HomeMy WebLinkAboutMiscellaneous - 85 CARLTON LANE 4/30/2018Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS, Ch. 139, Sec. 3B
To: Building Commissioner or
Inspector of Buildings
1600 Osgood Street
North Andover, MA 01845
RE: Insured:
Property Address:
Policy Number:
Date/Cause of Loss:
File or Claim Number:
Jerry Lemmon & Stacey Hodgkins
85 Carlton Lane
HP2262511
3/24/2015, Water/Ice Dams
31664-W
Claim has been made involving loss, damage or destruction of the above captioned property,
which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER
143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS,
CHAPTER 139, SECTION 3B is appropriate, please direct it to the attention of the writer and
include a reference to the captioned insured, location, policy number, date of loss and claim or
file number.
Wade Anderson
On this date, I caused copies of this Notice to be sent to the persons named above at the
addresses indicated above by First Class Mail.
J`- q
it
%(ChRr6re and Date
ANDERSON ADJUSTMENT CO., INC.
50 Nashua Road, Suite 303
PO Box 1098
Londonderry, NH 03053
8953
NORTq
ti D
,SSACHUS�
Date. 3116-41//. .
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
AL
This certifies that ... I`A.................. P: ............. s .. .
has permission to perform ... �! lct,4 �...S f-1 I/— � � "Ota,\
plumbing in the buildings of .. !.%?................... .
at....�� ..... 1�. TUn.....1AA1,t .. , North Andoverass,-
Fe. ��(�.(tC).. Lic. No.. , It
..............
PLUMBING INSPECTOR
Check x11T_ dt
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
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e S�1�C�V c R MA. Date' `t �'4'�
' Permit#
_ tion:1Owners Name:�t-MVAQ Q
pancy: Commercial[] Educational ❑ Industrial ❑ Institutional ❑ Residential
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Installing Company Name: �� C(") FCheck-15�One Only Certificate #
Address: 2Q iaCAv , City/Town: orationLilr,. State•�>�Business Tel `»�) ership
�Fax: 1e� 9�2 `<'1Company
Name of Licensed Plumber: M
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YesNo
If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. ❑ E]
A liability insurance policy.
7
Other type of 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
Si nature of Owner or Owner's Agent Owner ❑ Agent ❑
t 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 iPe m the General Laws.
By
Type of License:
Title na
¢Plumber St g tura ofLicense Plumber
CitylTown aster
APPROVED OFFICE USE ONLY) ❑Journeyman License Number:
7664 Date... �.f . J. !.....
OF NORTH 9h
3? TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
's,9S$AC MUSES
This certifies that ...A.5 .... &.Q.....
has permission for gas installation ... ... ...:
in the buildings of .. fi111'!.!1...........................
at.... � 14ne- .. , North Andover, Mass.
FeiGI S ,LO. Lic. No..1 �p� ." � • . .�
GAS INSPECTOR
Check # i� �l—y
S—N
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
I ur,
City/Town: �3. r NU000C2_ , MA. Date: 1-t •�1. 1I Permit#
Building Location: -Ws- cA ohi Owners Name:
Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential [
Renovation: 1< Replacement: ❑ Plans Submitted: Yes El ❑
New: ❑ Alteration:If-
FIXTI IRFS
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.
A liability insurance policy Other type of 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
Signature of Owner or Owner's Agent Owner ❑ Agent ❑
By checking this box ❑; 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 olumbina work and installatinns narrnrmarl unrlar rha nermif i --A s,.r a:� . :: a ...:u �_ :-
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r
Ty a of License:
By
Plumber
TTitle Gas Fitter Signa ur
)Master e of Licensed Plumber/Gas Fitter
Cit /Town [Journeyman License Number:
City
APPROVED OFFICE USE ONLY ❑ LP Installer
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BASEMENT
1 FLOOR
2Nu FLOOR
3 FLOOR
4 IH FLOOR
61HFLOOR
6 FLOOR
7 1H FLOOR
8 FLOOR
Check One Only Certificate #
Installing Company Name:
(�(\.�
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El Corporation
Address: 10
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City/Town: VIMdA iG,
State:
❑ Partnership
Business Tel:
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Fax:
7�W
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�Firm/Company
Name of Licensed
Plumber/Gas Fitter:
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.
A liability insurance policy Other type of 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
Signature of Owner or Owner's Agent Owner ❑ Agent ❑
By checking this box ❑; 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 olumbina work and installatinns narrnrmarl unrlar rha nermif i --A s,.r a:� . :: a ...:u �_ :-
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r
Ty a of License:
By
Plumber
TTitle Gas Fitter Signa ur
)Master e of Licensed Plumber/Gas Fitter
Cit /Town [Journeyman License Number:
City
APPROVED OFFICE USE ONLY ❑ LP Installer
Naive (Business/Organization/Individual): \ 4-A
Address: 7,0
City/State/Zip: caw 01 Phone##: '-I
Are you an employer? Check the appropriate box:
The Commonwealth of Massachusetts
r ; I
Department of Industrial Accidents
%
' t �
Office o Investigations
ff f g
` ���' ►`'
600 Washington Street
UA V1
Boston, MA 02111
\`
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information
Please, Prinf Leaib
Naive (Business/Organization/Individual): \ 4-A
Address: 7,0
City/State/Zip: caw 01 Phone##: '-I
Are you an employer? Check the appropriate box:
Type of project (required):
1. r� I am a employer with �—
4 . ❑ I am a general contractor and I
6. E] New construction
employees (full and/or part-time).*
2. ❑ I ara a sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet. #
7• ❑ Remodeling
ship and have no employees
These sub -contractors have
8. ❑ Demolition
working for me in any capacity.
workers' comp. insurance.
5. ❑ We its
9_ ❑ Building addition
[No workers' comp. insurance
are a corporation and
10.❑ Electrical repairs or additions
required.]
3. ❑ I am a homeowner doing all work
officers have exercised their
right of exemption per MGL
11.Plumbing repairs or additions
myself. [No workers' comp.
c. 152, § 1(4), and we have no
12.n] Roof repairs
insurance required.]
employees. [No workers'
13.❑ Other
comp. insurance required.]
*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 anew affidavit indicating such.
#Contractors that check this box must attached an additional sheet showing the name of the sub -contractors acid their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: CT r n N \
Policy # or Self -ins. Lic. #: ,� I T % '�> Expiration Date: I I ' ft)--) ' I (
Job Site Address: k 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 tnay be forwarded to the Office of
Investigations of the DIA for insurance'coverage verification.
I do hereby certify
D under the pains andpenalties ofpetjury that the information provided above is true and correct'
Signature: Date:
Phone #• ' �1\� c�� —
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. Hoard of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, 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, §25C(6) 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, MGL chapter 152, §25C(7) states "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 out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub -contractors) name(s), address(es) and phone nuinber(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit maybe 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. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
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 pennit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license, applications in. any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or pen -nit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
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 CQmmQnwealth of Massachusetts
DepartmeMt of Industrial Accidents
Office of Investiptions
600 Washington Street
DQ:ston, MA 02,111
Tel. # 617-7274900 ext 406 or 1-8777 MASSAFE
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia
0069 Date .... I .... ......... ...... ..... / ... / .....
Cf HOR7p 4,
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
SA US
1) -5 ZtiF-A,"wp"/
This certifies that ........................................................ a
... / —
has permission to perform ........re-4/en'l/
.................................................................
wiring in the building of .......... 4 ...........................................
c4oa 4 7 7-9
. ........... I ....................................................... North Andover, Mass.
7
Lic. No./A.Y"If// ............. /L ...
Check # 70LIR
Vh
Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No. J to 1
BOARD OF FIRE PREVENTION REGULATIONS Date Issued:
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: S" _3 / /
City or Town of: A/O S77� /t54w3 e✓c-`- To the Inspector of Wires:
By this application the undersigned gives notice or nis or her intention to perform the electrical work described below.
Location (Street & Number) c4e L %-QUI/ LN
Owner or Tenant /)')/�, 4,� 4419 /' Telephone No.
Owner's Address'L
Is this permit in conjunction with a building permit? Yes Q No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity 4--/%C
Location and Nature of Proposed Electrical Work:
Completion ofthe following table may be waived by the Inspector of Wires.
No. of Recessed Fixtures
No. of Ceil: Susp. (Paddle) Fans
No. of 'Total
Transformers KVA
No. of Lighting Outlets
No. of Hot Tubs
Generators KVA
No. of Lighting Fixtures
Swimming Pool Above ❑ In ❑
end. grnd.
o. of Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS No. of Zones
No. of Switches
/No.
/
of Cas Burners
No_ of Detection and
Initiatin.p. Devices
No. of Ranges
No. of Air Cond.
Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
Nu_mber..._
Tons
KW
..
.................
No. of Self -Contained
DetectionfAlerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances
KW
Security Systems:
No. of Devices or Equivalent
No. of Water
Heaters
KW
No. of
Signs
No. of
Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors
Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licen-
see provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies
that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE IM BOND ❑ OTHER ❑ (Specify:)
(Expiration Date)
Estimated Value of Electrical Work: y060, (When required by municipal policy.)
Work to Start: �j .. �—�/ Inspections to be requested in accordance with MEC Rule 10, and upon completion.
I certify, under the pains andpenalties ofperjuty, that the information on this appl' a6 is true and complete.
FIRM NAME:O&a /A/C ®S!-fG etygie&`f LIC. NO.:A: 7%
Licensee: Signature L LIC. NO.: E:eai
(If applicable, ,gguu��er " m t" !n thg?,license number line. Bus. el. No.a�/ 21 %J--�a//
Address: GSC% X cX�.2 ���IN In/9- Ziwo/ i� Alt. Tel. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law_ By my
signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent-
Owner/Agent Signature Phone:
I Insurance on File: Will Fax: Permit Fee: Receipt #t: Date: I
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (BusinesslOrganization/Individual): Q S 1
Address: rQ BOX 02001,
City/State/Zip: R6'A D 1M G, MA. 0 t 36 7 Phone #: G t 7 7 f? 3®/ l
Are you an employer? Check the appropriate box:
Type of project (required):
LK I am a employer with q
4. ❑ 1 am a general contractor and 1
6. ❑New construction
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet.
7. ❑ Remodeling
ship and have no employees
These sub -contractors have
g, ❑ Demolition
working for me in any capacity.
employees and have workers'
9. ❑Building addition
[No workers' comp. insurance
required.]
comp. insurance.:
5. ❑ We are a corporation and its
10.® Electrical repairs or additions
.,. El 1 am a homeowner doing all work
officers have exercised their
11. Plumbing repairs or additions
p
myself. [No workers' comp.
right of exemption per MGL
12.❑ Roof repairs
insurance required.] t
c. 152, §1(4), and we have no
13.❑ Other
employees. [No workers'
comp. insurance required.]
*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 policv and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #: WC $ 3 7 Fg 7 Expiration Date: 3 -26 -do t a
4 Job Site Address: 9S ctr�2 1— MM i—�J City/State/Zip: N, i9tJDo VY ---
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 certifyyunder the pains and penalties of perjury that the information provided above is true and correct.
Signature: ���� /�Lt'��(.tu 0(fl� Date: �J"� 3-11
77 7
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
Contact Person: Phone #:
Date— X1. -IV-. '!�4 - -
TOWN OF N
PERMIT FOR (
H ANDOVER
INSTALLATION
14
This certifies that
has permission for gas installation<7/ ..........
in the buildings of ... ...........................
at.
. •
.......... North Andover, Mass.
Fee.Lic. No'dl*�i4l'� ... .. ).,e -e * .........
a 0�
G
Check
5759
MA%ACHUSEI1s UTIIFORM APPUCATON FOR PERNIlT TO DO GAS F1TTiNG
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Date j 0/1006
Building Locations
Permit # /r7
Amount $
Owner's Name
New ❑ Renovation ❑ Replacement Eq- Plans Submitted ❑
(Print or
Name—
Address
Name of Licensed Plumber or Gas Fitter 1 tr 2e L
C one: Certificate Installing Company
Corp.
Partner.
Firm/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes SM No�
If you have checked Les, please indicate the type coverage by checking the appropriate box.
Liability insurance policy kri Other type of indemnity ❑ Bond rl
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
harp -,Lw •.o.r: F., �r......tl ..0 .t,,, .1.�.,.a.... _.i :-r__-"--`--
- - - - �•• •� • • �__• �• �__ . u.� au111uiou kur c,uereu) in aoove application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Per, it s ued for this application will be in
compliance with all pertinent provisions of the D:lassachusetts Sta sas Co an ha r l4. of the General Laws.
esy:
Title
City/Tow n
(APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
Plumber 1!(, V Lo
ElGas Fitter icensr um er
Master
Journeyman
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SUB -BASEMENT
BASEMENT
1ST. FLOOR
2ND. FLOOR
3RD. FLOOR
4TH. FLOOR
5 T H. F L O O R
6TH. FLOOR
7TH. FLOOR
STH. FLOOR
(Print or
Name—
Address
Name of Licensed Plumber or Gas Fitter 1 tr 2e L
C one: Certificate Installing Company
Corp.
Partner.
Firm/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes SM No�
If you have checked Les, please indicate the type coverage by checking the appropriate box.
Liability insurance policy kri Other type of indemnity ❑ Bond rl
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
harp -,Lw •.o.r: F., �r......tl ..0 .t,,, .1.�.,.a.... _.i :-r__-"--`--
- - - - �•• •� • • �__• �• �__ . u.� au111uiou kur c,uereu) in aoove application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Per, it s ued for this application will be in
compliance with all pertinent provisions of the D:lassachusetts Sta sas Co an ha r l4. of the General Laws.
esy:
Title
City/Tow n
(APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
Plumber 1!(, V Lo
ElGas Fitter icensr um er
Master
Journeyman
Location
No. 0 0 �—
g C4 r Nom -c-
Date '�'- Iy-63
NORTh TOWN OF NORTH ANDOVER
_ O
10. 9
# ; ; Certificate of Occupancy $
Building/Frame Permit Fee $ 1"
J�cwus
Foundation Permit Fee $
Other Permit Fee $
' TOTAL $ / b o
Check #
'I 65e4
Building Inspector
• 4 #
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER: D DATE ISSUED: / 3
SIGNATURE:
Building Commissioner/In for of Buildings Date
SECTION 1- SITE INFORMATION t
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
IOLG 9__
Map Number Parcel Number
O
�j � l� �Lr�fi,9 tile,
i
1.3 Zoning Information:
X
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Areas Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard Rear Yard
Required Provide I geguired Provided Re red Provided
M
/a
z
O
'C�
SECTION 4 - WORKERS COMPRNSATION rM r_ i r ta') C
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit Hill result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes .......0 No ....... ❑
SECTION 5 Description _ Proposed Work check aviDlIcable
New Construction ❑
Existing Building ❑
Repair(s) ❑
Alterations(s) 1"—
Addition ❑
Accessory Bldg. ❑
Demolition ❑
Other ❑ Specify
Brief Description ofProposedWork:
/.
—6-
SECTION ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
OFI♦ICIAL USE QKI Y
Completed by permit applicant'
1. Building
(a) BuildingPermitFee
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
as Owner/Authorized Agent of subject property
H eby a rite C A 11 to act on
y alf, in all matters relative to work authorized by this building permit application.
(� 12W/3
Signature of Owner Date
SECTION 7b`OWNEPJ O ED AGENT DECLARATION '
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
r
Print Name
Si at, O(vner/A en Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR T20BERS iST2 3 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 LIN.
G
P
FORM U - LOT RELEASE FORM ls' e CCL
INSTRUCTIONS: This form is used to verify that all necessary approvals/permi a 3
Boards and Departments having sis from
p g 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_ LE rti T-6rj J� PHONE
LOCATION: Assessor's Map Number C_ I PARCEL
SUBDIVISION LOT (S)
STREET �NL 1v
ST_ NUMBER.
ENDA
CONSERVATION ADM
COMMENTS
USE
AGENTS:
DATE APPROVED
DATE REJECTED
TOWN PLANNER DATE APPROVED
DATE REJECTED
COMMENTS
FOOD INSPECTOR -HEALTH DATE APPROVED
iJ / __ '; DATE REJECTED
SEPTIC INSPECTOR -HEALTH
COMMENTS G
DATE APPROVED
DATE REJECTED -
PUBLIC WORKS - SEWERAVATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
6
RECEIVED BY BUILDING INSPECTOR DATE
Revised 9W jm
Town of North Andover
Building Department
The following is a list of the required forms to be filled out for the appropriate
permit to be obtained.
FOR ROOFING, SIDING, INTERIOR REHABILITATION PERMITS
1) BUILDING PERMIT APPLICATION
2) DEBRI REMOVAL FORM
3) WORKERS COMP AFFIDAVIT
4) PHOTO COPY OF H.I.C. AND/OR C.S.L. LICENSES
5) COPY OF CONTRACT
6) FLOOR PLAN OF PROPOSED INTERIOR WORK
FOR ADDITIONS / DECKS
1) BUILDING PERMIT APPLICATION
2) FORM U
3) MORTGAGE PLOT PLAN (MINIMUM)
4) DEBRI REMOVAL FORM
5) WORKERS COMP AFFIDAVIT
6) PHOTO COPY OF H.I.C. AND C.S.L. LICENSES
7) COPY OF CONTRACT
8) FLOOR/CROSSSECTION/ELEVATION PLAN OF PROPOSED
WORK WITH SPRINKLER PLAN AND HYDRAULIC
CALCULATIONS (if applicable)
9) MASCHECK ENERGY COMPLIANCE REPORT (if applicable)
FOR NEW CONSTRUCTION (SINGLE AND TWO FAMILY)
1) BUILDING PERMIT APPLICATION
2) FORM U
3) GROWTH MANAGEMENT BYLAW
4) CERTIFIED PROPOSED PLOT PLAN
5) PHOTO COPY OF H.I.C. AND C.S.L. LICENSES
6) WORKERS COMP AFFIDAVIT
7) TWO SETS OF BUILDING PLANS (one to be returned) TO
INCLUDE SPRINKLER PLAN AND HYDRAULIC
CALCULATIONS (if applicable)
8) COPY OF CONTRACT (if applicable)
9) MASCHECK ENERGY COMPLIANCE REPORT
In all cases if a variance or special permit was required the Town Clerks
office must stamp the decision from the board of appeals that the appeal period is over. The
applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with application.
106120;2003 .09:52
I .I
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6175239519
EQR BOSTON
E K SURVEY INC
•
Zoe R'
hu s
Phd.rR76rIifYt#AS s F#A 075AHL7046
MORTGAGOR 1EL�.,a M� lx+�lilXOLffid�tlQS
ADDRESS OF PRINCtpLE BVILDING
/-()I ;I LO
1:FRTIFIQATION TC'
VIA. b.4—D.0- rIl-a 131 'r%F mrrl crtrifiriih for
310ri0 pvrpmw onN srvd A 1 o9 4 srr`dsd 4r reprt�eftt0d
.� t� - r•+r-•fir rl'•' e' I.ul Thia histi A tid In be used
to q�utNish •nY of eh� property nri. for my purpose Ne
4tiS �� 1{e..tt1� 04 c nw a crups"I -
lie
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ac, i fe/ 01.4.
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PAGE 0'?
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PLAN REF, Pal
DATE 49 IM$PIR~TiON SCALE. V •fit •-
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"rLlSl�y' {� wrgn aic Iw..w �..�uny w,l.... I:FWr�"�I'•• nnnnn�rl�
a ` L` Rmal or I% sAwnpi f[me tidgjcl n Nmio;Cbrt'tnw,'}I
aw M� ..••J- hi-.� O.L. Y.ny wee. r-h11r1 me, ier. 7
a 5ubjW pulbr+ty Is rot In a Fbt,d HOWd Ares2
n C�Ih,rt h1�4�,1p�t dt_IrLs Floc FIIAef4 Ar4e.
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 Facility)
--4 ;�A/
Sign ure LotPe'rmitpplicant
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through. the Office of the Building Inspector
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Afdavit
Name Please Print
Name:
Location:
Cit`/ Phone #
F7
I am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
am an employer providing workers' compensation for my employees working on this job.
Company name:
Address
City. Phone #-,
Insurance: Co. Plnliry#
Company name: ,
Address
City Phone #
Failure to secure coverage as required. under Section 25A or MGL 152 can lead to the imposition of criminal penalties of:a•fkm up to $1.9
and/or one years' imprisonment as well.as.ctwd onaais inlhelmnAta-S79PYAORKDRDER-aW afhaa-($1_0D_M-adayagainstMa,
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
Official use only do not write in this area to be completed by city or town official'
r5?
City or Town PermiNLicensi
Building Dept
[]Check if immediate response is required 0 Licensing Board
El Selectman's Office
Contact person: Phone # E] Health Department
I] Other
TOWN OF NORTH ANDOVER
PUBLIC HEALTH DEPARTMENT
27 CHARLES STREET
NORTH ANDOVER, MASSACHUSETTS 01845
Sandra Starr
Public Health Director
July 10, 2003
Cliff Speicher
43 Water Street
Beverly, MA
Re: Application for open deck
Dear Mr. Speicher:
NQ�FN
QF �cs.ac ie t'�tT
4 8 #
9��acuu4��
Telephone ('978) 688-9540
FAX (978) 6889542
Your application for a building permit for an open deck at 85 Carlton Lane, North Andover has been reviewed by
the Health Department. The application was denied on July 10, 2003 for the following reasons:
1. X Missing information
2. ❑ Passing Title 5 inspection of septic system required
3. ❑ Location of structure not acceptable
To address the problem(s):
If#I is checked, please supply:
a. Floor plan of existing and proposed addition — all rooms
b. Certified plot plan no smaller than 1" = 40' showing house, septic system and proposed
project in scale. Please show the exact location of all 4' concrete footings in relation to the
septic tank.
If #2 is checked:
a. Have the septic system inspected by a certified Title 5 inspector to determine the size of the system
and whether it is operating properly: OR
b. Tie-in to municipal sewer
If 43 is checked:
a. Relocate the project
Please feel free to call the Health Office at 978-688-9540 with any questions you may have.
Sincerely,
Reviewer
Cc: /Auilding Department
Homeowner
File
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