HomeMy WebLinkAboutMiscellaneous - 9 CIDERPRESS WAY 4/30/20180
PO Box 55098
Boston, MA 02205-5098
617-951-0600
Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS, Ch. 139, Sec. 3B
To: Building Commissioner or Board of Health or
Inspector of Buildings Board of Selectman
City Hall City Hall
NORTH ANDOVER, MA 01845 NORTH ANDOVER, MA 01845
RE: Insured: CARL A PRESTIA and SANDRA A PRESTIA
Property Address: 9 CIDERPRESS WAY, NORTH ANDOVER, MA
Policy Number: HMA 0289797
Claim Number: BOS00053537
Date of Loss: 3/2/2015
Company: Safety Insurance Company
Claim has been made involving loss, damage or destruction of the above -captioned property,
which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be
applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 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 number.
Eric Gill Claim Examiner 3/5/2015
Safety Insurance Company
Homeowners Claims Unit
P. O. Box 55098
Boston, MA 02205-5098
Phone: (617) 951-0600 EXT 3321
Fax: (617) 531-5774
Email: EricGill@Safetylnsurance.com
Date.. �` 5po
TOWN OF NORTH ANDOVER
° p
PERMIT FOR PLUMBING
SA US
/?
This certifies that ...,
........ ...........
has permission to perform ....
. ;1.'�' !"'//�'�'..............
plumbing in the buildings of ...
...... ........... .
at .. ; . (�....!... '+`��'..�/.� S ,�............
. North Andover, Mass.
11
Fee. rA!..... Lic. No.. ! 5...
, '-
.......�...................... .
PLUMBING INSPECTOR
Check #
L�J��3
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
- . ..
Owner 1crwi
New d . Renovation
Replacement
FTXTT Tit rc
Date 02
Permit #
Amount
Plans Submitted Yes [] No
(Print or type) Check one: Certificate
Installing Company Name U/ Re f f ❑ Corp.
Addressjk Q
� n Partner.
Business Telephone — 3 S Firm/Co.
Name of Licensed Plumber:
Insurance Coverage: Indicate the of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity Bond
11 El
Insurance Waiver: L the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner Agent rl
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 Massachusgftsbi a and Chapter 142 of the General Laws.
By. gnauaa �i a accu�cu rltauoer
Title
Type of Plumbing License City(s—/5-
rcense um er Master Journeyman ❑
APPROVED (OFFICE USE ONLY
,. -C—N The Commonwealth of Massachusetts
16 Department of Industrial Accidents
Office of Investigations
Ut 600 Washington Street
Boston, MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip:
Phone #:
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
2. ❑ I am a sole
have hired the sub -contractors
listed
proprietor or partner-
on the attached sheet I
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5• ❑ We are a corporation and its
required.]
3. ❑ 1 am a homeowner doing all work
officers have exercised their
right of exemption per MGL
myself [No workers' comp.
C. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. ❑ Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12.0 Roof repairs
13. ❑ Other
-------......• ....wrW U.,:. -: a:.�, t tt:JU IM Ola [Ce section ne_ew chn..ninb We•- worixts, Co:`•tr,,;iSat3:7n pp1C)' :nfOr2..`ation.
? 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 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:
Policy # or Self -ins. Lie. #:
Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature: Date
Phone #:
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):
I. Board of Health 2. Building Department 3. City/Town Clerk
6. Other
Contact Person:
4. Electrical Inspector 5. Plumbing Inspector
ft
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-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of d
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 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. 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 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 "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 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 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 can.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investibations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-05
mww.mass..gov{dia
Date.....
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
%..
+This certifies that ....,.�%� ! !. .......................
has permission for gas installation . / . y . l.'. ............ .
in the buildings of ...... .'.. `.!:..../:..:.:'::r..?......
at . `........`.'`�.. �'� s. S........... , North Andover, Mass.
Fee"/P G .... Lic. No...�? / t .. ��`�........... .
ir�%•
GAS'INSPECTOR
Check #
.4d
MASSACHUSETTS UNIFORM APPLICATON FOR PERMUT TO DO GAS FrrrING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Locations
Date _ to
Permit #
Amount $
Owner's NameTO
L_ and
New Renovation ❑ Replacement ❑ Plans Submitted
(Print or type)A �1w �� r Check one: Certificate Installing Company
Name_ 1v` k
Corp.
Address �d a in v► t (� �t� ❑ Partner
y�a� (- —
Business Telephone�`r i ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter MA SjyA g j 6 , Up jr
INSURANCE COVERAGE Check on
I have a current liability Insurance policy or it's substantial equivalent. Yes No❑
If you have checked yes, pleasecate the type coverage by checking the appropriate box.
Liability insurance policyErOther 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 ❑
• "="".Y ""'___)' —1 — V1 ulG UGi J1D G11U 1111U1111aL1Un 1 nave suominea for 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 State GasBode pnd C��te�10 ; 42 of the General Laws.
n.
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
❑ Plumber ! —
❑� as Fitter License Number
1=1 Master
❑ Journeyman
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SUB -BA SEM ENT
BASEMENT
1ST. FLOOR
2ND. FLOOR
3RD. FLOOR
4TH. FLOOR
5TH. FLOOR
6TH. FLOOR
7TH. FLOOR
8TH. FLOOR
(Print or type)A �1w �� r Check one: Certificate Installing Company
Name_ 1v` k
Corp.
Address �d a in v► t (� �t� ❑ Partner
y�a� (- —
Business Telephone�`r i ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter MA SjyA g j 6 , Up jr
INSURANCE COVERAGE Check on
I have a current liability Insurance policy or it's substantial equivalent. Yes No❑
If you have checked yes, pleasecate the type coverage by checking the appropriate box.
Liability insurance policyErOther 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 ❑
• "="".Y ""'___)' —1 — V1 ulG UGi J1D G11U 1111U1111aL1Un 1 nave suominea for 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 State GasBode pnd C��te�10 ; 42 of the General Laws.
n.
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
❑ Plumber ! —
❑� as Fitter License Number
1=1 Master
❑ Journeyman
The Commonwealth of Massachusetts
Department o f Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
wwK.mas&gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: Phone #:
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
2. ❑ I
have hired the sub -contractors
am a sole proprietor or partner-
listed on the attached sheet I
ship and have no employees
These sub -contractors have
working for me in any capacity.
[No workers' comp. insurance
workers' comp. insurance.
5. ❑ We are a corporation and its
required.]
3. ❑ I am a homeowner doing all work
officers have exercised their
right of exemption per MGL
myself. [No workers' comp.
C. 152, § 1(4), and we have no
insurance required] t
employees. [No workers'
comp. insurance required-]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. ❑ Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12.0 Roof repairs
13.❑ Other
auy:GtJ.f rIL' CL'j jne eC'jrb^.. begnv, sbn,,VL^g t.^err 4JorL=! com+ policy
„ F
t Homeowners who submit this ar�davit 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 their workers' comp. policy information.
lam an employer that is providing workers' compensation insurance for my employees. Below is the policy? and job site
information.
Insurance Company
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
signature:
Date.:
Phone #:
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):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. 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 apartna ents 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, §25CM 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 number(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 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 Dem
partent of
Industrial Accidents. Should you have any questions egardinLg 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 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 "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 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 Office of Investigations would Bice 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 Washington Street
Boston, MA 0:2111
Tel. # 617-727-49.00 ext 406 or 1-877-MASSAFE
Revised 5-26-05
Fax # 617-72.7-7749
wvvw mass.-gov/dia
BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: . 7
Date Issued: L2z21911 0
IMPORTANT:
LOCATION I C,
Date Received
must complete all items on this
Print C/
PROPERTY OWNER M efA Ll- C
Print
MAP NO: /0 PARCEL: ZONING DISTRICT: 1 Historic District
Machine Shop
v -t4
1-0-
11
/ "',
Or
SSgCHU`+�
yes _" no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
Buildin
One family
Addition
Two or more family
Industrial
Alteration
No. of units:
Commercial
Repair, replacement
Assessory Bldg
Others:
Demolition
Other
Septic Wel
Floodplain Wetlands
Watershed District
'�,,Water/Se--w-gir
PTION OF WORK TO BE PREFORMED:
I& ntification Please Type or Print Clearly)
OWNER: Name: Meed LLQ. Phone:cl -
Address: f 1 r Cr gke,�P1&Jx A)•A'Jel-,er oA4 o 1AS-
CONTRACTOR Name: ,VjR � .a Ct LL�- Phone:97R -6V-
Address: tl S7 (�e-? r
Supervisor's Construction License: Exp. Date: q Al,
Home Improvement License: lU
Date:
ARCHITECT/ENGINEER D}S��%rv��, ? Phone:_ !-�Z2 (61 4J6
Address:SSD "�1�1w��; R n�, 0I9-67 Reg. No. 6 O
FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
7917sP'+ZV(sFto `
Total Project Cost: $'Zo41 A Z -V :1400 sF = FEE: $ 309'. * 166 t -o + ►oo F.D-T - Ioo�DTr'
Check No.: f 400 Receipt No.: 22!�:Z
NOTE: Persons contractin=Signature
tractors do not have access to &theuaran nd
Signature of Agent/Owner of contractor
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/Massage/Body Art
Swimming Pools
Well
Tobacco Sales
Food Packaging/Sales
Private (septic tank, etc.
Permanent Dumpster on Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
A r
COMMENTS
CONSERVATION Reviewed on
COMMENTS
HEALTH
COMMENTS
Reviewed on
F1
Sianature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Locatea 664
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
� COMMENTS
Street
Dimension
Number of Stories: e- Total square feet of floor area, based on Exterior dimensions. (797 -S
Total land area, sq. ft.: 3o • 2 6 G
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine
NOTES and DATA — For department use
❑ Notified for pickup - Date
Doc.Building Pernut Revised 2008
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses
o Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
Q Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
NOTE: All'dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
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 the building application
Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2008
Location '7
No. C, 1-7 Date
Check # /Y Gy
22; i"
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
BUild'ing Inspector
•
4
CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Building Permit Number 657 Date: July 23, 2010
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 9 Ciderpress WE, at Meetinghouse Commons,
North Andover, MA 01845
MAY BE OCCUPIED AS residential dwelling, unit 9
Fee: $100.00'
Receipt: 22976
Certificate Issued to:
Bui ding Inspector
9 Ciderpress Way
Meetinghouse Commons
115 CarterField Road
North Andover, MA 01845
CA
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APPLICATION FOR CERTIFICATE OF OCCUPANCYIINSPECTION
Building Permit # (0
ADDRESS/LOCATION OF PROPERTY: s V v
Map 16 C Parcel 3) Lot Number (y) 07
SUBDIVISION
DATE REQUESTED FILED/READY FOR INSPECTION
CLOSING DATE ON PROPERTY: 7 Z 7X n
ALL WORK AND SIGN -OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A RE.
INSPECTION FEE OF TWENTY DOLLARS $20.00) WILL BE CHARGED IF THE STRUCTURE
DOES NOT MEET ALL APPLICABLE CODES_
Permit Issued to: —Me,.-Jt(-&-4fAAj Ur—
Address /%S— (:;7,Ae ! e(j Kms.. JN* 4 VLr kA4
CONSERVATION
PLANNING NIA- Gil q02
DPW - WATER METERWWI -7 64) ID
SEWERIWATER CONNECTION
NOTE
DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO
SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST
DPW �A
Signature
File: Application for OC -form revised Jan 2007
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Date ...... 4.-00 .................
,AORTN
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ............ /---- 12 z W
.................................................................................
has permission to perform ..... && ,0-/ e>r /,.:-
............................ ...... .............................
wiring in the building of .....IM( b.7i!i.-ft ... ...........
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at ......... 5 ..................... le North Andover, Mass.
Fee ..;W.--Lic. No. ......... -��---#ECrRICAL INSPECTdi
Check #
Commonwealth of Massachusetts Official Use Only
J
Department of Fire Services Permit No./YS
lug BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev. 1/071
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All .work to be performed in accordance with the Massachusetts EIectrical Code (ME ) 527 C 12.00
(PLEASE PRIIVTININKORTYPE ALLINFOR ATIOA9 Date:
City or Town of: NORTH ANDOVER 0
To .the Inspector of fires:
By this application the undersigned gives notice of his or her her intention to perform the electrical work described below.
Location (Street & Number)
Owner or Tenant AA. Y1. L � ;
-
Owner's Address
TeIepho a No.
Is this permit in conjunction with a building permit? Yes No
Purpose
� ❑ (Check Amzgu-�—
of Building lL
� �
Utility
Authorization No.
ExistingService Amps
/ Volts Overhead ElUnd
gi'd ❑ No. of Meters
New Service / Amps.
W/ —
p( /,� Volts Overhead ❑
Undgrd No. of Meters
Number of Feeders and.Ampacity/li�l/ 4 ZOO 9,y
/
Location and Nature of Proposed Electrical work: /r
No. of Recessed Luminaires
Completion o the ollowin table may be waived by the Inspector of wires.
No. of Ceil.-Susp. (Paddle) Fans o• o otal
No. of Luminaire Outlets
No. of Hot Tubs
Transformers KVA
Generators KVA
No. of Luminaires
Swimming Pool Above ❑ -
d•
o. o mergency g
0
- No. of Receptacle Outlets
d.
No. of Oil Burners
Batte Units
; FIRE ALARMS
No. of Zones
No, of Switches
No. of Gas Burners
o..of etection and
No. of Ranges
No. of Air Coad. otal
Initiating Devices
Tons
No. of Alerting Devices
No. of waste Disposers
eat PSP
Tom'
umber ons
No. o Self -C
No. of Dishwashers
Space/Area Heating KW
Detection/AlerdnE Devices
Local ❑ Municipal
Connection ❑ Other
No. of Dryers
Heating Appliances KW
Security Systems:*
o. of WaterNo.
KW
. o. of
of Devices or E uivalent
Heaters
signs Ballasts.
Data wiring:
No. Hydromassage Bathtubs
No. of Motors Z o gp
No. of Devices or E uivalent
elecommunications iring:
OTHER:
No. of Devices or E uivalent.
Estimated Value of Electrical Work: --
Attach additional detail tjdesired, or as required by the Inspector of wires,
(When required by municipal policy.)
In
Work to Start spections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: 'I nless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee 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 '(- BOND ❑ OTHER ❑ (Specify:)
I certify, under the airs and enalttes of perjury, that the information on this application is true and complete
FIRM NAME: ,/ �„ G,- � ,�, f � C . LIC. NO.:
Licensee: �" Signature
(If applicable enter "exempt" in t e license number line.) LIC. NO.:
Address: �� S 1�T { Bus. Tel. No.:
*Per M.G.L c. 147, s. 57-61, security work requires Department of Pub Safety "S" License: AltL c. No.
m-�r
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the Iiability 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 Telephone No. PERMIIT FEE: $
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�Submitte,�
PlansWaived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer
Tanning/Massage/Body Art
Swimming Pools
Well
Tobacco Sales
Food Packaging/Sales
Private (septic tank, etc.
permanent Dumpster on Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING A DEVELOPMENT
J 7 -
COMMENTS N)A , Z`C A Ch. 01
CONSERVATION Reviewed on / `� Si naturel?'1 4�,
COMMENTS -DE Q 2i4Z— it t -
ad- 1,-a Plu -oiu,��/ 121.z� A-4 '(1c, /U-. I -b-tz
HEALTH Reviewed on -Si nature �a
COMMENTS o N S6ru fR 1y O
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: �2 Comments i
Water & Sewer Connection/si natur t wvkk-ivewayPermft l
DPW Town Engineer: Signature: U".
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REScheck Software Version 4.3.0
Compliance Certificate
Project Title: Meeting House Commons
Energy Code:
2006 IECC
30.0
Location:
North Andover, Massachusetts
124
Construction Type:
Multifamily
30.0
Building Orientation:
Bldg. orientation unspecified
132
Conditioned Floor Area:
3399 ft2
19.0
Glazing Area Percentage:
7%
91
Heating Degree Days:
6322
Climate Zone:
5
Construction Site:
Owner/Agent:
Designer/Contractor:
Building 1
Tara Leigh Development, LLC
O'Sullivan Architects, Inc.
North Andover, MA
115 Carter Field Road
580 Main Street
North Andover, MA
Suite 204
Orientation: Unspecified
978-6876-2635
Reading, MA 01867
781-439-6166
Compliance: Maximum UA: 1174 Your UA: 1165
Floor 1: All -Wood Joist/Truss:Over Unconditioned Space
3769
30.0
0.0
124
Ceiling 1: Flat Ceiling or Scissor Truss
3769
30.0
0.0
132
Front Walls: Wood Frame, 16" o.c.
1778
19.0
0.0
91
Orientation: Unspecified
Window 3: Vinyl Frame:Double Pane with Low -E
137
0.330
45
SHGC: 0.30
Orientation: Unspecified
Window 4: Vinyl Frame:Double Pane with Low -E
39
0.280
11
SHGC: 0.27
Orientation: Unspecified
Door 1: Glass
80
0.280
22
SHGC: 0.42
Orientation: Unspecified
Sides: Wood Frame, 16" o.c.
7840
19.0
0.0
463
Orientation: Unspecified
Window 5: Vinyl Frame:Double Pane with Low -E
104
0.330
34
SHGC: 0.30
Orientation: Unspecified
Window 6: Vinyl Frame: Double Pane with Low -E
26
0.280
7
SHGC: 0.27
Orientation: Unspecified
Rear Walls: Wood Frame, 16" o.c.
1922
19.0
0.0
88
Orientation: Unspecified
Window 1: Vinyl Frame:Double Pane with Low -E
343
0.330
113
SHGC: 0.30
Orientation: Unspecified
Window 2: Vinyl Frame:Double Pane with Low -E
13
0.280
4
SHGC: 0.27
Orientation: Unspecified
Door 2: Glass
40
0.350
14
SHGC: 0.31
Orientation: Unspecified
Door 3: Glass
60
0.280
17
SHGC: 0.42
Project Title: Meeting House Commons Report date 01/14/10
Data filename: K:\Zahoruiko\Meetinghouse Commons - No Andover\Townhouses\CD's\Building 1\Building_ 1.rck Page 1 of 2
Orientation: Unspecified
Compliance Statement. The proposed building design described here is consistent with the wilding plans, specifications, and other
calculations submitted with the permit application. The proposed building has been designe to meet the 2006 IECC requirements in
REScheck Version 4.3.0 and to comply with the mandatory require is listed in t e RES eck Inspection Checklist.
•
Name - Title 1 9ignature Date
Project Title: Meeting House Commons Report date. 01/14/10
Data filename: K:\Zahoruiko\Meetinghouse Commons - No Andover\Townhouses\CD's\Building 1\Building_l.rck Page 2 of 2
Aiassachusetts - Del ill-tmni of Public Safct�
Board of $uitciin��
Regutatifins and Stantlai•c1s
Construction Supervisor License
License: CS 55417
Restricted to: 00
THOMAS D ZAHORUIKO
115 CARTERFIELD RD
N ANDOVER, MA 01845
{'otnmiissi" er
t
Expiration: 4/5/2012
Tr#: 21090