •••••• TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .......... ........................... has permission to perform ............. • • • plumbing in the buildings of ..' ' ' ' ' ' ' ' ' ' ' North Andover, Mass. at �.5 Z' ....... . Fee: Lic. No... • • • • • PLUM�rN NSPECTOR Check #.?-// (t- — WHITE: Applicant CANARY: Building Dept. PINK: Treasurer A liability Insurance policy 0 Other type of indemnity ❑ Check one: Corporation Partnership Firm/Co. Certificate 714 the requirements of MGL Ch. 142. jopriate box. 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 installations performed under the permit issued for this application will be in compliance with all . pertinent provisions of the Massachusetts Stale PluAn and Cha�nr f the jGenerai Laws. By SIcensad Tills Type of License: Master [X Journeyman ❑ City/Town $ 2 2 APPROVE O IC S ONL) License Number___._ 0 z m J a O a 0 r r o z � a ci U O w J z z a 0 J a m O LL LL O m z W LL O CL O r r Z O V W p I IL I 4 I OIL < z J d e r I Location No. / %a / v Date NORTH TOWN OF NORTH ANDOVER O?• �••OOR b A Certificate Occupancy $ of �'�S'••° • E.�' �ACMUS Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ { Check # AP w� 7 i Building Inspector' TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING TWs Se tio»:fdr Off 11 BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Buildin Commissioner/1c r of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: '7 y &A 4;e s ;— 1.2 Assessors Map and Parcel Number: jv Map Number Parcel Number 1.3 Zoning Information: Zoning Dia;ic—t Proposed Use 1.4 Property Dimensions: Lot Area (so Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide RegWred Provided Re red Provided 1.7 Water Supply M.G.1-C.40. 54) Public ❑ Private ❑ Zone 1.5. Flood Zone Information: Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record, / E 14 -7117, Name (Print) / `= 7 9�r- Address for Service - Signature ' v Telephone 2.2 Owner of Record: N,,ame Print Address for Service: Signature Tel hone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone T M X LTJ 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. Si ned affidavit Attached Yes ....... V No ....... 0 SECTION 5 Description of Proposed Work(check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: �J /" Jai I n ti G l L i lG de e_ k re, SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY 1. Building �{(a) 0. Building Permit Fee Multiplier S p 2 Electrical (b) Estimated Total Cost of Construction 14/ 3 Plumbing Building Permit fee (a) Y (b) r 4 Mechanical HVAC 5 Fire Protection 6 Total (1+2+3+4+5) Si; o Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, �R i c ,C Ae4 gAc J[ �'� as Owner/Authorized Agent of subject property Hereby authorize to act on My b halt; in all matter rela • ye to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, E-2, c_. 6' 1> 4 c -I -S Ac 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 Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2 ND 3 RD SPAN DIMENSIONS OF SILLS DM ENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHRVINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordanc:, 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 IVIGL c11,S150A.. The debris will be disposed of in: (Location of Facility) Signature of Permi Applicant �oov Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector A w r Y � e � ex, c P S f J41a fP "I (1' Tor k p /c�; I VSC'. os � �" L / C :l The Commonwealth of Massachusetts y Department of Industrial Accidents Office of Investigations =— Pi Boston, Mass. 02111 Workers' Compensation Insurance,.Fdavit f`Jame Pe2se !::rinc Mame r>ri IJ4L64c>t ,JP_ Lr'C_ti rn 7 � f!r i A� -S i F _ P"cre 6b'L - 7,� I cm a ilcmecwner periCn-nln4 all work mySe!i. . CI am a sole pro;,rletcr and have no one vitt-king in any CaC:^/ I am an employer Crcvidinc wcrkers' C cmcens2zicn for m!/ emcici/ees w&N,ino Cn this Job. C o m c a n v narne: Address Phcne =' Insur_nce Co. Pclic/ r Comcanv name: Address C; N: Phcne Insurance Co. Polio T Failure to sec::re ccverace as recuirea under Section _°A or MGL 1 _C ccn lead to the mccsiticn cf crminai cenaities of a me uo tc S ;,cCC.00 anc.'cr one years' imCnscnmen,t as -,veil as ciwi penalties in the form or, a STCP INCRK CR.CE= arc a vire '_� (S1 CC.CC) a day against ,me. I understand :hat a cc y of :ills Szzement may to tu^rNarce_ tc the Cf,,ce aInve�acaticns of t e'CIA ,;cr C_'.erace verinc2acn. i cc herecy cer:, l under the coins and cenaities ci ce. jury that the informer cn orcviced etcve is ;rue arc ccrrec_ Sicnature Gate !L z ao 0 Frint name Rte .Ac1>f- J R P�cne = 684- 7A 6Z Criciai use only cc not write in this area to de ccmcietea cy c,ty cr tc r, 1—:cal C;ty cr 7 c.yn ❑C`ecic ,7 immediate res�cnse is required Ccnrc: �ersor: =hcre r. ensi LJ Eu;idirc Dept Lic; nsrg Ecard seiectman's o Ca L h'eaith Departmernr C Other Town of North Andover Building Department 27 Charles Street North Andover, MA. 01845 D. Robert Nicetta Building Commissioner (978) 688-9545 °(978) 688-9542 Fax HOMEOWNER LICENSE EXEMPTION Please print DATE y// L/ 2 c d c JOB LOCATION 7 9 G R ,4y ST. 16-7 Oo 3 Number Street Address Map / lot "HOMEOWNER !' 14— Name 3A_ -r1 & 681 - Home Phone PRESENT MAILING ADDRESS 7 y (r- fly! Y 5,1 Work Phone Av p oye: 2 A/// _ d / S Y,;-- City SSCity Town State Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings of two 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 108.3.5.1) DEFINITION OF HOMEWOWNER: 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 or two family dwelling, attached or detached structures ac- cessory 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. 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 No. Andover' Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNER'S SIGNA APPROVAL OF BUILDING OFFICIAL . ... ...... 1-3 . ... ...... m M, f ' 1 i 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 ERiG 6- 144t6ACiI 3/t_ PHONE .iC-71L7 LOCATION: Assessor's Map Number PARCEL 00515 SUBDIVISION LOT (S) STREET GKAy 5.7. ST. NUMBER_Z9_ **********************************OFF 1 C IA L USE ONLY************************** ******** RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED 'A t0bfl DATE REJECTED COMMENTS VU TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR -HEALTH 4EPPT>e1 'ACINS TOR -DEAL COMMENTS DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIONS APR 1 2 2000 DRIVEWAY PERMIT " FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm i UIENT 9 NOfi-418AIE iNIPECI10N PIAN City/Torsi 1J b -- L.21LY1 is States__-__ pit #I L---------- Scales---�,o-----U Orners Cs Q r r int __--_•�- sayers L C�3S Deed Ret. 2A 0 4 7 Plan No. 12-4 t ` ---_•--_•----_•-• rho 3llRVE�� Drive per CitylTovs of _ Tax Assessors Nap. L-" r r - (s Iz G Lb; N Tot _ n17o�E�lL. ;� �nsG 1 hereby certify that the above Mortgage Inspection Plan vas prepared for ase in connection vith a Rev Mortgage and is not intended or represented to'be a property line orland survey. It cannot be used for establishing fence, hedge , valls or building lines. No responsibility is extended herein to the land owner or occupant. The location of the original buildings) as shove herein was in compliance with the local applicable toning bylays in effect when constructed, vith respect to horizontal dimensional requirements, to lot lines or is exempt (roe violation enforcement action under Mass G.L. Title VII, Chap. 40A, Sec, 71 unless othervise shown herein. Subject building(s) lies in a flood zone designated Ione: _ and shovn on FIRM map Community -Panel 1 %) C' c'_� 9_,- e— i G (? Date& 6-1", t... 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It r1 . ,: h a�� li S 4': � Ytyii J''Vir � `����{t'�{I{I�'S ,•;i DEPARTMENT OF PUBLIC SAFETY t a 1010 COMMONWEALTH AVE. BOSTON, MASS. 02215 r; I LII= ENSE r:i71u'�1-R. ��UPERVI: rIR :I e RESTRICTIONS EFFECTIVE DATE • NINE 1789 Cid./: }i)/ 19'8 9 LIC -N0. DAVID 'REI-T'ANO S., # 028-46-441-'-3 S6 PLEASANT ST F'OBX 396. t w , PHOTO (BLASTING OPR ONLY) FEE: •� M1=1 I-il_IEN MA !�11J4'4- +41'v1'it1( 1 1()O� �10 I tlt' Ir4 tF,n 1'} L ?'"• 1 p NO VALID UT SIGNED BY LICENSEE OFF (ALLY HEIGHT: s MPED - SIGNATURE TH O MISS NCR o r.i�rt(C•i I .i. 2/04/1957 t �•� tk 'tt iJ 1 L y,: • t THIS DOCUMENT MUST BE SIGNATURE OF ICENSEE t CARRIED ON THE PERSON OF � THE HOLDER WHEN ENGAG /n}�_Q r i , •r.f t OTHERS - RIGHT THUMB PRINT ED' IN THIS OCCUPMCION. ':..�//'! COMMISSIONER t i r rylI L2} y l Ali 't i 5y /i r S•, 1 y'l 4 ,1 Y yr�ft :tt� I r I i t Y ,�'y " J '; I f t •t'1 � � r -'v J 1', •r .:' y + ,