HomeMy WebLinkAboutMiscellaneous - 79 ROCKY BROOK ROAD 4/30/2018 (2)Date ............ 1.14>11-4..
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that .... / ... alv/4
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..... ....... ......... .................
for gas installation .... ........
has pernussion f ... ..... 4e, ............................
:in thdbuildings of
............ .........................................................................................
at Nolth Andover, Mass
. ..........................
P,-1- A% 15 0..... Jo. No.. . 13SYC'...
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Check#
9651
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I -e 1411,1 /1 1 4'1
hereby certify that all of the details and information I have submitted (or.entered) regarding this 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
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER/GASFITTER NAME:jXft,4C 11" , a LICENSE # SIGNATURE
COMPANY NAME: �,-��,,�s,`_ ADDRESS:iJ So'
CITY '/ " rl �! f .,w- STATE: ,eXA— ZIP: _ ®L y P9 °�` FAX:
TEL: CELL: q')r-f.,6 3 EMAIL:
MASTERJOURNEYMAN ❑ LP INSTALLER ❑ CORPORATION [ # PARTNERSHIP E1#— LLC ❑ #
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MASSACHUSETTS UNIFORM APPLIC ION FOR A PERMIT TO PERFORM GAS FITTING WORK
GOWNER
TYPE OR
PRINT
CLEARLY
CITY: JuxT MA. DATE: /I0 1 Y PERMIT #o
JOBSITE ADDRESS: -'79 e���`� OWNER'S NAME: S
ADDRESS: , . A;u4- TEL: � 78r'g - ,f32AX:
OCCUPANCY E: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL
NEW: RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO
APPLIANCES?
FLOOR- Bsmt 1 2 3- 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE �-
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCK
MAKEUP AIR UNIT
OVEN
., POOL HEATER
j -ROOM / SPACE HEATER
,_
ROOF TOP UNIT
TEST
UNIT HEATER ,
UNVENTED ROOM HEATER
WATER HEATER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO ❑
If you have checked YES, please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY [ OTHER TYPE INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
hereby certify that all of the details and information I have submitted (or.entered) regarding this 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
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER/GASFITTER NAME:jXft,4C 11" , a LICENSE # SIGNATURE
COMPANY NAME: �,-��,,�s,`_ ADDRESS:iJ So'
CITY '/ " rl �! f .,w- STATE: ,eXA— ZIP: _ ®L y P9 °�` FAX:
TEL: CELL: q')r-f.,6 3 EMAIL:
MASTERJOURNEYMAN ❑ LP INSTALLER ❑ CORPORATION [ # PARTNERSHIP E1#— LLC ❑ #
�foV+t,x WOH-41'
The Commonwealth of Massachusetts Print Forme=
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston, MA 02114-2017
www. mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): 1q- "44 t�RC.4
Address: t—<fn`c-5�. t
City/State/Zip: WI—C Up, «z�, Phone #: al iC� - 3�' 2 �q
Aan employer? Check the appropriate box:
rey
I am a employer with 4. ❑ I am a general contractor and I
emplovees (full and/or part-time).* have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
listed on the attached sheet.
These sub -contractors have
employees and have workers'
comp. insurance.1
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. ❑ Electrical repairs or additions
I L ❑ Plumbing repairs or additions
12. ❑ Roof repairs
13. ❑ Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.?
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. ����
Insurance Company Name: /
Policy # or Self -ins. Lic. #: O 9S(3 d lib S_3 —710 Expiration Date: IZ�(
Job Site Address: ISD (�I ✓Vl S'- City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certif
y under the pains and penalties ofperjury that the information provided above is true and correct.
r,+0 1!1 It 0 L -m) 4
Phone#• U $_ D�°Z03
Official use only. Do not write in this area, to be completed by city or town officiaL
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
11 Contact Person: _ Phone #:
y �
+P location
o Date 17 1119Ln
5
1
.TOWN OF NORTH ANDOVER
aaORTH - `
» .•gyp p:y..ao .stip
} p 'Certificate of Occupancy $
Building/Frame Permit Fee $
4 �sSACH uSEs Foundation Permit Fee $
Other Permit Fee $
a Sewer Connection Fee $
'.Water Connection Fee $
is TOTAL $:.a
Building Inspector
;�
-8,73.10Div:: Public Works
TOTAL
v - ild'n, Ins dor
.. O D v.� f iibli Works
�. ,.�. +•k7-,3a�.-. �-.r'� .� `` tib• _ - ..
_-vr�'ti�e..�`e>�
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7 12"
Loi
.:�
Locatio loi��-c
, on
w
i
.
8-17-ps'
MNo Date
F
Noaryl TOWN OF NORTH
ANDOVER
Certificate of Occupancy
$
BuildinglFrame Permit Fee
$
:.Foundation Permit Fee
ACHUSE .
$
z
Other Permit Fee.
$
'y�Sewer,Connection Fee.......
��
z
Av Water Connection Fee
$
7.
TOTAL
v - ild'n, Ins dor
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PERMIT NO.
APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS.
PAGE 1
MAP h40. i.
LOT NO. 14C
I
2 RECORD OF OWNERSHIP IDATE
BOOK PAGE
ZONE
SUB DIV. LOT NO.
I
LOCATIONX% /J
i o 0
PURPOSE OF BUILDING
OWNER'S NAME v74 Y64
NO. OF STORIES SIZE
oDWNER'S ADDRESS
"flo
ARCHITECT'S NAME /�
Cq
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS IST , 2ND W 4> /40 3RD
•BUILDER'S NAME
-A, 1111�
SPAN % Y �(joosr
v r (i
I DISTANCE TO NEAREST BUIL INC , J
DIMENSIONS OF SILLS
POSTS - W`bRl
!!DISTANCE FROM STREET 7
'
DISTANCE FROM LOT LINES - SIDES '? '&,, ! -REAR �7
GIRDERS (�
�T !
AREA OF LOT �- 7& FRONTAGE
HEIGHT OF FOUNDATION j THICKNESS j
f
IS BUILDING NEW 7/,p
SIZE OF FOOTING t1 J X ' ^
IS BUILDING ADDITION Nl
MATERIAL OF CHIMNEY led J G
IS BUILDING ALTERATION
IS BUILDING ON SOLID OR FILLED LAND -
WILL, BUILDING CONFORM TO REQUIREMENTS OF CODE v :;F a,,, ax5.
IS BUILDING CONNECTED TO TOWN WATER
BOARD OF APPEALS ACTION. IF ANY/�. /
✓(/ �/V
IS BUILDING CONNECTED TO TOWN SEWER
IS BUILDING CONNECTED TO NATURAL GAS LINE
INSTRUCTIONS
1
' SEE BOTH SIDES PERMIT FOR FOUNDATION ONLY
PAGE 1 FILL OUT SECTIONS 1 - 3 REGULATED BY PARA. 114.8-S. B.C.
PAGE 2 FILL OUT SECTIONS 1 - 12
ELECTRIC METERS MUST BE ON OUTSIDE OF FEE PAID Zrx)
ATTACHED GARAGES MUST CONFORM TO STATE FIRE RAE IONS
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
I YDATF 1 ED L
Ile-
SIGNA RE R OR AUTHORIZED E t /
FEE /1
PERMIT GRANTED SIC) �+ PERMITTOR FRAME/BUILDING
196ATE... EEE PAID:.�.,.�
_
i ? - l �L
�-_L- BLDG. PERMIT FEEfm
:
r
AUG 17 10,95 WE FRAME PERMIT ;L2_
3 PROPERTY INFORMATION
LAND COST
EST. BLDG. COST Zs3I S -bo
LD
EST. BG. COST PER SQ. FT. JVV
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
AvIl
QUI NaINmm.
OWNER TEL. #
CONTR. TEL. #
CONTR. LIC. # �CLC
H.I.C. #
bL,
'n A. ..
OIL
-4
I ti
BUILDING RECORD
1 OCCUPANCY 12
SINGLE FAMILY' c :
S.-ORIES
MULTI. FAMILY i
OFFICES
APARTMENTS
_
CONSTRUCTION" \
2 . FOUNDATION
8 INTERIOR FINISH
CONCRETEI
PINE `. ',
B
1
2
I3 }
CONCRETE BL'K.
BRICK'OR STONE
HARDW7D
PIERS t
PLASTER. Z.%.
DRY WALL
f
_
UNFIN.
3 BASEMENT'S
AREA FULL
1/1 1/2 I/•
FIN. B'M'T AREA \.
FIN. ATTIC AREA
_
N_O 8 M T
HEAD ROOM 4.
FIRE PLACES ''
MODERN KITCHEN
_v
4 WALLS I
9• FLOORS
CLAPBOARDS
DROP SIDING
WOOD SHINGLES
1 2
CONCRETE
°EARTH
HARD\!J'D
COMMON _
ASPH. TILE
ATTIC STRS. & FLOOR
3
_
ASPHALT SIDING
ASBESTOS SIDING
_
VERT. SIDING
STUCCO ON MASONRY
STUCCO ON FRAME
BRICK OW MASONRY
BRICK ON FRAME
CONC. OR CINDER ELK.
WIRING
I '
STONE ON MASONRY
STONE ON FRAME
SUPERIOR 1,Kl POOR _
ADEQUATE NONE
5 ROOF
GABLE HIP
GAMBREL MANSARD 1
FLAT SHED
ASPHALT SHINGLES-._
10 PLUMBING
BATH 13 FIX.) X
TOILET RM. 12 FIX.)
WATER :CLOSET
.LAVATORY
WOOD SHINGES
KITCHEN SINK
SLATE
NO�PLUMBINGI
TAR & GRAVEL
STALL SHOWER
ROLL ROOFING
MODERN FIXTURES
_
TILE FLOOR
TILE DADO
6 FRAMING
I 11 HEATING
WOOD JOIST
PIPELESS FURNACE
FORCED HOT AIR FURN.
TIMBER BMS. & COLS.
STEAM
STEEL BMS. &COLS.'
_
HOT W'T'R OR VAPOR
WOOD RAFTERS
AIR CONDITIONING
_
RADIANT H'T'G
UNIT HEATERS
7 NO OF ROOMS
GAS
THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM f
,LOT LINES AND EXACT DIMENSIONS 'OF., BUILDINGS. WITH PORCHES. GA-
RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT•PLAN.
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FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT:
Phone&A-9 A,
LOCATION: Assessor's Map Number Parcel,
SubdivisionL-J
Lots) 4
Street St. Number 2
*********************** Official Use Only************************
RECOMMEND ONS OF TOWN AGENTS:
�ADate Aptiroved -/ 2
nsery ion Administrator Date Rejected
Comments
-fes b 1 7CkJQ_ Date Approved
Town Planner Date Rejected
Comments
Food Inspector -Health
Septic Inspector -Health
Comments
Date Approved
Date Rejected
Date Approved
Date Rejected
Public Works - sewer/water connections <_f_ -TJ 8 -f7 -?-5
- driveway permit __TT�J S -/7 -?5
Fire Department .t�IV141rrvA4
r
r !Hk_ ed bye.,
AUG 1 7 1995
id ing Inspector
Date
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Commonwealth of Massachusetts RECEIVED
City/Town of `
System Pumping Record DEC 15 2009
Y � 9
Form 4 TOWN OF NORTH ANDOVER
wN s•• ,t HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be, substantially the same as that provided here. Before using this form, check with your
local Board of Health tQ determine the form they use. The System Pumping Record must be submitted to
the local Board of Health oFottter approving authority. .
A. Facility Information
1. System Locatio aft cirla of h��ht side of house, Left front of house, Right front of house,
Left rear of house, Right rear of hous�eft rear of building. Right rear of building.
t.
Address
Cityrrown
2. System Owner:
Name
Address (rt different from location)
Cityrrown
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
State
Zip Code
State Zip Code
C, u —
Telephone Number
o0 l 2. Quantity Pumped
Date
Cesspool(s) Septic Tank
4. Effluent Tee Filter present? ❑ Yes
5. Condition of System:
6. System Pumped By:
Neil Bateson
Gallons
❑ Tight Tank
No If yes, was it cleaned? ❑ Yes ❑ No
Name _
Bateson Enterprises Inc
Company
7. Locatiorywhem-Wntents were disposed:
G.l .S.D Lowell Waste Water
Signature of Hauler
t5form4.doc• 06703
F5821
Vehicle License Number
Date
'_9__1z1-v'�
System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
FRECEIVED
City/Town of
L011 System Pumping Record
Form 4
°�M s TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms ma I e
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use: The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left front of house, right front of house, eErEro
5uj
se right side of house, Left
rear of house, right rear of house, left side of building, right mg,under deck.
City/
Town State Zip Code
2. System Owner: 6V\ �
kc 6
Name "
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system ❑
❑ Other (describe):
StaZ()
^ Zip Code
S�
_,B
Telep one Number
Date 2. Quantity Pumped
Cesspool(s) p Ic Tank
4. Effluent Tee Filter present? ❑ Yes []-go-
5.
- o5. Condition of System
6. System Pumped By:
Neil J. Bateson
Name
Bateson Enterprises Inc.
Company
7.
contents were disposed:
Gallons
❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
F5821
Vehicle License Number
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts 111 =
City/Town of
System Pumping Record MAY UQ
s` Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may be us , e
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left / Right front of house, Left / Right rear of house, Left t'side of ho u , Left/
Right side of building, Left / Right front of building, Left / Right rear of building, Under eck
Address _ n t ? e
City/Town
2. System Owner:
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe)
State
Zip Code
St7t, SJ Zi Code
Tete -phone Number
V--3C-)4c)- [S
Date 2. Quantity Pumped: Gallons
Cesspool(s) Septic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Conditi n f System:
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Lo a contents were disposed:
G.LS.,W j Lowell Waste Water
(—A
O.t Q1.�---�
t5form4.doc• 06/03
F5821
Vehicle License Number
Date
System Pumping Record • Page 1 of 1
Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS, Ch. 139, Sec. 3B
To: Building Commissioner or Board of Health or
Inspector of Buildings Board of Selectman
City Hall City Hall
NORTH ANDOVER, MA 01845 NORTH ANDOVER, MA 01845
RE:- -Insured:-
Property Address:
Policy Number:
Claim Number:
Date of Loss:
Company:
- PAUL' F KOCHANSKI and -SHELLY A KOCHANSKI
79 ROCKY BROOK ROAD, NORTH ANDOVER, MA
HMA 0101367
BOS00059613
3/15/2015
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 313 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.
Joshua Terenzoni Claim Examiner 4/21/2015
Safety Insurance Company
Homeowners Claims Unit
P. O. Box 55098
Boston, MA 02205-5098.
Date:7 � : C .31 .
O11
TOWN OF NORTH ANDOVER
'• O
p PERMIT FOR PLUMBING
41
This certifies that !` ............
has permission to perform ..... ��.� :. ....................... .
plumbing in the buildings of .. 1 t.0 c n `
...........................
ir
... �'�........� . . .....j .� y ............ . North Andover, Mass.
at....
Fee. . .. .. Lic. No........` ... ........ ... �t- .: ......
PLUMBING INSPECTOR
Check #
5646
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Date t ' `' 0
Building Location QkVVk Owners. Name . ;Gt /yG6� Permit^� Y`
Amount
Type of Occupancy
New Renovation ® Replacement ® Plans Submitted Yes ® No
FIXTURES
(Print, or type) Check one: Certificate
Installing�mp�yame k& 'yr'y 1 r&�& Corp.
4
Name of Licensed ;Plumber: '
Insurance Coverage: Indicate type
Liability insurance policy
ElPartner. .
® Firm/Co.
ance coverage by checking the appropriate box:
Other type of indemnity El 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 El
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 Iteio der Permit Issued for this application will be in
compliance with all pertinent provisions of the Massac1 Code and Chapter 142 ofthe General Laws.
BY: signaluMoTIMs um r
Type of Plumbing License.
Title .'-
City/Town License Num6er Master Journeyman
APPROVED (OFFICE USE ONLY
rk. ,
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