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Miscellaneous - 79 JOHNSON STREET 4/30/2018
A�- Date. K— ?�'. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 1P This certifies that ... U1. I ............................ has permission to perform ... ch. (' %,-. � f 1, --- ................. plumbing in the buildings of ... 0% c ...................... at ... .......... , North Andover, Mass. Fee. Lic. No.. 6.11.) ......... �. PLUMBING INSPECTOR Check ff 6511 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location A Owners Name �,5( t� DO PLUMBING Date —11, Y-f� Permit # Amount Type of Occupancy ��SlrIf7C�f New 0 Renovation � Replacement � Plans Submitted Yes � No ❑ �Pt1) 00 FIXTURES (Print or type) Check one: Certificate Installing Company NameElCorp. 1. Ad*ess� C_a k,� Sf%Y%� Partner. Business Telephone Firm/Co. Y Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: ' Liability insurance policy 0 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 information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work a install tion erformed un r Permit Issued for this application will be in compliance with all pertinent provisions of the M s chuse s S e P b'rtgde and Chapter 142 of the General Laws. By re o icena um er Type of Plumbing License Title3% 3 City/Town icense um er Master Journeyman APPROVED (OFFICE use ONLY Im Date...' "?/-? .... ry0 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION �tl - This certifies that ...` ....�............... has permission for gas installation . ........... ,1 in the buildings of ..... 1-G� .......................... r at �,�... !=-�-..-. ��,t"'..:`�. , North Andover, Mass. Fee r���..... Lic. Nd?��.. �... .. ............ �j GASIN + OR Check # ! 41 V 5160 i MASSAC WSEITS UNIFORM APFUCATON FOR PERNffr TO DO GAS Fr3rnNG (Type or print) Date —CQ - NORTH ANDOVER,, MASSACHUSETTS Building Locations �`"" �1 Permit # Amount $ 570" Owner's Name Ne RI Renovation El Replacement Plans Submitted El Chec one: Certificate Installing Company C�T Corp. ElPartner. qFirm/Co. Name of Licensed Plumber or Gas Fitter t � )1 LQ lJl i lam► INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes [3 No If you have checked ,es, please indicate the type coverage by checking the appropriate box. Liability insurance policy 0 Other type of indemnity 13 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: Signature of Owner or Owner's Agent Owner 13 Agent I hereby certify that all of the details and information I have s --t-- tted (or entered) in ariderbov application are true and accurate to the best of my knowledge and that all plumbing work and inst ations a e�� Pe t Issued for this application will be in compliance with all pertinent provisions of the Massach netts St e Cod ter 142 of the General Laws. APPROVED (OFFICE USE ONLY) �' ature of Licensed Plumber Or Gas Fitter P'Enber 2l ,�/ 3 MGas Fitter License Number 0 Master WJourneyman -§UB-BASEM ENT 4T FLOOR -H. :6T FLOOR -H. Chec one: Certificate Installing Company C�T Corp. ElPartner. qFirm/Co. Name of Licensed Plumber or Gas Fitter t � )1 LQ lJl i lam► INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes [3 No If you have checked ,es, please indicate the type coverage by checking the appropriate box. Liability insurance policy 0 Other type of indemnity 13 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: Signature of Owner or Owner's Agent Owner 13 Agent I hereby certify that all of the details and information I have s --t-- tted (or entered) in ariderbov application are true and accurate to the best of my knowledge and that all plumbing work and inst ations a e�� Pe t Issued for this application will be in compliance with all pertinent provisions of the Massach netts St e Cod ter 142 of the General Laws. APPROVED (OFFICE USE ONLY) �' ature of Licensed Plumber Or Gas Fitter P'Enber 2l ,�/ 3 MGas Fitter License Number 0 Master WJourneyman C Permit No. V� %O. S Dia 4;vd& saw Occupancy & Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK. All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 1200 (Please Print in ink or type all information) Date_ To the Inspector of Wres: Townof _-- _ - /- -y-or F/1_ The undersigned applies for a permit to perform the electrical work described below. Location Owner of Owner's Is this permit in conjunction with a building permit Yes Purpose of Building Existing Service J/11- i/ Amps /� -2 Y& Voits New Service Amps Volts Number of Feeders and Ampacit� Location and Nature of Proposed No 0 (Check Appropriate Box) Utility Authorization No. J :2� O O 3 Overhead Undgmd 0 No. of Meter; / Overhead 0 Undgmd 0 No. of Meters WOW OTHER: INSURANCE COVERAGE. Pursuant to the requirernenfs of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantia! equivalent 6= NO have submitted valid proof of same to the Office & - NO - if you have checked YES please indicate the type of overage by checking the appropriate box. INSURANCE - BOND - OTHER - (Please Specify) q - v S Estimated Value of Electrical Works (Expiration Date) Work to Start % // -v S Inspection Date Resquested �a- , �� �`� .4G Rough Final Signed under the Penaltl of per ry: FIRM NAME 0-7 .t // y , LIC. NO. J 3 Licensee +. . ` SignatureXr LIC. NO. % i 3 D ut TedNo._��7— Address is Yr y Alt Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts eneral Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) (Signature of Owner or Agent) �S r-✓ Telephone No, PERMIT FEE $ U Total - No. of Lighting Outlets No, of Hot fuse No. of Transformers KVA Lighting Fah—Above I In 0 No. of Swimming Pod qmd I grnd 0 Generators KVA of Lighting � No.1io. of Receptacles Outlets 2. No. of Oil Bumers Battery Units � No. of Switch Outlets No of Gas Burners FIRE ALARMS No. of Zone No. of Detection and Total No. of Ranges No of Air Cond Tons Initiating Devices Heat Total Total No. of Diposal No. Pumps Tons KW No. of Sounding Devices NoJ of Self Contained No. of Dishwashers SpacelArea Healing KW Delectior✓Sounding Devices No. of Dryers Heating Devices KW I Municipal 8 Other Local Connection No. of No. of Low Voltage No. of Water Heaters KW Signs Bailases Wiring No. Hydro hbss2ge Tuds No. of Motors Total HP OTHER: INSURANCE COVERAGE. Pursuant to the requirernenfs of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantia! equivalent 6= NO have submitted valid proof of same to the Office & - NO - if you have checked YES please indicate the type of overage by checking the appropriate box. INSURANCE - BOND - OTHER - (Please Specify) q - v S Estimated Value of Electrical Works (Expiration Date) Work to Start % // -v S Inspection Date Resquested �a- , �� �`� .4G Rough Final Signed under the Penaltl of per ry: FIRM NAME 0-7 .t // y , LIC. NO. J 3 Licensee +. . ` SignatureXr LIC. NO. % i 3 D ut TedNo._��7— Address is Yr y Alt Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts eneral Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) (Signature of Owner or Agent) �S r-✓ Telephone No, PERMIT FEE $ U Ro C', C9 59u3 Date.... ........................ TOWN OF NORTH ANDOVER p PERMIT FOR WIRING This certifies that ..... I.., ... 12, ..... e -P., ....... rr�� ................................... has permission to perform .: C......:..... •....... `'`'....................................... wiring in the building of ....`.......................................................... at .........-`-'.- ................. . North Andover, Mass. Fee..�4............ Lic. No!. Tlv .................................. ... �...................... ELECTRIC/cTOR Check # S'/�f Permit No. %O-� Occupancy & Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 APPLICATION FOR PERMIT TO PERFORM TRICAL WORK. All work to be performed in accordance with the Massachusetts E I Code 527 CMR 12:00 (Please Print in ink or type all information) Date To the inspector of ;4,9res: Town of The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number. Owner or Owner's Address Is this permit in conjunction with a building permit Purpose of Building ], a X_ Existing Service J11110- I/ Amps Yes No 0 (Check Appropriate Box) „ r 2-- Volts New Service Amps Voits Overhead Overhead 0 Authorization No. ? �r 6161 3 Undgmd 0 No. of Meters / Undgmd 0 No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work OTHER: INSURANCE COVERAGE. Pursuantto the requiremen6ts of Massachusetts General Laves Shave a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent NO have submitted valid proof of same to theOffiee XIS-= NO - if you have checked YES please indicate the type of coverage by checking the appropriate box. INSURANCE - BOND - OTHER - (Please Specify) �p -if v S (Expiration Date) Estimated Value ryof. Electrical World Work to Start / 'tel / -v S Inspection Date Resquested 41, /`�/ AG Rough Final Signed under the Penattl of perpry: FIRM NAME %%� L } /moi .r �r f 4 ' i_ % 1l // LIC. Licensee Z_ SignatureLIC. NO. 2' Te u .Tel No.- Address -� / a��S ��i= Yr �- Alt Tel. No. OWNER'S S RANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) (signature or Owner or Agent) Telephone No. PERMIT FEE $ fo' __ Total No. of Lighting Outlets No. of Hot fuse No. of Transformers KVA No. of Lighting Fodures Z Above 0 Swimming Pool qrrid 0 In 0 gmd 0 Generators KVA Emergency Lighting No. of Receptacles Outlets Z No. of Oil Burners Battery Units r No. of Switch Outlets { No of Gas Burners FIRE ALARMS No. of Zone No. of Detection and Total No. of Ranges No of Air Cond Tons Initiating Devices r Heat Total Total No. of Diposal No. Pumps Tons KW No. of Sounding Devices NoJ of Self Contained No. of Dishv►2shers SpacelArea Heating KW DefectioniSounding Devices No. of Dryers Heating Devices KW 0 Municipal 0 Other Local Connection No. of No. of Low voltage No. of Water Heaters KW S' rm Bailases Wiring No. Hydro Massage Tuds No. of Motors Total HP OTHER: INSURANCE COVERAGE. Pursuantto the requiremen6ts of Massachusetts General Laves Shave a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent NO have submitted valid proof of same to theOffiee XIS-= NO - if you have checked YES please indicate the type of coverage by checking the appropriate box. INSURANCE - BOND - OTHER - (Please Specify) �p -if v S (Expiration Date) Estimated Value ryof. Electrical World Work to Start / 'tel / -v S Inspection Date Resquested 41, /`�/ AG Rough Final Signed under the Penattl of perpry: FIRM NAME %%� L } /moi .r �r f 4 ' i_ % 1l // LIC. Licensee Z_ SignatureLIC. NO. 2' Te u .Tel No.- Address -� / a��S ��i= Yr �- Alt Tel. No. OWNER'S S RANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) (signature or Owner or Agent) Telephone No. PERMIT FEE $ fo' __ M Location No. Date 06 TOWN OF NORTH ANDOVER 9 Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # Pyt 18337 `-` Building Inspor TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: Uw SIGNATURE: Building Commissioner for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: ,t Map Number Parcel Number 1.3 Zoning Information: 14(77 C'7 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Rapired Provide R 'red Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. blood Zane Information: 1.8 Sewerage Disposal System: Public 0 Private ❑ Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System 0 SECTION 2- PROPERTY OWNERSHIP/AUTHORIZEDAGENT Historic iS CIC : Yes 2.1 Owner of Record ame (Print) Address for Service: Signature 1,or Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Cons ton Supervisor. -'--r- �✓540—��� License Number Address 1 �Ieign�ature� 67 Expi tion D# Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ z / r 5 ls� Company Name Registration Number 7/4 Awo A�Gal7% /9 76 Eip(rafi9fi Date .324, Si ature Telephone 0 rn SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Faili in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Workcheck all applicable) New Construction ❑ Existing Building Repair(s) ❑ Alterations(s) ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: I SF.CTInN 6 - FCTiMATF.T1 CnNCTRTTrTinN MQTC T to provide this affidavit will result Addition ti Item Estimated Cost (Dollar) to be Completed by permit applicant O CLkL tJSE ONLY,,,. " 1. Building ®_ (a) Building Permit Fee 2 Electrical --Multiplier (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) 4 Mechanical HVAC 5 Fire Protection 61, 6 Total 1+2+3+4+5 t' Check Number '3r1%.iiv1. is WVTP%rrLtaulIIVr"Z4R11VA LV BE UVMrLh 1Jb0 Wli f4 OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Her by autho a to act on My eh f, in 1 afters relative to work authorized by this building permit application. Si e of Date j SECTION 76 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 Print Name Signature of Owner/Agent Date .. p NO. OF STORIES SSE SE R LAW SIZE OF FLOOR TIMBERS OT 2 ND 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 C t 0 1 � C � o a a C � O H G U CJ d� � O A O C :Z O a Ea w c CO w w U G ii = is o c N UM E � w to LU z cm ro t 2 I ccm O•— V� Q 'C C CD mm CD CD �3 CD Q L C3 o a Q 44 o =� c eo R10 CL 0 CD C46 Z o CL C.3 h O C c c CL(a Q ui U) U) 19 W C9 W N C � O O C � O H G U CJ d� d C O A O C :Z O O � Ea c 0 0_ = is o c N E � c$ v $ !k ca mG I N g m O O �` N 3 cm m� C �m �hC O � N :o a8 �mm ICLO' c Oa y O O f NZ t° o .i o co n = m p F- +O„ N F� • ,� •� dt !.s f. E SON Lu C* d •� Os CL.- Cc cm ro t 2 I ccm O•— V� Q 'C C CD mm CD CD �3 CD Q L C3 o a Q 44 o =� c eo R10 CL 0 CD C46 Z o CL C.3 h O C c c CL(a Q ui U) U) 19 W C9 W N . 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W 0 W U) • 6 z LU CL o ;F, O a a O c x •� �n w C CL O O v Uwa°' CD C u, a B a°' O � w" r�4° w w' 0 z cn cn LU CL E co O C O m ca c m 0 cm C C N ID t r 0 Z O s cl I y y E a. CD O CD U cv r •A L ts CDCL y C r—I LLI LU U/ 1. W 19 LLIW U) ;F, O CIS 0 ` C N O c •� C CL O O CD C :Z O_ O � Ea CF mis o a H :0= c .. w$ C mD c_ k Call mm C �' mI CD 3 m c _m CO _ C� Cie W ' � O JD m 0 acw m 0 .15 o e oa m �Io m o c no a m i0 c F=- : « ID o m W mF. m W E v'0 a0 y a 9, OC Fc to IoGo� a4m E co O C O m ca c m 0 cm C C N ID t r 0 Z O s cl I y y E a. CD O CD U cv r •A L ts CDCL y C r—I LLI LU U/ 1. W 19 LLIW U) 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 SECTIO APPLICANT LOCATION: Assessors Map Number y SUBDIVISION -� STREET`2 c OFFICIAL USE ONL TOR MAT9 sooen...,. PHONE PARCEL LOT (S) ST. NUMBER TOWN PLANNER DATE APPROVED DATE REJECTED FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR -HEALTH DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWERIWATER DRIVEWAY PERMIT FIRE DEPARTMENT_iy�✓ , 4/�3/0-- RECEIVED BY BUILDING INSPECTOR__ DATE_ Rwlpd 07 Jm r �e!L% !irm 3 r -q nuc uy/ CIo O -f rput t 2� m 0 S�/70 39dd b -Io I 514VI d I).V'TI NO.I.$ n.q A t T'11 c'3vr%-i NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accord c with the provision of MGL c 40 S 54, a condition of Building Permit at: D A KUso vj is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 10A. The debris will be disposed of in: WAR30 acility) Fire Department Sign off: Dumpster Permit of Peiinit Applicant Date Name The Commonwealth of Massachusetts Department of Industrial Accidents Mice of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print Ci Phone # / I am a homeowner perfortfing all work myself. 0 I am a sole proprietor and have no one working in any capacity aI 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 d,a fine up to 61,500.00 and/or one years' imprisonment_as_wag-as_civil..penaltles inbeform dA.STOP WDRK_ORDER..and_a fine 4.(6100.00)-aAw againat.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 nder the pains an alties of perjury that the information provided above is true and correct. Signature Date 64:�" Print name " !` � Phone # ' 6 ; 6, / -7 5 Official use only do not writ6A this area to be completed by city or town official City or Town Permit/Licensi []Check if immediate response Is required ❑ Building Dept ❑ Licensing Board C] Selectman's Office Contact person: Phone #. ❑ Health Department ❑ Other I Location 1 ( No. �' f Date /0/Ict Oy NORTIy TOWN OF NORTH ANDOVER F i w 9 Certificate of Occupancy $ sACMUSEt� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 36Z 0 Check 4y, # 7725 -Aul( Building Inspector 2161oR , 6 _00&!, TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER:` DATE ISSUED: z�� SIGNATURE: Building Commissioner ns for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: R-3 Rpsia"4a 1 Zoning District Proposed Use Lot Ards s Fr ft 1.6 BUILDING SETBACKS 00 Front Yard Side Yard Rear Yard Required Provide Regaired Provided Re red Provided 3o a o 3 n 1.7 Water Siply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public AV Private p Zone Outside Flood Zone 1.8 Sewerage Disposal System: Municipal /`�/ On Site Disposal System C SECTION 2- PROPERTY OWNERSEIP/AUTHORIZEDAGENT 2.1 Owner of Record 060o- Jit. W(l.(,I19-+M P- Name (Print) Address for Service Signature Telephone 2.2 Owner of Record: r Na e P 'nt Address for Service: 14 q79 37 /9T Signature Tele hone SECTION 3 - CO 5 TION SERVICES 3.1 Licensed Construction Not Applicable ❑ 7rvisor: 7 C.J 071 Licensed Construction Supervisor: 1 License Number j�4v„ � Pv� 7 ddress ��`� (, /�,01 7a 376 U Expiration Date natur Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Compkany Name 137701 r 70— 6r Registration Number L, 'b Ad rass 7i 7-�) 916-1 Si enure Telephone Expirati Date SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 & 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all a Hcable New Construction X Existing Building 0 Repair(s) 0 Alterations(s) 7_Addi tion 0 Accessory Bldg. 0 Demolition 0 Other ❑ Specify Brief Description of Proposed Work: '0,eT?Ach ed -- ;5 e e ,471-,e_he_ �x SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by p2rmit applicant OFFICIAL USE ONLY 1. Building Ute (a) Building Permit Fee Multiplier 2 Electrical y ,�,�/, ' (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x tel 4 Mechanical HVAC 5 Fire Protections 6 Total1+2+3+4+5 (' Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,AW me as Owner/Authorized Agent of subject property Herebv authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, 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 >Iftme ,f G S ig6gtYe of O e ent Date NO. OF STORIES SIZE BAS IViENT R SLAA , SIZE OF FLOOR TITVIBIERS 1 s 2' 3 —" SPAN DIMENSIONS OF SILLS �- �L . _ . . DIMENSIONS OF POSTS DIlaNSIONS OF GHZDERS HEIGHT OF FOUNDATION _ THICKNESS SIZE OF FOOTING X �'--- MATERIAL OF CHIMNEY` 1S BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 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 -( t �C l ! v PHONE LOCATION: Assessor's' Map Number PARCEL SUBDIVISION//� LOT (S) STREET_ �7 —TQ h I,</:5 07,<J ST. NUMBER ********* OFFICIAL USE ONLY ***** TOWN TION ADMINISTRATOR DATE APPROVED DATE REJECTED TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS ruuu IN,rtG I VK -HEALTH r) n SEPTIC INSPECTOR -HEALTH COMMENTS DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIONS tt DRIVEWAY PERMIT le '?e (5 t i N y 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 FNility) nature of Permit Applicant DA t -K Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector 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 D(' o �i uiSc�X/ 5re��T . JOB LOCATION / -/ Number "HOMEOWNER Name Street Address '�0 376 X12 Home Phone PRESENT MAILING ADDRESSZj . -'10 1-e1$ ;r City Town State F61-31 M /lot Work Phone The current exemption for "homedwners" 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 inspectipn procedures � requirements and that he/she will comply with said procedures and req*ements. ` / HOMEOWNER'S SIGNATU APPROVAL OF BUILDING OFFICIAL Zip Code CAi-6}X. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name . Please Print Name: Location: City Phone # 0 I am a homeowner performing all work myself. I 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. Comoanv name: Address City: Phone # Insurance Co. Policv # 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.penaltiesin the fwnnfa_STOP WORK_ORDER..and..a fine .of (.$100.00.)a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature Date Print name Phone # Official use only do not write in this area to be completed by city or town official' City or Town Permit/Ucensin ❑ Building Dept []Check if immediate response is required ❑ Licensing Board E] Selectman's Office Contact person: Phone #: r-1 Health Department ❑ Other mpm CERTIFICATE OF LIABILITY INSURANCE$/31/2004 DATE(MWDDNM) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Circle Business Insurance Agency Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 247 Newbury St. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Danvers, MA 01923 '978-777-7030 INSURED WILLIAM POGOR 79 JOHNSON ST NORTH ANDOVER, MA 01845 1978-685-2425 CAVFRAPF-A INSURERS AFFORDING COVERAGE NAIC# OrSURER A: ASTERN WORLD INSURANCE CO. INSURER s: LIBERTY MUTUAL INS. Co. INSURER C. INSURER 0: 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 4 LTR RD TYPE OF INSURANCE POLICY NUMBER EFFECTIVE EXPRA LIMITS GENERAL LIABILITY EACH OCCURRENCE S 1, 0 00,005 X COMMERCIAL GENERAL LIABILITY CLAWSMADE ® OCCUR PREMISES oaawence S 50,000 MEDEXP(Myonepemm) $ 5,000 A NPP872779 09/04/04 09/04/05 PERSONAL&ADVINJURY s 1 000 000 GENERAL AGGREGATE s 2,000,000 GEML AGGREGATE LIMIT APPLIES PER: POLICY ECT LOC PRODUCTS-COMPIOPAGG S 1_,000,000 AUTOMOBILELIABILITY ANYAUTO COMBINED SINGLE LIMB S (Eaacadm) - ALLOWNED AUTOS SCHEDULEDAUTOS BODILYINJURY S (Pe'Person) HIRED AUTOS NON-OWNEDAUTOS BODILYIN.IURY S (Perms -9 PROPERTY (DAMAGE S GARAGE LIABILITY AUTO ONLY-EAACCIDENT $ OTHERTHAN _ EAACC $ ANYAUTO AUTOONLY: AGG S EXCESSNMBRELLA LIABILITY OCCUR E � CLAIMSMADE EACH OCCURRENCE $ AGGREGATE $ - S DEDUCTIBLE $ RETENTION $ $ - WORKERSCOMPENSATIONAND EMPLOYERS'elaARYM . ,._ ANY PROPRIETOitlPARTNERlE7fECUTIVE _ C-351037-014 03/27/04 _. -- 03/27/05 rCSTMtTS. ER. _. ----. E.LEACHACCIDENT s 100,000 B OFFICEWMEMWR M=m0EDT 11yes, dem�ettnder E.L. DISEASE - EA EMPLOYE4 S 100,000 E.L. OLSFJISE-POLICY LIMIT S 3 0 0 0 0 0 SPECIAL PROVISIONS below OTHER HOLDER TOWN OF NORTH ANDOVER BUILDING DEPARTMENT TOWN HALL NORTH ANDOVER MA 01845 ACORD25(2001/08) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIC DATE THEREOF. THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES.__ zee ©ACORD CORPORATION 1988 /BOARD 0�l G`&ULl+"""S License: Number: CS 083917 Birthdate: 06128/1957 Expires:- 06128/2006 Restricted: 00 WILLIAM H POGOR 79 JOHNSON ST NO ANDOVER, MA 01845 Tr. no: 83917 Administrator Board of Building Regulations and Standards I: HOME IIIIAPROVEMENT CONTRACit1R !' Registration- 139701 Expiration: 81512005 Type individual .a. BILL POGOR I WILLIAM POGOR . 79 JOHNSON ST. NORTH ANDOVER, MA 01845 Administrator rA W to ui c c 0 0 C y O C _ V •nom dC A ea m C •L _O O O y E �. am o� mm 3�= y O C s;mo CO, CLS cm Z L O �• COQ � mCO CO _ m � CJ Z cm o� Q E NCL. C 0C QC = m dw p Q COO a Lit C Ate= H .y = C O.Z U= E 35 ca ci m mO S CL w • 'O O H w m di p �91' w 0 O v CY. O E co L s Z Q. O y I Ccm C y Q 'E- m m a ~� 4D O� 3� 4D O G O cc o C- CL COD C Q c cc v Its CL c C xCL � V 02 cc c C _cc d CA D W O U) U) W W N x 12 u• 0 w 0 r� u a x a o a a w" w w o w w P o u: w � c4 z cn o cn ui c c 0 0 C y O C _ V •nom dC A ea m C •L _O O O y E �. am o� mm 3�= y O C s;mo CO, CLS cm Z L O �• COQ � mCO CO _ m � CJ Z cm o� Q E NCL. C 0C QC = m dw p Q COO a Lit C Ate= H .y = C O.Z U= E 35 ca ci m mO S CL w • 'O O H w m di p �91' w 0 O v CY. O E co L s Z Q. O y I Ccm C y Q 'E- m m a ~� 4D O� 3� 4D O G O cc o C- CL COD C Q c cc v Its CL c C xCL � V 02 cc c C _cc d CA D W O U) U) W W N 365; TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .,K ...........7** *** ......................... ............. ... *"**** ... **.... * .... 1 ... has permission to perform .................. . wiring in the building of ................................................... at ... ...... ... .......... . North Andover, Mass. Fee Lic. N��4dl).'. . ............. ...................... ELECTRICAL INSPECTOR Check # 27ff09MM0AWE4LTH0FMA SqCZr17 DMARTM ATOFPtIBLICS MY ' . BOARDOFFREPREYRWON 527Cat ZZ* Office Use only Permit No. Occupancy & Fees Checked �Q PLICATTONFOR PERMIT TO PEUORM R. U RICAL WORK ALL WORK To BE PERFORMED iN ACCORDANCE WrfH THE MASSACHUSSTS BLEs MCAL CODE, 527 CMR 12:00 (PLEASE PRINT IN IMC OR TYPE ALL INFORMATION) Date Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street J Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: YcS MNo (C Appropriate Box) Purpose of Building ��`-�Cf'�?f!/ j/ 114ttr � _ Existing Service /M Amps/2?/ (Holts 7 New Service 0 Amps/ -,19 / oits Number of Feeders and Ampacity % Rrll' Location and Nature of Proposed Electrical Work ` No. ofLiahtin¢Oudets J ., of Hot Tuba Utility Authorization No. �/���S-7 Overhead Underground No. of Meters Oveltte`.,d Under rd 3 No. ometers No. of Trarafonnets T No. of Receptacle Outlets / ` No. of Oil Burners Na ofEme rgency Lighting Battery Units No. of Switch Outlets No. of Gas Burners x4adflafts No. of Air Cond. Total FIRE ALARMS .^ss T� No. ofZoaft No. of Disposals A/,- / / �/ %,� „ i No. of Heat Total Total Na of Detection and Jo. iw'' ishwashers Space Area Heating ?obs KW KW kisaingticea Na ofSoned' �e6.Devices _ No. orseliGoat#ined lo. of')ryem lo. of Water Heaters KW Heating.DevicesKW irig:Drviees Local Maucipal Othe 0 Connections No. ofof No. o. Hydro Massage Tubs Signs No of Motors Bailasis Tont Hp is MCotorGft Pisst210b9teGaiaaiiam . eacumvtLid,*Yk prat rdkYin3&,Caeca is isi"t�egti►aloiE y O est#mi>OadwGdp�oafcisamebiheO�ivC Y)`5 NO **baL - - imyeQtthii -o------`Y�.�..aaotpa�ar°YC.ielt�hll.aV18 � $tilt ce check one) Owner Agent Telephone No. PERMIT FEE $ 14 Date lj� ... . -01 ......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies ............................. ....................... . ..... has permission to ............ wiringin the building of ........... I ............................................................ . ................................................ . North Andover, Mass. Fee ..................... Lic. N? ... .......................... ELECTR[CALINSPECTOR Check # WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Office Use THE00W0A F4LTH0FAf SSA0ffJSE JS only DEPARTMENTOMBLIMFEfY Permit No. BOARD 0FFIREPREVENTI0NREGM770NN527CMR 1200 Occupancy & Fees Checked APPLICATIONFOR PERMIT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 2/,�00,v (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date q 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) -3 q 3—m H �-� ry K% Owner or Tenant Owner's Address ,16 Z M 7-1� 91,% Pllr f' Is this permit in conjunction with a building permit: Yes No a (Check Appropriate Box) Purpose of Building / I%gMiC_N /-�aCJst_ `� G���(% Utility Authorization No. Existing Service 2.264 Ampsl gl Z y olts Overhead Q Underground a No. of Meters / New Service Amps/ Volts Overhead Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work 27) /,S' C'DXj ec +! G✓' / AL, No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA ground 1:1ound No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets 6 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 v Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipala 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 OTHER • hts&ra =Cbvw g Rm& ttothetegtmwvxllsdMwsadilsftCmwALam Iha%eaametLiablkybtsm=Pblqm&6gCar pkt CaeaWcritsmbstrtWeWK-elat YES NO F1 Iha%e%bn tmdN,A dpoofofmrnebthe0ffi= YES M NO If}ouhmed�adWYES�pimemdc*thet p ofwmaWbydrdargthe �--+ INSURANCE [Z] BOND CARER (PlemeSpe*) Estirrmbdvaiueof1k:ftica Wak $ WotkiDSto�fpa : '— hgad�onD&-Recg�Imed Rag#t �%!LL �t9GL Frttal F RM ANIS Lioaee J�i�J/�k� JG�Y� •—� LioaueNo _...� B&sirxssTV. amt76 ._ AILTVh OWNER'SINSURANCEWANER;Iammvm&ttheLjoerseduesnut1hem=snoeooyaaWontss&s1arrtiale asmq=WbyNtmmdas&C..,erodLaws anddatmysgw ttaearthspanftq#atmwarwmthism m To i (Please check one) Owner M Agent 17 Telephone No. PERMIT FEE $ >N° 3 5 �} Date.................................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .... -' 1� has permission to perform . .-S - wiring in the building of .... z� ��-� ... ..,%...........................................................L,.... - :/ ... North Andover Mass. at ...... , Fee. ..... ..... Lic. No h./.. � ? -....x .:.................................................... ' . ELECTRICAL INSPECTOR Check # / / r WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Y It I The Commonwealth of Massachusetts office Use Only Permit So.— 3 0,S— rt PH Department of Public Safety?,L i ( Occupancy 6 Fee Qhecked'�`�—� BOARD OF RRE PREVENTION REGULATIONS S27 CMR 1200 U3/90 cleave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL- WORK All work to be performed in accordance with the Macaachuietts Electrical Code, S27 CMR I2:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date City or Town of"e &- To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) % � �� /�/c�GN �Or Owner or Tenant Owner's Address Is this permit: in conjunction With a building permit: Yes No ❑ (Check Appropriate Box) Purpose of Building Ho L)% f_ jJtility Authorization NO. Existing Service Amps - / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of liters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No. of Lighting Outlets No. of Lighting Fixtures No. of Receptacle Outlets No. of Switch outlets No. of Ranges No. of Disposals No. of Dishwashers No. of Dryers No. of Water Heaters No. Hydro Massage Tubs OTHER: No. of Hot Tubs Swimming Pool Above itrnd . ❑ No. of Oil Burners No. of Gas Burners No. of Transformer.. LVW -4 KVA id. ❑ Generators INA No. of -Emergency Lighting Battery Units No, of Air Cond. tons No. of HPwts Total Total Tons KW Space/Area Heating KW Heating Devices KW KW No, of Si o. o Signs Ballasts No. of Motors Total HP FIRE ALARMS No. of Zones No. of Detection and Initiating Devices No. of Sounding Devices No. of Self Contained Detection/Sounding Devices ❑ Municipal Local Connection❑Other Low Voltage INSURANCE COVERAGE: Pursuant to the requirementsf Massachusetts General Laws I have a current L ility Insurance Policy includinog Completed Operations equivalent. YESONO ❑ I have submitted valid proof of same othis nofficeragYESr VsNsO❑ INSURANCE �BONp ubstantial If you have checked YES, please indica te the type of coverage by checking the appropriate box. ❑ OTHER ❑ (please Specify) Estimated Value of Electrical Work Work to Start Inspection Date Requested: Signed under the penalties of perjury: FIRM NAME Rough Expiration Date Final LIC. N0,_ Licensee Q� �n7 U�. �7/�J���/a Signatures_ v Ad LIC. N0. &Z% L Address 3 ?t������� Uj�% Bus. Tel. No. ((�� OWNER'S INSURANCE WAIVER: I am aware that the Licensee does !not have the insurance cocveerage or its/ sub- stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) Telephone No. PERMIT FEE $ (Sig Iture of Owner or Agent - Z O F— CL CL Q J Q U F— U W w F— LL W Q CL C 0 W F- W 7 J Q d z Ej 0 O cr— U ULj Q W W Date . `i' ........ TOWN OF NORTH ANDOVER ° PERMIT FOR PLUMBING This certifies that .... •.':� has permission to perform,.-:...-....:.. .`. `................. . plumbing in the buildings of . :.....!�` at ....%.�' ... r.' -�-- ". • • "�" • • • • , North Andover, Mass. Fee .4... J .. Lic. No. ,A.,?,/.G... .......!....,< . ?.,^ ........... PLUMBING INSPECTOR Check # WHITE: Applicant CANARY: Building Dept. PINK: Treasurer • 1 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, -MASSACHUSETTS Building Location Owners Datekwt� t�, - a6o I Permit # 4/79-c' Amount ys5 New E] Renovation tQ Replacement E] Plans Submitted Yes No K f' G . (Print or type) l Check one: Certificate Installing Company Name ��� �- Corp. Address V A F]Partner. Business Telephone 1Ilk® Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance 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 threeinsurance ignaturewner11 R Agent I hereby certify that all of the details and informa on I have s bmitted (or ente bove application are true and accurate to the best of my knowledge and that all plumbing work an ' talla perfoi i ed under it Issued for this application will be in compliance with all pertinent provisions of the Massachus lu bi g C 142 of the General Laws. By igna o icense um er Type of Plumbing License Title -(-� 1 City/Town 71censeNumber — Master ❑ Journeyman y APPROVED (OFFICE USE ONLY Location / �© "ti SU'� s4 No. [- 1 Date TOWN OF NORTH ANDOVER Check # j / 6 111 2' 1/, - i Building Inspector n ' Certificate of Occupancy $ t;7SJcHus'•••°•,t�' Building/Frame Permit Fee $ Foundation Permit Fee $ j Other Permit Fee $ TOTAL $ Check # j / 6 111 2' 1/, - i Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT ��-�e� APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING Number: F/ Parcel Number BUILDING PERMIT NUMBER: cx /5— DATE ISSUED: SIGNATURE: �ll-- Building Commissioner/I for of Buildings Date Frontage ft bhU 111JA 1- n l l h LN 14 UKr A 11k)A l 1.1 Property Address: 79 --%w.s ��-�e� 1.2 Assessors Map and Parcel _ Map Number Number: F/ Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area Frontage 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. 54) Public 0 Private 0 1.5. Flood Zone Information:—F-:1.8 Zone Outside Flood Zone 0 Mipal Sewerage Disposal System: ❑ On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record rNe (Print) Address for Service: r %CJ a re Telephone 2.2 Owner of Record: G�Tff 5iel*e 0 �9 �%Ls��oGG Name Print Address for Service: ~ pOF6,Ys y, S� Tigtra6reIele hone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ,, Licensed Construction Supervisor: License Number Address Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable Company Name Registration Number Address Expiration Date Signature Telephone t SECTION 4 WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: 1��/no DL/v�G 13fi�H/�Doivl ��� /Q�iYla(�c /KJG kiT H�u� I SECTION 6 - F.CTTMATRII t-nNCTRTT!'TTnN 9-v14ZTc Item Estimated Cost (Dollar) to bez UFCIAL>�TSl• feted b ermit a licant 33F3 Y I. Building �-5 (a) Building Permit Fee _v OQU Multiplier 2 Electrical r (b) Estimated Total Cost of Construction y 3 Plumbing QDj Building Permit fee (e) X (b) / 4 Mechanical HVAC j 5 Fire Protection Q 6 6 Total 1+2+3+4+5 Check Number l�a:.i� AV 111V1�1L�A11V1\ lv Dr, —%-POR In" wl'mi'N OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby authorize My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION to act on I, �//L L / �—� �p i� as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief %G G / /� rYi /�O lreJ2 Owner/. Date NO. OF STORIES 2_ SIZE 60 �ASENTM OR SLAB SIZE OF FLOOR T&IBERS iST 2 3RD SPAN DEMENSIONS OF SILLS Da ENSIONS OF POSTS DM&ENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHEVINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Town of North Andover Building Department 27 Charles Street North Andover, Massachusetts 01845 (978) 688-9545 Fax. (978) 688-9542 DEBRIS DISPOSAL FORM �^ •�q CO[w�1CM1 KA y7 �R1Ten �Pp` •(5 In accordance with the provisions of MGL c 40 s 54, and a condition of Building permit# the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL cl 1, s150a. The debris will be disposed of in /at: Facility location . Signature Applicant Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. D. Robert Nicetta Building Commissioner (978) 688-9545 ,'(978) 688-9542 Fax Town of North Andover Building Department 27 Charles Street North Andover, MA. 01845 HOMEOWNER LICENSE EXEMPTION Please print DATE `L JOB LOCATION 7�' "HOMEOWNER Number Name //e9,07 - Street Address 17 g 374 1873' Home Phone WAN 0 �a /3/ TI 0—t 7 Work Phone PRESENT MAILING ADDRESS /v 4%2% City 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-►aws, 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 helshe will comply with said procedures and Te- f ents. HOMEOWNER'S SIGNATURE /J�/J��� s�T APPROVAL OF BUILDING OFFICIAL a A .� [i C/) � o w2 r2 ,, U CO w Q. a°' w 0 w U w w a°' -C�' C/) w 2 C w a a w M pq o N (i) v o '.00 cn c o m c o C2 c � O y O C.) C.3 •m c O O O C z E a h s - mC� .. O y E � •c Us �J os �mc(E CL= L. CD a O � � cp � Go 0.: .m� y .m •> > Z = C y y W c O 94:E `D m ® mgla CJ L.:m .La : C7f CzQ c 1.2cc O : .«. CD ca o CL 0 c = m m -o N :a ~ $ uiCO) ev = m W c r •O = LL •� O cc go O w •a= c Z W •E c=s .0 v .y O ` C3 m E co COD CS m 'Foh O CL 32 _ t �•a O F-- O r0. d r 90 a M y h E O 0� O ao 0 cts r'1� L O v CD CLy C CM D � m m 3� 0 L. fl. O CL C Q Ccc O CO Z cs co CO)CL C r-7 LLJ 0 U) U) ccw W crW LLJ U) Town of North Andover Building Dept. James Decola Electrical Inspector Dear Jim Decola; 4/9/2002 I have released Bayside electric from any further responsibility for electrical work at 79 Johnson Street North Andover Massachusetts. To be replaced on the permit by Robert Minichiello of Tewksbury Massachusetts. (Lic# A12132) who was also the previous electrician of record at this job. 3Thaou Pogor (owner) 79 Jo son Street North Andover, Massachusetts 01845 978-376-1875 cell Location 'y S u n. -j S No. 3 Date NORTM TOWN OF NORTH ANDOVER 3? ' �0 • ; ; Certificate of Occupancy $ 9 cHuBuilding/Frame /Frame Permit Fee $ s�sE Foundation Permit Fee $ Other Permit Fee $ ► TOTAL $ 3 Check # 5, ',, X6173 4q Building Inspector C- ov D33 o o (D (/1 0 �m 0 co W o (D O O O o (D -., CD 0 0 m D CD 3 CD a 0 < (u 3 U) CD 0 0 1 TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING eCfi ;fbral tini , BUILDING PERMIT NUMBER: � � � DATE ISSUED: SIGNATURE: C C,.—__— . . BuilTng Commissioner/Inswtor of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area (so Frontage 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. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record 7 A� KI me (Print) '` 7 `Address for Service / 7,�-- tgnature V Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervi or: 0 Licensed Construction Supe �r: Address m Signature' Telephone Not Applicable K License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable 0— Company Name Registration Number Address Expiration Date Signature Telephone rn O Z rn go O mn r v M r r Z Q ow SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building Repair(s) ❑ Alterations(s) 9 Addition ❑ Accessory Bldg. ❑ 1 Demolition ❑ 1 Other ❑ Specify Brief Description of Proposed Work: I SECTION 6 - ESTIMATED CONSTRUCTION COSTR I Item Estimated Cost (Dollar) to be Completed by permit applicant OMCIAL,USE ONLY - 1. Building v 'q (a) Multiplier Fee 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (e) X (b) 3 4 Mechanical HVAC— 5 Fire Protection 6 Total 1+2+3+4+5 Check Number az%-llvl'l I UW1\EK AU 1n"Kt/.A11U1N I ISE UUUMYLElEll WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby authorize My behalf, m all matters relative to work authorized by this building permit application. Signature of Owner SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION Date to act on 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 Name of Date NO. OF STORIES SIZE �')v ASEME OR SLAB SIZE OF FLOOR TIlVIBERS IST 2 ND 3 SPAN DIMENSIONS OF SILLS DINIENSIONS 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 n Calculation Sheet Project Name: Pogar House Location: North Andover, MA Date: 1/28/2003 Engineer: Chris Mauck, PE D L C -- LQ 4 v" K r_a �i 5.2 3� 24q) ikl- 3 40 C 'L Cma LU IV-% 11� 4 F —0. -.3 J Al Calculation Sheet Project Name: Pogar House Location: North Andover, MA Date: 1/28/2003 Engineer: Chris Mauck, PE 0.1 % k %40 J ... . ... .. 52 j S col 7' v4 Z- F—F- I LL -LL - I z -e-+-� - -3,641- 10 -1446A `Lbb L Q 14 0.1 % k %40 Tel: 978-688-9545 Please print. DATE JOB LOCATION Number o .= Town of North Andover Building Department " _ �• QDA�itD �PPS.(G 27 Charles Street °SSACHUSE North Andover MA 01845 HOMEOWNER LICENSE EXEMPTION Street Address Section of Town "HOMEOWNER S/Y Number Home Phone Work Phone PRESENT MAILING ADDRESS Zl�� 7H- 1146;e colg41,9— 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 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 to six family dwelling, attached or detached structures ac- cessory to such use and 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, a form acceptable to the Building 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 No. Andover Building Department minimum inspection procedures an requirements and that he/she will comply with said procedures and regj4irements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFICIA Note: Three family dwelling 35,000 cubic feet, or larger, will be required to comply with State Building Code Section 127.0 Construction Control. O z 4 x q a v u� p w° E p Un o � z w° °' U co w b zi O rz in r w a o w w W o0 O c4 u C w a o z m 7 w w w A w v W z C/)U) Q o c� o m c w. C N O C v U v Cc Cc ga L o 1 o CD M N: E c s Dm C. :oma �0 5 r E CD N A m N: O fir: N n •; N m 3 v cm m �� H N O C O IL' E O CLU m .�Nmm CM _ = o «.,o oQc c ♦: M a c 'cc m �Z Lo O ... cm �; CD ED IA c Q o c N y ` Z m Z mm •N C ci m C m E: C a� V1 C m y 'm O : Q _ca A =� O .� �Cm a -' CO) W CLO C 0 CO) 0 CL V CO2 O O .0 Q COD 0 CD CL CO) C O CM C CD O .0 O� m m 0 co D O CL 0 0 Q. cnQ *-6 C ccc J.0 O O Z CD CL CA C 0 ui C!1 ir W w W VJ MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTIMG (Print or Type) I c NORTH ANDOVER Mass. Date l4uilding Locatio5,07-It Permit i Ow ers Name_ i- AD &��s . New "7 Renovation 13Replacement U3111, Plans Submitted D FIXTUR=I (Print -or Type)Che one: Certificate Installing Company Name ANDOVER PLG. & HEATING CO. , . Corp. 2,122 Address 571-1/2 SO. UNION ST. Partner. LAWRENCE, MA. 01843 Firm/Co. Business Telephone: 508 685-8383 Name of Licensed Plumber or Gas Fitter GEORGE I AROSE Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of Insurance Waiver: I, the undersigned, have this application does not have any one of the Signature of owner/agent of property indemnity Q Bond ED been made aware that the licensee of above three insurance coverages. Owner U Agent M 1 hereby certify that all of the deuils and iefocmation 1 have submitted (or entered) in above application ace true and accurate to the best of my knowtcdge and tltat all plumbing work and Installations performed under' Permit iuced to: this application will -be in co plianee with all pertinent Provisions of the Massachusetts State Cas Code and Chapter 14: of the General 1Jwa. By YPE LICENSE: Plumber Title Isfitter• Sign ure of Licensed City/Town:Master Plumber or Gasfitt:er APPROVED (OFFICE USE ONLY) Journeyman _ 9983Lcense Number OEM (Print -or Type)Che one: Certificate Installing Company Name ANDOVER PLG. & HEATING CO. , . Corp. 2,122 Address 571-1/2 SO. UNION ST. Partner. LAWRENCE, MA. 01843 Firm/Co. Business Telephone: 508 685-8383 Name of Licensed Plumber or Gas Fitter GEORGE I AROSE Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of Insurance Waiver: I, the undersigned, have this application does not have any one of the Signature of owner/agent of property indemnity Q Bond ED been made aware that the licensee of above three insurance coverages. Owner U Agent M 1 hereby certify that all of the deuils and iefocmation 1 have submitted (or entered) in above application ace true and accurate to the best of my knowtcdge and tltat all plumbing work and Installations performed under' Permit iuced to: this application will -be in co plianee with all pertinent Provisions of the Massachusetts State Cas Code and Chapter 14: of the General 1Jwa. By YPE LICENSE: Plumber Title Isfitter• Sign ure of Licensed City/Town:Master Plumber or Gasfitt:er APPROVED (OFFICE USE ONLY) Journeyman _ 9983Lcense Number To 2403 Date..... !... !.. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION �SSACMUSEt This certifies that has permission for gas installation, in the buildings of ✓j :. (. ` (1 k o/ ............... . at ...� , North Andover, Mass Fee...la.... Lic. No.�.. PANAY: GAS INSPECTOR l'i'cantWHITE: AppBuilding Dept. PINK: Treasurer GOLD: File MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAWrl-riNG Wrirtt Type) c -Mass. Date\\ 1g_,___ Permit Building Luca �S� ry • S -t Owners Name_1�F-` -0O (tTL - to N4) Type of Occupancy tQ eS• New rul Renovation ❑ Repiaoement �,•� Plans Submitted: Yes[] No 9 Installing Company Name A H E R N C O N T R A C T I N r Check one: Certificate Address_ _ # 4 ELI 0 T STREET )U Corporation S O M E R V I L L E, MA., 02143 ❑ Partnership Business Telephone__.6 21- 4 5 51 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter J -os e r- r yl INSURANCE COVERAGE: I have a current IWAlty Insurance policy or its subatarft equivalent which meets the requirements of MGL Ch 142. Yes ® No ❑ If you have chec4od yo, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy I; Other type ot 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: Signature of Owner or Owner's Agent 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 pli with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. By Tme of license: Kjcqr--r umber Signiture ofpansed Run- or Gas FER True Gasfitter Master License Number p q a 2 YI1PP�0 .D Journeyman r ,r CM Installing Company Name A H E R N C O N T R A C T I N r Check one: Certificate Address_ _ # 4 ELI 0 T STREET )U Corporation S O M E R V I L L E, MA., 02143 ❑ Partnership Business Telephone__.6 21- 4 5 51 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter J -os e r- r yl INSURANCE COVERAGE: I have a current IWAlty Insurance policy or its subatarft equivalent which meets the requirements of MGL Ch 142. Yes ® No ❑ If you have chec4od yo, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy I; Other type ot 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: Signature of Owner or Owner's Agent 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 pli with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. By Tme of license: Kjcqr--r umber Signiture ofpansed Run- or Gas FER True Gasfitter Master License Number p q a 2 YI1PP�0 .D Journeyman r ,r Date..................... I TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ....... ; ....... ..; ...................... has permission for gas installation................ in the buildings of ............ / ............ .................. at ..................................... North Andover, Mass. Fee..A /, I ...... -Lic. No ............ .......................... GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File �•••••�••••j •+r�. e.cl Vr LYle9.fjf� Office Use only /71 DAPART�{LI�R'OFPIIBLAC&jMy " BOARDOFFIREPRL77VTIO1V1?E Permit Na fa►�7,%4TIA'1L�'Sr27CSf�12aAD occupancy dt Fees C6ecw APPLICATTONFOR PERMT'TO PERFrORMH,Ecn;U, WORK ALL WORKOBEMFORMmtrtnCCORD,wcEwmjT hjASSAC"US=,ELB=CALaw, rLPLEASE PRINT IN INK OR TYPE ALL INFORMATION) 527 Town of North Andover 'he undersigned applies thr a it to To the Inspector of Wires: Pin perform the electrical work described below. ocation (Sheet & Number) °r g J CIA w! c r7 Al <'7– • . wner or Tenant Niter's Address p AL— this permit in conjunction with a building permit: yesNo Pose ofBuilding 1-1646e– sting b �--■+ stir Service 69 U overhead s,.,, g .L..._,r._ Amps��Volts �ce� Ames` yolhr Odd fiber ofFeeders and gmpacity; tion and Nature ofProposed gteetrical Work fHat Tubs "T Total Kecexacle outlets switch thdets Ranges haposds• gshwashers Win. iter Heaters k MamBe Tube mew A»ntbl LLO (Check Appropriate Box) Utility Autha No. un&valmd N ----.. t C3. Ute. NO. ofM ! 0 Na of.Air Coed 7otat F ALUM 1. Toes - Na orzaaft Na of Hest T This Taal UK Gfpddiw� - --'—� Spm Area w Na ofSoMdj ,pr yica --•• Na ofSt$:. ••r�!....!w 1`�g.[kvieer Na or � Na of KVII LOW�� ,,.. t;°GINctrow Bar Na of Molars Tow HP JRANCEWAiVEp,IamauMefltatihelioer C AItTdjNh .�nttaspeQt�eppl�tion�sdlstegedener�t a�"0'ear�s�Mca,�dlLaws Oane) Owner Agent (�� L�...J Telephone No. PERMIT FEE MAY. 3.2001 1.2! 00PM SON PIERCE INS NO. 793--T-P.2— ��„� g`L r 1 NSURAN A RD CERTIFICATE i� 09/03/1001 (731)r30-8770 (181)729-0053 OKYANTHOU"DC949HOPliNiTSUP01lTliECERTIPICJ►T6 Jahn A. pierce InAYrsnee ACOMay. Inc HOLDBIL THOCMMWAMD=NOT ANW,WMVOR ALTISRTtlE00VFMNAFF41i�D TFIti POLICIR�E BELOW.4. 934 IIsln St. VihehEster, NA 01890-10l4 INJURMAPPORDINOCOVMGR pobert W Rieichiel3o 7r INSURPA. CGU 239 Maple Street MIdAN& Uwksbery, NA 01176 euAUlll E 11111140" !? nyAuntl+ E: r KAVI 5EEN IBBUHDTOINSURED19ma ADOW FV L P D. DING DOCUMlNTWITH AfipWrT'O V"Cw TI46 ClRTIMYE iMAY EE IBBU9ID OR ANY R oui;EmENT, TOW OR CONDITION OF ANY OONTK447 OR OTHM pOLIC16R DEWIUS9D MVto IS SIJe WrTO All, THE TERIM& OXCLUSIONS AND GONDMONS OF SUCH IMAM pgtTAVI, THC INSURAHMAMOIt= BYTHe poUM& ACORMTE L, **W MAY FAYE 9EEN REDUGISD NY PAID CLAW. ros OP MUM worm OB�OMALLIAMUIY sPs�1.i80! 04/30/E00i 04/10/3002 + i� i,aoo 000 COMMI RMAL WJ dk% LIAan rtY FMOAMAOE L+V7Y one t(e) c 300.009 CL M MAD! O!p MGD Up IAay eee pereery A� 5 000 L J P iAVVIINURY e 1 900 000 AGEWIL 'J8N{RN.AtiOWeATL` s 1 0 0 000 AQQMsONDUKTA HAIPM rR000CTA•COUP00PAGO :_ 2.000.000 rOL.10Y P El t40 ALMOMlOelll tlAWIT i1NGLfa LIMIT e� AMY ALMO wmyi ALL WO AUTOO OGHEOU M AUT01 pQDLLY Immy r KMAUM crKtanLnAw►oe A 31 WUVARLumLaY AL"MY.GAACCDW 9 FAACC i Onn* ANYAL7TQ AGO 6 dC08Ai LMLL{i iTY mK C+ tNtlt8N0i s OCCUR CLUMMADE AGOIIESM A L] A R0T0NTION s � WGI11f0RA OOAI I7FttAror ANo WPi 'uAmm EL,wMACCDONT 6 - !L Ge9AAG • � ANviave e E.L MW ME - POLICY LAAtT A 4lID1MOMAt INS M; VAUL0R LETTOR OHOU,PANY OF TIM Move 0000NMO I GLICIEA 0t OANO1111111111UP 008011E THE 0RPAIATION GATITHOMOf, THE MANN OOMI MY WILLCN21AVOR TO MALL IA_ IPAYA YNMTf GN NOTICO TO 7M8 OWMWAtA HOLOIM MAM V TD TMi LOT, WTP4IUN18T4 Ni HV110eSPALLl1POMN000L10AYLOMORL1AMM W AMY 10Nb COMANY, no TIVOt RAY, eamISI-2716 i �j � Location—71/ No. Date TOWN OF NORTH ANDOVER A Certificate of Occupancy $ Building/Frame /Frame Permit Fee $ s�cMust 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ r Check # 151 i Building Inspec TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING :..... BUILDING PERMIT NUMBER: DATE ISSUED: O SIGNATURE: Building Commissioner/Ifor of BuildingsDate SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number /J fD n 5# /)WDDvae �l/ 1.3 Zoning Information: Zoning Distrid Proposed Use 1.4 Property Dimensions: 3°.oSY 330 1?7 Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide RegWred Provided Required Provided 1.7 Water Supply M.G.L.C.40. § 54) 1.5. Flood Zone Information: Public fJ/ Private 0 Zone Outside Flood Zone B— 1.8 Sewerage Disposal System: Municipal On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record CU/LL t* -W I�06-D/2 %l�' Li.r�Sow 5 i 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: 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 V M X Z CA 00 m r Town of North Andover Building Department 27 Charles Street North Andover, Massachusetts 01845 (978) 688-9545 Fax (978) 688-9542 DEBRIS DISPOSAL FORM tAORTy 0, �zLeo �a 9q.� O L �'9 r�q're o rva�t,�5 In accordance with the provisions of MGL c 40 s 54, and a condition of Building permit # the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL cl 1, s150a. The debris will be disposed of in /at: / Facility location Signature of plicant Z, Ail �� Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. IF The Commonwealth of Massachusetts Department of Industrial Accidents Office of investigations , Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print Name: Ll//GG /*,w Ad 6e2 Location: W ::76" /705, l� 51XJO,' - am a homeowner performing all work myself. =I 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 andlor 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 certify uder the pains a9y pe)faities of perjury that the information provided above is true and correct. Signature, Date 7.2i1.4- Print namel/!//GG.�/9��1 �os�2 Phone # j �� Official use only do not write in this area to be completed by city or town official' ❑ Building Dept ❑Check /f immediate response is required Building Dept ❑ Licensing Board ❑ Selectman's Office Contact person. Phone #: ❑ Health Department ❑ Other FORM WORKMAN'S COMPENSATION FORM - U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all -necessary approval / permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. APPLICANT kkl PHONE 97 158 3� ASSESSORS MAP NUMBER fLOT NUMBER SUBDIVISION LOT NUMBER STREET A w So'w 5 STREET NUMBER 7f OFFICIAL USE ONLY RECOMMENDATIONS OF TOWN AGENTS DATE APPROVED( CONSERVATION ADMINISTRATOR DATE REJECTED TOWN PLANNER COMMENTS �9- t.qzzjt-� Vk i -, (o,1/ DATE APPROVED DATE REJECTED DATE APPROVED FOOD INSPECTOR - HEALTH DATE REJECTED DATE APPROVED SEPTIC INSPECTOR - HEALTH DATE REJECTED CON24ENTS PUBLIC WORKS - SEWER / WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPARTMENT DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR NOTE: SEE DEED BOOK 3647 PAGE354. SEE PLANS 4259 ANO 6452 N.E.R.O. THE ZONING DIST. IS R3. 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