HomeMy WebLinkAboutMiscellaneous - 790 OSGOOD STREET 4/30/2018 (2)I
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Date .... /� ..%. �.....................
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
�This certifies that .. ...... ...... /G15 .................................
has permission for gas installatiar"'-n . C -.. .. ........
in the buildings of ...............................
at...r.... ......................................
Fee .D............... Lic. NQ3c?.....V.1......
Check #
Ci
I �U`i
North Andover, Mass.
.:................................................
GAS NSPECTOR
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY MA DATEJ-._7- I PERMIT #
JOBSITE ADDRESS OWNER'S NAME
GOWNERADDRESS
of jTEFAX
TYPE OR
OCCUPANCYTYPE COMMERCIALF-1 EDUCATIONAL RESIDENTIALPRINT
CLEARLY -jNEW:
F-.1 RENOVATION: Q REPLACEMENT/ PLANS SUBMITTED: YESF71 NO j
APPLIANCES -1 FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 1 12 13 14
BOILER -
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM [SPACE HEATER
ROOF TOP UNIT
j
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATERHEATER �j
OTHERT
me: -c Er- -.CU7r 7--D
'111-- 1
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 0 NO [71
I IF YOU 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 C-1 AGENT
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true 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 sion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME 1.400— --ILICENSE #[/24 2. IGNATURE
mpFAMGFF--] JPEI JGFR LPG[ ❑ CORPORATION Q9#FJ—b—F- PARTNERSHIP -
]# 1� LLC F -1#
COMPANY NAME: 1=tom-+ �� a -a- ADDRESS
C 'I .
ITY r-A.-VIS�v- STATESMA ZIP - TEL
FAX[.,_, CELL 4tMAILF-777-
q
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AF
Date .... -'- -'�99
....................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ......_T.01..1 ..S.......L..` �1'9..0A
...........................
has permission to perform ...O. Jz ...........11 r --A .............................
wiring in the building of .......... .....................................
-7 9 C9 49 5 74,----) S;—
at ....................................... . ....... n ..................... North Andover, Mass.
40�
— k38197 6Fee ...7.5.....Lic.No...........A
ELECTRICAL IN S E�
A$
Check #
8 4 j
owmad Use 0*
Permit No. 27 z _-� 0
Occupancy and Fee Chedmd
Ptev- Mm blank
APPLICATION FOR PERMIT TO PERFORIN ELECTRICAL WORK
(pLUM.PRIIVTINAW OR TTPEAU 1NFORA!fAT70An 1 - Date: 11 s"
-. _. _City yr Tam oL /i�d rl�l► �n a�_•,.1. .To the I►c�etoro}'yYu�es. ... _ -.
gy appficafion the mdm4ped gives notice ofth'arbern-deMonto per>;oam the electrical work d mind below
Low .Ion (Sheet aE �% i P1 t)S 6,D 042E
OwnworTmont C -I t -7 -It /b 0 i� 1
Owiees Address
Is this permit is owejnmc0m vdtka peradt? Yes ❑ No
Tdq&ese Na
(Check Appropriate Bo=)
Purpose of BovaNg el° j-('�''t-� 1. IItlfity Audmwkndm No.
Zddbg Service Amps wits Ovi. ❑ Ubdpd ❑
New se>! dm Amps / Vohs Ovsfrkead ❑ Uadpd ❑
Nasti®m of Feeders and Ampaft
Na of Meters
Na of Modern
Location aced NstN" of Proposed Eketrieyd work l u / rP O [ 6-10d gro l fre-m
(pmt Brow fidowhm &a& . he,vmziwed hvv tap sRe vr- r nrWvr'r
Na of Racesaed 1AUNINSIM
Na of Q? !dtSe) FatesNoof
rumowmers KVA
Na of Lumbudme OaBebs
Na of Hot Tab
Geaaators "A
Na of Lu�aiutsSwimmingPool
Above
0
❑
Ulft
No. of Reeeptaek OaBets '
Na of Haraaias
ALA1tM5 Na of Imes
Na of3ivitcies.. - - •
Nm ofGssBis i
Devices
Tow
a ofAbr Cold. , Toes
Ift OF,".- gDevias
ofWaste'Die�esera
FNea,
Totals: ► NNmar ` �• I
rib, of Saw-Centsh"
Devices
of Dbbwmbm
3psoelAeea K'oV
Lando ommmh, lior< ci Ota
Na of Dryers
Besting Aff &meesKw
SWU"bystemNa of •or ZmWalent
NO. Of Waftr KWBmUmft
Healers
Na of Deviioes orfdVjbmjW
Na Hydrosarmge Bmfttmbs
No. of Motors TOW HP
Na of Devices or
OTIEM-
!
- - -- - Attar ae&donot &UN V-dm6eA or as regrmed by the bapwor of Ww- m
B�,ated Vahffi of P. trical wooiC Q (w�mby policy.)
work to Start to be requested in aooa Wmm with NEC Rule 10, and won commple ion.
INSURANCE COVIMAG& Unless waived by the owner, no permit for the pa%ramnoe of electrical work may ism unless
the uoensee provides proof of ley iosaranoe `boomed q aloe coverage or its mbstsntial equi� The
undersigned cerafim tbat such coverage is in force, and has exhibited proof of
- to bepmtgafl
CEWAXON& MWRANCE O—� ❑ 0TWK ❑ sr) 7r�
14C'�
Iadd, Ander awpo bur @nd , AN Me an Adr app5mWen & nota aaconFirm
lum NAME: rh L 1z LIC NO.: /
L LIC NO--
iffqWWaW � rhe ltoaawe raceNWIJ I Bum- Tel
AAdrem-cB l AIL T& Na:
'Per M.G.L. a. 147. L 57-61, woolly wok nequi= DMWkmeat of Pab&c Safety► "S" LioM= Ica Na
OWNER'S U4SURANCg WAIVES: I an aware that the Luiamm aloes not have the 7' insurance coverage nomully
required by law. By my signatme below, I hereby waive this requirommut I am the (check oma owner 0 owmekajouL
Simmature A Te>ephon�No. PERMIT'ISE ';
Location
191, C, 0Scodn�b s�-
SD
Date :3-19— O
NORTN TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
TOTAL
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`Check # M93 3
18(69
Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A��ONE TWO FAMILY DWELLING
�TpQOppR
5%y.fi E,.w ay fortIjaa Yl�rO.nl }-,7
,s <
BUILDING PERMIT NUMBER: -��
DATE ISSUED:
TAME S MCAL.odlll
1.3 Zoning Information:
Zoning District Proposed Use
SIGNATURE: 1 I
Building Commissioner/lAq=tor of Buildings Date
gF.CTInN 1- CTTTi 11hWn1D1k4♦9rrni►r
1.1 Property Address:
1.2 i Assessors Map and Parcel Number:
1
Map Number Parcel Number
V
TAME S MCAL.odlll
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
i
i
Lot Areas Frontage 00
1.6 BUILDING SETBACKS ft
Front Yard
Side Yard
Rear Yard
Required Provide
Required Provided
Re uired
Provided
GG �
i
Signature
Telephone
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone information:
Public ❑ Private 0 Zone Outside Flood Zone ❑
CF!`TT(1N 7 _ DD/1DL•DTV ntirwm ticyrrm,
1.8 Sewerage Disposal System:
Municipal 0 On Site Disposal System ❑
--------•� +��..�..+a.ai v��1�1'+1�JilairHU111VtL/S•L A1t1:1V1
2.1 Owner of Record
TAME S MCAL.odlll
Name (Print)
Address for Service
vrzx
9?S-Sgo—
GG �
Signature
Telephone
2.2 Owner of Record:
Nam Print
Address for Service:
r
Si nature
Telephone
i
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable ❑
Licensed Construction Supervisor:
License Number
Address
Expiration Date
Signatures Telephone
3.2 Regighed Home Improvement Contractor
Not Applicable ❑
DAV0AST ZoA-)rz
►FFG,
���C-
Company Name
-. ,Db .S'u-1�--%_'O__/j 0:
su'I'T16
�
-2,/ �i
t�
Registration -Number
ress
Expiration Date
Si nature
Telephone
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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 Descri tion of Pro osed Work check all annUcablel
New Construction ❑ Existing Building 5 Repair(s) ❑ Alterations(s) ❑ TAddition ❑
Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify
Brief Description of Proposed Work:
Sn Y --
I SECTION 6 - ESTIMATB.n CONWRITCTMN CncTc I
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
",. OFFICIAL VSE ONLY
1. Building
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) x (b)
�-
4 Mechanical (HVAC)
5 Fire Protection
6 Total 1+2+3+4+5
Check Number
amS,iivil is %JWF4E'KAu1rivKl1,Al1UA lV BES UUMPLE'lED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
i, as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf. in all matters relative to work authorized by this building permit application.
Signattire of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
1, D4 V C_S 7"k t C.0 /y E ,as Owner/Authorized Agent of subject
property '
F
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 1 2 ND 3 RD
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS'
TIEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
APPLICANT INFORMATION
The Commonwealth of Massachusetts
Depantment ofhulustria -Accidents
Office of Investigations
600 Washington Street
(Boston, W) 02111
Workers' Compensation Insurance Affidavit
Name: 7 pN F S' M c - A -LO OJ i
Location: Al
l 7 s Lao 7)C�
City: /V o, 141) Z)o VF—lP-, Telephone #: 998 -- ST O A C %
❑ I am a homeowner performing all work myself.
❑ I am sole proprietor and have no one working' in
I am an employer providing workers' compensation for my employees working on this job
Please PRINT Legibly
Company Name: Dn h V i i) l t4S Tjl�n c— fog RQQF1%V (�- 4-
Address: /C pS' X7-7-0 Al cS L ,
City: a R TIJ h /W 12p V F—k &A Telephone-#: !? !% �o . ' 3 —0
Insurance Company: P,6,YA,! Swu At4ZAA'"Ca Policy #: /2 4 Z k Q% 9�.4 D
❑ I am (circle one) sole proprietor, general contractor or homeowner and have hired the contractors listed below who have the following
workers' compensation policies:
Company Name:
Address:
City:
Telephone #:
Insurance Company: Policy M
Company Name:
Address:
City:
Telephone #:
Insurance Company: Policy #:
Attach additional sheet if necessary
Failure to secure coverage as required under Section 25A of MGL 15B can lead to the imposition of criminal penalties of a fine up to 51,500.00
and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of i 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 hereb unde a pains pdpenaldes of perjury that the information above is true and correct
Signature: ��.�iC,�. „o _ Date: A IJ V 16 f
Official Use ONLY - Do not write in this area
City or Town: Permit/License #:
o Check if Immediate response is required
o Building Department
o Licensing Board
❑ Selectmen's Office
o Health Department
0 Other
INFORMATION & INSTRUCTIONS
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation
for their employees. As quoted from the "law" an employee is defined as every person in the service of another
under any contract of hire, express or implied, oral or written.
An employer is defined as an individual, partnership, association, corporation or other legal entity, or any two
or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased
employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing
employees. However the owner of a dwelling house having not more than three apartments and who resides
therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction
or repair work on such dwelling house or, on the grounds or building appurtenant thereto shall not because of
such employment be deemed to be an employer.
MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance
or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for
any applicant who has not produced acceptable evidence of compliance with the insurance coverage
required. Additionally, neither the commonwealth nor any of its political subdivisions shall enter into any
contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority.
Applicants
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation
and supplying company names, address and phone numbers as all affidavits may be submitted to the
Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the
affidavit. The affidavit should be returned to the city or town that the application for the permit or license is
being requested, not the Department of Industrial Accidents. Should you have any questions regarding the
"law" or if you are required to obtain a workers' compensation policy, please call the Department at the number
listed below.
City or Towns
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the
bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding
the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. The
affidavits may be returned to the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any
questions, please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 W ashinaton Street
Boston, MA 02111
Fax # (617) 727-7749
Telephone :# (617) 727-4900 ext. 406, 409, or 375
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
,F disposed of in a properly licensed solid waste disposal facility as defined by MGL
c11,S150A.
The debris will be disposed of in:
2?D es GaoD. s7;
(Location of Facility)
i
Signature of Permit Applicant
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
DAVID CASTRICONE
ROOFING, SIDING & REMODELING REPLACEMENT WINDOWS
HOME IMPROVEMENT CONTRACTOR REGISTRATION NUMBER 104569
200 SUTTON STREET, SUITE 226, NO. ANDOVER, MA 01845
7 HILLSIDE ROAD, BOXFORD, MA 01921
In North Andover 978-683-3420 In Boxford 978-887-6147
In Haverhill 978-374-7314
I/we the owner(s) of the premises mentioned below, hereby contract with and authorize you as contractor, to furnish all necessary
materials, labor and workmanship, to install, construct and place the improvements according to the following specifications, terms and
conditions, on premises below described: I /
Owner's Nam ..........:7711��../.1NM ......J..:I.G �. [.. Yl 1..............................................ner-L
phone #.....5. ,............C. .l... ..........
Job Address....... 1 /......D.4 .......
..l ...................... City....l.1t.P..+...�..�`�5��............. State....1`.L6••t:
d�
R.2.
.......Specifrcali........ ..........
s..l..t:1.jJ.......�.2Ci1 ..(.. .......... ................... ..1..5. .. �.. Sall. .......
....... .1.1.........(�a.....� L.C_A..:. ¢`
4 .......... ...........W. :...e:.d':...... ' ....t.. ......1�.>?.a...rx..zv?:,-.......L.t=:.......G..,>:...t�ar.,.. -....
...... .1. ..1.......1..........lfla..... .gt..'�.. . r.......... .......`..........................................................................
t..M ALt�i..l..t .......c ...... ,t. t .........� ..E..l..ajx,.�........
r.. ... . .....1/ ... ......J.... 5..... ? .�t ..r.......��..'.. ............
i..t.t.....J . ..... .f. ` .......... t ed Lu s .(.M ..t::... ` ...................
..:/LT......�.'D..�:.i..K.......1... .. ........�Y l �� .�. �.��. ..... ..r.�'.-.1_._..fci_1..1.. (,....i.. k�w,>p=
' r ...1i? .......... ... .. .. .... .... ....ti
...................................... .. -.....,w........ ........... .................................................................................
One Year Workmanship ransferable)
Manufacturer's Warra as ecified by m ufacturer f
Materials and Labor to c st $. _ , . g.$..Q........... Payable ... S.f y..V........ on ...... i . E R . .............
Payable............................. on ............... 7=............. Balance payable on completion of job
Owner or Owners are not responsible for Property Damage or Liability while job is in operation.
Contractor is not responsible for any damage to the interior of property, including pre-existing conditions (i.e. water stains, crumbling plaster, exposed nails) or
conditions resulting from application of materials specified above (i.e. objects coming loose from walls, crumbling plaster, exposed nails, dust in attic or other living
spaces, water stains when roofing shingles have not had adequate time to cure).
Upon completion of above work, all undersigned agree to execute and deliver to contractor, their joint note in accordance with his (their) above obligation as requested
by contractor. Upon refusal to do so, contractor may at its option declare the entire contract price or so much as then remains unpaid, immediately due and payable. It
is agreed that, if permitted by law, contractor shall be paid by the owner(s) all reasonable costs, attorney fees and expenses, in addition to the amount due and unpaid,
that shall be incurred in enforcing the terms and conditions of the contract and/or any lien in connection herewith.
It is further agreed that this contract may be assigned by contractor, and also that the obligations hereof shall bind and apply to their heirs, successors or estates.
The undersigned warrant(s) that he is (they are) the owners(s) of the above mentioned premises and that legal title thereto stands of record in his (their) namcs(s).
There are no representations, guaranties or warranties, except such as may be herein incorporated, if any, nor any agreements collateral hereto, nor is the contract
dependent upon or subject to any conditions not herein stated. Any subsequent agreement in reference hereto shall be binding only if in writing and signed by all
parties.
All Home Improvement Contractors shall be registered and any inquiries about a contractor or subcontractor relating to a registration should be directed to:
Director, Home Improvement Contractor Registration
One Ashburton Place
Room 1301, Boston, MA 02108 Tel: 617-727.8598
Any and all necessary construction -related permits shall be obtained by the Contractor. Any Owner who secures his own construction -related permit or deals with
unregistered contractors shall be excluded from access to the Guarantee Fund.
Approximate starting date of work..................................................................... Completion date ..............................................................
Receipt of a copy of this contract is hereby acknowledged, and it is further acknowledged by the undersigned that the foregoing
provisions have been read and the contents thereof understood and that no representation or agreement not herein contained shall be
binding upon the parties and that all of the agreements and understandings of said parties are contained herein.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
Owner has three business days to cancel this contract and incur no penalty.
IN WITNESS WHEREOF, the parties have hereunto signed their names this . ....... day of ....... IVI,k>:y.......... 20...t::. .
Accepted: /
v
Signed.. .. ............Owner
Signed........................................................................................ Owner
Per.......................................................................
Representative
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