HomeMy WebLinkAboutMiscellaneous - 85 RUSSETT LANE 4/30/2018Date ...1. �.........................
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ... ........ 62
.. ....�', ............
1 .......................
has permission for --gaff�s installation V 7 : 4,`i'�..... �- p
in the buildings of.. .i,.. n.!, ,,,,,,,,,,,,,,,,
.............................................................
at .. .R.....,...._.._..L �--- North Andover, Mass.
....... .
Fee.,—;30 ....... Lic. No.........&.A:4 ... ...............................................................
GAS INSPECTOR
Check # (�
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY I N. ANDOVER MA DATE 2/ 2016 PERMIT #
JOBSITE ADDRESS 85 RUSSETT LANE OWNER'S NAME MELISSA DONAIS
GOWNER ADDRESS SAME I TE 978-807-1413 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ ! N0k
APPLIANCES -1 FLOORS—
BSM
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 ISPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
R
UNVENTED ROOM HEATER
WATER HEATER
OTHER
f
W=®®M
I
M M�; M' j
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Q OTHER TYPE INDEMNITY ❑ BOND
❑ NO ❑
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.
i
CHECK ONE ONLY: OWNER ❑ 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 tt best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in %p,,,ancW'th�AaPetrtine provision'.ofthe
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME I BRUCE J. LIPINSKI LICENSE # 3735 GN RE
MP ® MGF F-,,] JP ❑ JGF ❑ LPGI ❑ CORPORATION Q# 99 PARTNERSHIP#LLC ❑#
COMPANY NAME: NEW ENGLAND GAS SYSTEMS INC ADDRESS 1102 LOCUST ST
CITY I DANVERS STATE MA ZIPI 01923 TEL 978-774-7030Li
FAX I 978-739-4302 CELL 508-843-4724 EMAIL office negas.us
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The Commonwealth o f Massachusetts
Department of Industrial Accidents
F 1 Congress Street, Suite 100
n o
— Roston, MA 02114-2017
www mass.gov/dia
Workers, Compensation Insurance Affidavit: ]Builders/Contractors/Electriciansfriumbers.
TO BE JFII.ED WITH THE PEpMTTING AUTHORITY.
Name (Business/Organization/f divid�ual):
SV
Address: V� C"�, � W
City/Slate/ZxC � Q)lA 8`S Phone #: C17a kA— -V')1\
re -you an employer? Check the appropriate box: Type of project (required):
`•1_J am a employer with `1...: employees (full and/or part tune).' 1. 0 New construction
2. ❑ I am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling
any capacity. [No workers' comp. insurance required.] 9, ❑ Demolition
3. Q I am a homeowner doing all work myself [No workers' comp. insurance required.] t 10E] $.uil(�ng addition
4. ❑ lam a homeowner and will be hiring contractors to conduct all work on my property. I will
1.❑ Electrical repairs or additions
ensure that all contractors either have workers' compensation insurance or are sole 1_
_proprietors witli no employees:– Q -Plumbing xepau's ox' additions —-
5. ❑ I am a general contractor and I have hired the sub-cointractors listed on the attached sheet. 1`21,0 Roof repairs
These sub -contractors have employees and have workers' comp. insurance.1 14: Other
6. Q We are a corporation and its ofligers have exercised their right of exemption per MGL c.
152, § i (4), and we have no, employees. [No workers' comp. insurance required.]
*Any applicant that checks box#1 must also rill. out the section below showing their workers' compensation policy information.
Homeowners who submiti #his affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
?Contraotors 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. IN the sub -c6"
Tuve employees,liey must provide their workers' comp
. policy number.
I am an employer that is pYovidirzg works rs' co�npens tion insurance for my employees.' Below is the policy and jolt site
information.
Insurance Company Name:
Policy # or Self ins, Lic. #: C �� � Expiration Date �y
g
fob Site Address: City/State/Zip:
��,,y�co1a5
Attach a copy' of the workers' compensation policy declaration page (showing the policy number and. expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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 $250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA. for insurance
coverage verification.
I do her if�un�de�hze�ppaxjMqa�jnidpen es ofper jury that the informution pr ovi abov is true and correct.
Date: 1
oq Z$ ---'1."-)v = W?A
Official use only. Do not write in this area, to be completed by city or town offzcia%
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 #:
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 bf lure,
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
o£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 tha boxes that apply to your situation and, if
necessary, supply sub'contractox(s) name(s), address(es) and -phone number(s) along with their certificate(s) of
insurance.—Limited-Liabijity Companies -(LL -C) -or Limited -Liability Partnerships (LLPrith no e-�oyees of er ann a
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 may be submitted to the Department of Industrial
Accidents for confirmation ofinsurance 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 iir'sured 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 permit/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 "rob 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. Anew affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit 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 Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-NUSSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
I
Location e 5
PuSSc ! //W
No `-.-') 4 Date
�O*TN
TOWN 00 NORTH ANDOVER'
�p
Certificate of Occupancy $
Building/Frame Permit Fee $
S2
►,s',^• • Eta
s�CHus
Foundation Permit Fee $
Other Permit Fee $
Sewer Connection Fee $
m
o.
Water Connection Fee $
TOTAL $
Buildin
spector
Div. Public Works
PERMIT NO.
APPLICATION FOR PERMIT TO BUILD NORTH ANDOVER, MASS.
PAGE 1
MAP KJO.
LOT NO.
2 RECORD OF OWNERSHIP lll^Tl
BOOK ;PAGE
ZONE
I SUB DIV. LOT NO.
LOCATION �r—+S t4SSC Jie-
PURPOSE OF BUILDING
OWNER'S NAME` `�
NO. Of STORIES SIZE
OWNER'S ADDRESS Q+'� .r ��r
V 6`
J
BASEMENT OR SLAB
ARCHITECT'S NAME
SIZE OF FLOOR TIMBERS 1ST 2ND 3RD
BUILDER'S NAME
SPAN --
DISTANCE TO NEAREST BUILDING r!
L
DIMENSIONS OF SILLS ---
POSTS
DISTANCE FROM STREET S7
.ASO
DISTANCE FROM LOT LINESSIDES REAR
•�J
'/,
GIRDERS
A—
FRONTAGE�
AREA OF LOT .A� U�-c
A,v�
l'
HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW -�
SIZE OF FOOTING X
IS BUILDING ADDITION
MATERIAL OF CHIMNEY
IS BUILDING ALTERATION
`L']/
IS BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE
(
_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 1 ,
V -X i p &-Mr.a� lST q't'r l�I.e tZC/N
SEE BOTH SIDES��,i4�
PAGE I FILL OUT SECTIONS 1 - 3 C� ,,—/�F7�✓.�G. J�JJ`
PAGE 2 FILL OUT SECTIONS 1 - 12
ELECTRIC METEPS 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 L--� cl
,• SIGNATUfifjQF OW ER OR AUTHORIZED AGEN�
FEE
PERMIT GRANTED
Se19_
3 PROPERTY INFORMATION
LAND COST
EST. BLDG. COST /1 U O
EST. BLDG. COST PER SQ. FT.
EST. BLDG. COST PER ROOM .�.,.
SEPTIC PERMIT NO.
4 APPROVED BY
BUILDING INSP[CTOR
OWNER TEL.# ` 1 )-q A
CONTR. TEL. # '3339
CONTR. LIC. #, 1�� C) 9 1
H.I.C. #
IP
BUILDING RECORD
1 OCCUPANCY 12
SINGLE FAMILY STORIES
MULTI. FAMILY OFFICES
APARTMENTS
CONSTRUCTION
2 FOUNDATION
oe 8 INTERIOR FINISH
CONCRETE
B
1
2 13
CONCRETE BL'K.PINE
BRICK OR STONE
H RDW—
_
PIERS
PLASTER
_
DRY WALL
—
—
_
_
UNFIN.
3 BASEMENT
AREA FULL
FIN. B M AREA
'L '/v '/
FIN. ATTIC AREA
_
N_O B M
FIRE PLACES
_
HEAD ROOM
MODERN KITCHEN
_
4 WALLS
I 9 FLOORS
CLAPBOARDS
CONCRETE
EARTH
B
_
1
2
3
_
DROP SIDING
WOOD SHINGLES
ASPHALT SIDING
ASBESTOS SIDING
VERT. SIDING
STUCCO ON MASONRY
_
HARD"./"D
COMI.AGN
ASPH. TILE
STUCCO ON FRAME
_
BRICK ON MASONRY
BRICK ON FRAME
ATTIC STRS. & FLOOR
_
CONC. OR CINDER BLK.
WIRING
STONE ON MASONRY
STONE ON FRAME
SUPERIOR I� POOR _
ADEQUATE NONE
5 ROOF
10 PLUMBING
GABLE
GAMBRELMANSARD
11
I
HIP
BATH (3 FIX.)
_
TOILET RM. I2 FIX.i
FLAT
SHED
WATER CLOSET
_
ASPHALT SHINGLES
LAVATORY
WOOD SHINGES
KITCHEN SINK
_
SLATE
NO PLUMBING
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
OIL
B'M'T 2nd
ELECTRIC
_
to 13rd
NO HEATING
THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM
LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA-
RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN.
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OFFICES OF:
APPEALS
BUILDING
CONSERVATION
HEALTH
PLANNING
NORiry 1
°z Town of
� � m
NORTH ANDOVER
owusDIVISION OF
PLANNING & COMMUNITY DEVELOPMENT
KAREN H.P. NELSON, DIRECTOR
120 Main Street
North Andover,
Massachusetts O 1845
In accordance with the provisions of MGL c 40, S 54, a condition of Building Permit
Number 44— 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 111, S
150A.
The debris will be disposed of in:
(Location of Facility)
Signature of Permit Applicant
9 / (�/ /
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector.
2
I>
KEVIN MURPHY
BUILDING & REMODELING
169 Boxford Street
NORTH ANDOVER, MASSACHUSETTS 01845
(508) 688-5335
PHONEDAT
L'b l ^ � -)-L-t S Q
specifications and estimates for work to be performed and materials to be used:
Page No. ` of ` Pages
PROPOSAL
All home improvement contractors and subcontractors
engaged in home improvement contracting, unless
specifically exempt from registration by Provisions of
Chapter 142A of the general laws, must be registered with
the Commonwealth of Massachusetts. Inquiries about
registration and status should be made to the Director,
Home Improvement Contract Registration, One Ashburton
Place, Room 1301, Boston, MA 02108 (617) 727-8598
JOB NAME / NO.
JOB LOCATION
ARCHITECT DATE OF PLANS
..............-,� d.1................5.�%L.........V�,� n�..c................ G..n...r�..,................. ........?-.t1.,. ...
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9 2 I Date.
..- ...t> I . .
NORTH TOWN OF NORTH ANDOVER
pry ao 1e,�0OL
p PERMIT FOR GAS INSTALLATION
This certifies that- ......... ... ........ .... .
has permission for gas installation ••`� ... .................... .
in the buildings of ./ ! .,.. _ ......................... .
at . . ......... , North Andover, Mass.
�.
Fee 08/
35 Oil PARAS INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
RAS.SACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING
or print)
IN"KrH ANDOVER, MASSACHUSETTS
Date �Qys 7" 0 19 79
Building Locations s &2,s ' e Tr 44 ri _ Permit # a 9t�
Amount $
Row r4 -L N d e L/ i'f► A Owner's Name,
New ❑ Renovation Replacement ❑ Plans Submitted ❑
Print ore p Check one: Certificate Installing Company
'dame �AAV%V1 L 4 t Pta.n,Bla A f �Ae*7,1A 3 4rh , /❑ Corp.
y. Address Gjq, 4A &-4 QC- ZAAP- ❑ Partner.
Business Telephone ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter higa ex lWt Nu I e #47—
INSURANCE COVERAGE Check on
I have a current liability Insurance policy or it's substantial equivalent. Yes ff No❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policyUT I 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
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner ❑ Agent ❑
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts Stat s Code and Chapter 1429f the General Laws.
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas 13'itter
❑ Plumber 44 1 B 9
❑ Gas Fitter License Numner
Master
❑ Journeyman
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SUB-BASEM ENT
BASEM ENT
1ST. FLOOR
2ND. FLOOR
3RD. FLOOR
4TH. FLOOR
5TH. FLOOR
6T H. F L O O R
7TH. FLOOR
8T H. F L O O R
Print ore p Check one: Certificate Installing Company
'dame �AAV%V1 L 4 t Pta.n,Bla A f �Ae*7,1A 3 4rh , /❑ Corp.
y. Address Gjq, 4A &-4 QC- ZAAP- ❑ Partner.
Business Telephone ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter higa ex lWt Nu I e #47—
INSURANCE COVERAGE Check on
I have a current liability Insurance policy or it's substantial equivalent. Yes ff No❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policyUT I 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
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner ❑ Agent ❑
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts Stat s Code and Chapter 1429f the General Laws.
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas 13'itter
❑ Plumber 44 1 B 9
❑ Gas Fitter License Numner
Master
❑ Journeyman
x
1
14
n
Location J ,,, 4�i-- _
No. _ Date Ca
TOWN OF NORTH ANDOVER
9
Certificate of Occupancy $
Ana.,5 <� Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
TOTAL
Check # /
�/ Building Inspectq,
1.I Property Address:
1.2 Assessors Map and Parcel
Map Number
Number.
Parcel Number
NOY
1.3 Zoning luformatioony:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Area
Fronto 8
1.6 BUILDING SETBACKS ft
Front Yard
Side Yard
Rear Yard
Required Provide
Regaired. Provided Required
Provided
1
1.7 Water S M.G.L.C.40. 34)
Public Private ❑ zoe
1.3. Flood Zone Information: 1.8
Outside Flood Zone ❑ Municipal
Sewersp Disposal System:
9— On Site Disposal System ❑
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZEDAGENT Ut^t(ict:
2.1 Owner of Record J
2C5-y\a1ol C ( �2nn�Qr- POI�q� ��s %.) �%,01/P--N
l Name (Print) Address for Service
Si re Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor. Not Applicable
tLicensed Cadstruction Supervisor:
COI Uc-5+ ') 14.-1v�'r k P) AA fi � l �3 � License Number
Address '
Expiration Date
Signature Telephone
3.2 Registered Home Improvement Contractor Not Applicable ❑
Company Name
Registration Number
Address
Expiration Date
Signature Telephone
v-1
cvrr~rrnx a - WORKERS COMPENSATION (M.G.L C 152 8 25d61
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 it.
signed affidavit Attached Yes .......0 No ....... 0
SECTION 5 Description of Proposed Work Trek rapplicable)
New Construction ❑
Existing Building CY
Repair(s) ❑
Alterations(s) 5
Addition ❑
Accessory Bldg. ❑
Demolition ❑
Other ❑ Specify
Brief Description of�Proposed 1Work: L l �1 j � ' �/•'`_ - %�, a,,-
/
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SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollar) to be
Completed b t applicant
OMCL41 USE ONLY
1. Building LJ(a)
10 U f 7, s
Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) x (b)
A-- a�
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
Hereby authorize to act on
My be all mattop relative to wor u razed by this building permit application] '
SignaturL9,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
Si ture of Owner/ ent Bate
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 1Yr2 ND 3 Ku
SPAN
DIlIIENSIONS OF SILLS
DaMNSIONS OF POSTS
DINIENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS _
SIZE OF FOOTING X
MATERIAL OF CH ANEY
1S BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE __
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NORTH TOWN OF NORTH ANDOVER
OFFICE OF
p BUILDING DEPARTMENT
400 Osgood Street
y\;, a ;�►� North Andover, Massachusetts 01845
Telephone (978) 688-95454
D. Robert Nicetta, Fax (978) 688-9542
Building Commissioner
HOMEOWNER LICENSE EXEMPTION
Please print
DATE: 4 1 l J
JOB LOCATION: iJSSk n
Number Street Address Map/Lot
HOMEOWNER Pi )L1`.
Name Home Phone Work Phone
PRESENT MAILING ADDRESS (E�f L—a o a
City Town State Zip Code
The current exemption for "homeowners" was extended to include owner -occupied dwellings to 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 HOMEOWNER
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 structures. A person who constructs more that one home in a two-year period shall not
be considered a homeowner.
The undersigned "homeowner" assumes responsibility for compliances 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 North Andover Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING OFFICIAL
fI().U2DOF,WITAIS+iXB0541 CONSFRVATIONf)Xp0530 IIYALTIIGXX0540 11,.1N'NIM3t.M-9535
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 S93 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:
c _ ► .__ N _ ,�-,ie �,�,�. �, Q,1'_
(Location of Facility)
Sfignature of Permit Applicant
j� D
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector