HomeMy WebLinkAboutMiscellaneous - 83 COLGATE DRIVE 4/30/2018Claim # 033650752
Advantage Claim Services Adjuster Assigned: Glenn Guarente
522 Chickering Road #B
North Andover, MA 01845
orm of Notice of Casualty Loss to Building
Under Mass. Gen. Laws, Ch. 139, Sec. 3B
To:ilding Commissioner or Board of Health or
Inspector of Buildings Board of Selectmen
Town Hall Town Hall
North Andover, MA 01845 North Andover, MA 01845
Re: Insured: Stephen Diminico
Property address: 83 Colgate Drive
North Andover, MA 01845
Policy #: 30564400004
Loss of: 2015/11/05
File or Claim No. AD 1934
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,_Ch. _139_Sec. _3B is appropriate
please direct it to the attention of the writer and include a
reference to the captioned insured, location, policy number, date
of loss and claim or file number.
Glenn Guarente
Title: Adjuster
On this date, I caused copies of this notice to be sent to the
persons named at the addresses indicated above by first class mail.
�1-6-��
�lgn date
CUSTARD
INSURANCE ADJUSTERS
3135 Avalon Ridge Pl
Suite 200
Norcross, GA 30071
3/10/2015
CITY/TOWN BUILDING COMMISSIONER
Gerald Brown
Inspector of Buildings
1600 Osgood Street
Building 20, Suite 2035
North Andover, MA 01845
Claim Number: 033548867
Policy Number: 30564400004
Company Name: Arbella Mutual Insurance Company
Date of Loss: 2/14/2015
Insured: Stephen Diminico
Property Location: 83 Colgate Dr
North Andover, MA 01845
To Whom It May Concern:
Claim has been made involving loss, damage, or destruction of the above captioned property,
which may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6,
to be applicable.
If any notice under Massachusetts General Law, Chapter 139, Section 3B is appropriate, please
direct it to the attention of the writer. Kindly include a reference to the captioned insured,
location, date of loss and claim number.
Very truly yours,
Arbella Mutual Insurance Company
CC: City/Town Fire Dept, City/Town Health Dept
Q
Location
No. Date q
Check # ef
Building- Inspe!c1loi
TOWN OF NORTH ANDOVER
16.
Certificate Occupancy
$
of
C14U
Building/Frame Permit Fee
$
Foundation Permit Fee
$
Other Permit Fee
$
TOTAL
$
Check # ef
Building- Inspe!c1loi
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT WAIJ RENOVATF, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER: DATE ISSUED: Z.,>- -ZLt)s—
SIGNATURE:U r v –�
Building Commissionerfinspector of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Add
2,5
1.2 Assessors Map and Parcel Number:
Map Number Parcel Amber
1.3 Zoning Information:
ZoningDistrict Proposed Use
1.4 Property Dimensions:
Lot Area Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
ReqWred Provide RcqWred Provided
Required Provided
1.7 Wats Supply M.G.L.C.40. 34) 1.5. Flood Zone Information:
Public ❑ Private❑ Zone Outside Flood Zone ❑
1.E Sewerago Disposal System:
Municipal ❑ On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
+ { ! 'tr!rt: `,!^; No
2.1 Owner of Record
Name (Print) Address for Service
..�m� Ccn08�3
Signature Telephone
t
2.2 Owner of Record:
N'gme Print Address for Service:
Signature Tele on
SECTION 3 - CONSTRUCTION SERVICES
3.1 Li nsed Construction Supervisor:
Licensed Construction Supervisor: f
l1
�7� 6 - T ,^(a 3
St Telephone
Not Applicable ❑
vy �f
License Number
!HL"
Expiration Date
3.2 Registered Home Improvement Contractor
9
Not Applicable
Company Name
1,
Registration Number
Address
Expiration Date
%anature Telephone
Wo
m
SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 s 25,6Q
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 ......9 No ....... 0
SECTION 5 Description of Proposed Workcheck aB
app&able
New Construction ❑
Existing Building 0
Repair(s) 0
Alterations(s) 0
Addition 0
Accessory Bldg. ❑
Demolition 0
Other 0 Specify
Brief Description of Proposed Work:
N4- 0
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollar) to be
Completed bv permit aDolicant
OFFICIAL USE ONLY
1. Building
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) x (b)
4 Mechanical (HVAC)�----
5 Fire Protection
6 Total 1+2+3+4+5
Check Number
SECTION 7a OWNER AUTHORIZATIO TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, 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.
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
I, as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are L*ue and accurate, to the best of my knowledge
and belief
a
Print Name
Signature of Owner/.Agent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
Ku
SIZE OF FLOOR TIMBERS 1' 2 3
SPAN
DM ENSIONS OF SILLS
DIMENSIONS OF POSTS
DIIv1ENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
1S BUILDING ON SOLID OR FILLED LAND
IS BUU-DING CONNECTED TO NATURAL GAS LINE
PROPOSAL
rte."
sNEEMID.
r DATE
panPnGA1 SUBMITTED TO: WOPK TO RF PERFORMED AT:
ft here * O, e. to, fumi materials, and perform theme labor necessary for the compFei ort f
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All material is guaranteed to be as specified, and the above work to be performed in accordance with the dra in s�aands�ecifi-
cations submitted for above work and completed in a substantial workmanlike manner or the sum of
Dollars ($ 3 y 7 )
with payments to be made as follows.
6-D ,cos
Respectfully submitted
Any aHeration or deviation from above specifications involving extra costs
will be executed only upon written order, and will become an extra charge Per 14*1 S""
over and above the estimate. All agreements contingent upon strikes, ac-
cidents, or delays beyond our dbhtrol. Note —This proposal may be withdrawn
�.1Z 92a�' by us if not accepted within]_days.
i
a(7 y ACCEPTANCE OF PROPOSAL
Th rices, specific s and conditions are satisfactory and are hereby accepted.You are authorized to do the work
as specified. Paymen s will be made as outlined above.
Signature
Date Signature
ai, NC 3818-50 PROPOSAL
MADE IN USA
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
c 11, S 150 A.
The debris will be disposed of in:
rr Z�, -A)- 4 -11\1v -el -
(Location of Facility)
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
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The Commonwealth of Massachusetts
Department of industrial Accidents
OfRce of Investigations
Boston, Mass. 02111
Workers' CompemUm Insurance Alf ld"
fyslnre Please Print
Locdw:
City Phone #
0 1 am a hwmwner performing all work myself.
I am a sole proprietor and have no one working in any cape*
EW' I am an employer providing workers' compenssUon for my employees worldng on this job.
Cortoanv name'
FalMra to secure caverapa AS required under Section 25A or MGL 152 can lead to the Wgxe len d crknlnal pa wAw d.a 11na up to $1,500.00
and/or ane years' imprieorrrrent.ae.wd-m ridMand imintwf=dA 7DP VAORKDFU)ER=dA fkw d.(SIWAM-mAr mgdoot ma I
understand that a copy of this datunent may be forwarded to the Office of In estlpatlone of the DIA for coverepa verMlcadon.
I do hereby ow* under he Peine and penMtlee arpsofwy that the k*mN00" provddad ebm b bus and coned
Sigrtature Date
Print name _ Phone #
Of w use only do net write in this area to be completed by city or town dftt'
City or Town PerrrrflLicarnino
O 9uilding Dw
(]Check I immsdie(eresponse IS requied 13 Lkwmkv �W
p Sekx*rwn's 011lce
Contact parson: Phone t C1 HeeM Deperb7ort
Other
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-,No. Date
'LORT01
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
Sewer Connection Fee $
Water Connection Fee $
TOTAL $
Building Inspector
Div. Public Works
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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 (e, '—
LOCATION: Assessor's Map Number Parcel
Subdivision n Lot(s)
Street _ C') ` St. Number
************************Official Use Only************************
RECOMMENDATIONS OF TOWN AGENTS:
Date Approved � 01! 141
Conservation Administrator Date Rejected
Comments
Town Planner
Comments
Health Agent
Comments
Public Works - sewer/water connections
- driveway permit
Fire Department
Date Approved
Date Rejected
Date Approved
Date Rejected
Received by'Building Inspector Date
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Location
No. e- Date
7 -
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
HUS Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # I/( ;e
Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REP RENOVATF, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
i`>►,�1 � llie
BUILDING PERMIT NUMBER: / S --7 DATE ISSUED: --
C.l�
SIGNATURE:
Building Commissioner/Inspector of Buildings Date
SECTION 1- SITE INFORMATION
1.1 property Address:
g3 Ca,C-,yrs O2
1.2 Assessors Map and Parcel Number:
% / C�
Map Number Parcel Number
1.3 Zoning Information:
Zoning District
1.4 Property Dimensions:
I Lot Area Fronts ft
1.6 BUILDING SETBACKS 00
Front Yazd Side Yard
Rear Yard
Required Provide Required Provided
ReqWred�:[ Provided
—+
1.7 Water Supply M.G.L.C.40. 34) 1.5. Flood Zone Information:
❑ Zone Oafside Flood Zane ❑
Public ❑ private
1.6 Sewerage Disposal System:
Municipal ❑ On Sita Disposal System ❑
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
N
2.1 Owner of Record
Name (Print) Address for Service
7
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Si ature Tele on
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
i
Licensed nsed Construction Supervisor:
0 ��'-L` y i
Address �-{ C1
N - � �/ �' 6 � � ttJ `6 S�
Signature Tele one
Not Applicable ❑
License Number
� L)
Expiration Date
3.2 Register ome Improveme Contractor
Not Applicable k
Company Name
Registration Number
Address
Expiration Date
Signature_ Telephone
SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 2
Workers Compensation Insurance affidavit must be completed and submitted
in the denial of the iccnance of the hnildino nermit
N
this application. Failure to provide this affidavit will result
Signed affidavit Attached Yes .......0 No ....... 0
SECTION 5 Description of Proposed Work check aH
a cable
New Construction ❑
Existing Building ❑
Repair(s) 0
Alterations(s) ❑
Addition ❑
Accessory Bldg. ❑
Demolition ❑
Other ❑ Specify
Brief Description of Proposed Work:
7p_� o„14_ e ",S I-, LC-
7,
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollar) to be
Completed by permit applicant
OMCIAL USE ONLY
1. Building �t J v u
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee t,l X (b)
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5)
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, ��JU�%'�" ✓—��� as Owner/Authorized Agent of subject property
r
Hereby authorize to act on
Myr
y alf, in all matters rela ' e ta>NVrk authorize by this building permit application , /a
Si rahrre of✓� r
-—
Date 7
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 Name
of
Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR T v KERS 1f ! 1 2 ND 3
KD
SPAN
DIMENSIONS OF SILLS
DIIv1ENSIONS OF POSTS
DIMENSIONS OF GIRDERS _
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X —
MATERIAL OF CHDVINEY
1S BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
n
`D..C__>e K
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_ X 11 Ae 1 G✓�,, f r y.Dr4 K PHONE_
LOCATION: Assessors Map Number
PARCEL_
SUBDMSION LOT (g)
STREET�3 C Dti Gfi J E J7/� ST. NUMBER
OFFICIAL USE ON -Y*****—,
ADMINISTRATOR DATE APPROVED
DATE REJECTED
TOWN PLANNER DATE APPROVED
DATE REJECTED
COMMENTS
FOOD INSPECTOR -HEALTH DATE APPROVED
DATE REJECTED
SEPTIC INSPECTOR -HEALTH DATE APPROVED
DATE REJECTED
COMMENTS
PUBLIC WORKS - SEWERIWATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE
Rovl*W W Jm
The Commonwealth of Massachusetts
Department of Industrial Accidents
Ofice of Invoodgadons
Boston, Mass. 02111
Workers' Compensation Insum" AM"
Please Print
Qft Phone
I am a homeowner perforn ing all work myself.
I am a sole proprietor and have no one working in any capacity
I am an employer pmvidng workers' corn UOn for my employees worldng on this job.
Jnr rtarrte:
Address_ _ 3 6�
9 3Lo —qs-�o
03
Irtstuartce Co. Polar a
Fdkrn to ncun ewmapa • requlnd under Section 25A or MOL 1522 con lead to the knposNlon d crlrrAnal penalties d.a Ana up to $1,500.00
andtor ane years' ia"crnient_ar w d_mAhd4mmbnln tw loos dA STOP VIrDM OROER.AWA fin d.(,=1tn.Of AAA apahet ma I
understand that a copy of this dderne t may be forwarded to the Office of Investlpationr d the DIA for coverapa verification.
I do hereby cs►dy under the pokm and pe mWw d perjury that Me bb., dm provided ebow 1s true end correct
SignatureDate
Print name Phone #
Official use only do not write in this area to be completed by city or town afAdar
City or Town Pern�tlL++
� BuilaYng Dept •
OClteckYimmediate nraponse b rsqubed 0 L tOnSOU Board
p Sehxftan's Ofts,
Contac! person: Phone t C] Health Deparbnent
Other
I
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:
of Facility)
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
M CERTIFICATE OF LIABILITY INSURANCE I DATE(MMlDDl
03/15/2020
05
lRQDUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Ik. P . ROBERTS INSURANCE AGENCY INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
1060 OSGOOD STREET ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
NORTH ANDOVER MA 01845
978-683-8073 INSURERS AFFORDING COVERAGE NAIC#
NSURED ARTHUR ALLEN CONSTRUCTION INSURERA: UNDERWRITERS @ LLOYDS i
INSURER B:
369 WAVERLY ROAD INSURER C:
NORTH ANDOVER, MA 01845 INSURER D. ATLANTIC CHARTER INS CO
INSURER E:
:OVERAGES
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 OIC
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.
7SR ADD'L I
.TR SNSRD TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE POLICYEXPIRA
DATE MM/DD/YY DATE MM' DD/YYTION LIMITS
GENERAL LIABILITY
I
EACH OCCURRENCE $ 1,000 000
x COMMERCIAL GENERAL LIABILITY
PREMISES(EaRENTED--
Is 50 000
CLAIMSMADE OCCUR
II
MED EXP (Any one person) $ 5,000
Ai
LGL045009
05/28/04
05/28/05 PERSONAL&ADV INJURY $ 1,000,000
�--
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG $ 2,000,000
i
POLICY I JE� F— LOC
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT
$
ANYAUTO
(Ea accident)
I
ALLOWNEDAUTOS
I
BODILY INJURY
$
SCHEDULED AUTOS
(Per person)
I
HIRED AUTOS
BODILY INJURY $
NON-OWNEDAUTOS
(Peraccident)
(PROPERTY DAMAGE
(Peraccident) $
GARAGE LIABILITY
AUTO ONLY -EA ACCIDENT $
OTHER THAN EAACC $
ANYAUTO
I
AUTOONLY: AGG $
EXCESS/UMBRELLA LIABILITY
I EACH OCCURRENCE I $
�
I OCCUR I CLAIMSMADE
1
I AGGREGATE I$
$
I
I
$
DEDUCTIBLE
$
RETENTION $
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
TORYLAMTS X ER
E. L. EACH ACCIDENT $ 500,000
ANY PROPRIETOR/PARTNER/EXECUTIVE TO BE ISSUED BY
E. L. DISEASE - EA EMPLOYE $ 500 000
D OFFICER/MEMBER EXCLUDED? INS. CARRIER
If es,describeunder
SPEC IAL PROVISIONS below
E.L. DISEASE - POLICYLIMIT I $ 500,000
OTHER
IESCRIPTION OF OPERATIONS ! LOCATIONS /VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS
NOTE: WORKERS COMPENSATION CERTIFICATE TO BE ISSUED DIRECTLY BY INSURANCE CARR
IER. THANK YOU.
FAX: 978-664-2694
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORF THE EXPIRATION
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.
AUNT �ORIy�jED REPSENTAt IVE 4.
S A P
ACORD CORPORATION 1988
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Location F),3 co le -�f;;;,
No. Date /0
Tol
TOWN OF NORTH ANDOVER
41
Certificate
of Occupancy
$
MU
Building/Frame Permit Fee
$
Foundation Permit Fee
$
Other Permit Fee
$
TOTAL
s �3
Check #
I
1 767 1
Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCTREPAI RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
,n.
BUILDING PERMIT NUMBER:
DATE ISSUED: a
SIGNATURE:
Building Commissioner for of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
C�1 01
Map Number Parcel Number
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Area s Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
ReqWred Provide Reqdred Provided
R red Provided
1
1.7 Water Supply M.G.L.C.40. 34) 1.5. Flood Zone Information:
Public ❑ Private 0 Zone Outside Flood Zone 0
1.8 Sewerage Disposal System:
Municipal 0 On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIAED AGENT
Historic istrict: Yes No
2.1 Owner of Record
Name(Prmt) ' Address for Service
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
ECTION 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 ❑
Compilny Name
4
Registration Number
Address
Expiration Date
Si nature Telephone
ION
M
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 .......0 No ....... 0
SECTION 5 Description of Proposed Work check all applicable)
New Construction ❑
Existing Building ❑
Repair(s) ❑
Alterations(s) ❑
Addition ❑
Accessory Bldg. ❑
Demolition ❑
Other ❑ Specify
Brief Description of Proposed Work:
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
OFFICIAL USE ONLY
1. Building
) L
/ S 0C
(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
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, d , 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.
-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 Name
Signature of Owner/Agent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TRVIBERS iST2 ND3 RD
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
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
Please print.
DATE 2Zg
JOB LOCATION_ F S
Number
HOMEOWNER LICENSE EXEMPTION
Street Address
.i—gz��
Home Phone
PRESENT MAILING ADDRES–
City Town
State
1�l
Ma / 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 onehome in a
two-year period shall not be considered a homeowner.
The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other
Applicable codes, by-laws, rules and regulations,
The undersigned "homeowner" certifies that he/she understands the Town of No. Andover
Building Department minimum inspection procedures and requirements and that he/she will
comply with said procedures and reauirements.
HOMEOWNER'S SIGNATURE
Zip Code
APPROVAL OF BUILDING OFFIC
The Commonwealth of Massachusetts a
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Name Please Print
Name:
Location:
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 empl ees working on this job.
Com an name:
Address
Ci Phone
Insurance Co. PolicV #
Compgoy name:
Address
Ci : Phone #
Insurance Co. Policv #
Failure to secure coverage as required and 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 v¢ell. ivD_penalties3n thefmnof�_STOP ViIORK.ORDER_and_a fine .of (.5100.OD) day against me. I
understand that a copy of this statemen sy be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify under the pains d 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/Ucensinq
Building Dept
❑lperson:_
ediate response is required ❑ Licensing Board
E] Selectman's Office
CoPhone #. C] Health Department
O Other
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PERAUT NO. -2v
LOT NO.
1
t
BOOK PAGE
-
jI
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APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS.
PAGE 1
MAP NO.
LOT NO.
1
2 RECORD OF OWNERSHIP iDATE
BOOK PAGE
-
ZONE
_
�UB DIV. LOT NO.
LOCATION
LOCATION
.•/f
d-
PURPOSE OF BUILDING
OWNER'S NAME nr f��p
•lfG•` zeWW
NO. OF STORIES
OWNER'S ADDRESS d
c
BASEMENT OR SLAB
ARCHITECT'S NAME .��/
SIZE OF FLOOR TIMBERS 1ST2 Y 02ND 3RD
/`
BUILDER'S NAME f /Q�
SPAN
DIMENSIONS OF SILLS ---
DISTANCE TO NEAREST BUIL/DING ���/�j'�l
DISTANCE FROM STREET ,
r •
�/ 4-
" ' POSTS ox
/�
IAAq
DISTANCE FROM LOT LINES - SIDES / D REAR
•/
GIRDERS (ay 6
/ /`i1�
AREA OF LOT FRONTAGE✓/J
HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW
SIZE OF FOOTING ./� X
f�
IS BUILDING ADDITION V
/
MATERIAL OF CHIMNEY
IS BUILDING ALTERATION
IS BUILDING ON SOLID OR FILLED LAND �oG/®
r ,
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE vL�S
/[-
IS BUILDING CONNECTED TO TOWN WATER
BOARD OF APPEALS ACTION, IF ANY
IS BUILDING CONNECTED TO TOWN SEWER
IS BUILDING CONNECTED TO NATURAL GAS LINE
INSTRUCTIONS
SEE BOTH SIDES
PAGE 1 FILL OUT SECTIONS 1 - 3
PAGE 2 FILL OUT SECTIONS 1 - 12
ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
DATE FILED I/ / (C/ %3 A�
SIGNATURE OF'0fWNER/OF2 AUTHORIZED AGENT
F E E
PERMIT GRANTED
19 1
3 PROPERTY INFORMATION
LAND COST
EST. BLDG. COST /
EST. BLDG. COST PER SF . FT.
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
BOARD OF HEALTH
PLANNING BOARD
BOARD OF SELECTMEN
BUILDING INSPECTOR
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