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HomeMy WebLinkAboutMiscellaneous - 90 APPLETON STREET 4/30/2018N O cD O � v W rV o m O 0 z z o cn 8� o m CD M .4s down of North Andover payment Date Monday, September 19, 2016 )eposit Number 1709191 )perator Counter pc 1 ACR (BUILDING INSPECTION) $180.00 >x 'otal Paid $180.00 :ash $180.00 :hangs $0.00 teceipt Number gov00005009 1/19/2016 9:01:18 AM Jame 80 APPLETON STREET - 291-2017 :ashler Id. treascoll-17 Location C1 6 A eP1 L'"� -qry ST - No. t " / Date Check # C�kl TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $R. $6 r Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 9 Building Inspector 8760 Date .//,/./7/ TOWN OF NORTH ANDOVER r� PERMIT FOR PLUMBING I� t This certifies that ../.°'.T `/... .j. has permission to perform ... I t r.� !? 60 plumbing in the buildings of ......... • ......... . at ...1../`.. ........... .. . North Andover, Mass. Fee.. . Li c. No. .�v 1 `/ ............... ^, PLUMBING INSPECTOR Check # / � ':77 71. FIYTI IRFC MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING Y'�r1,� City/Town: v , MA. Date:11-1-7—W Permit# Building Location: 6 o ouaw,, Owners Name: Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential y New: Alteration: ❑ Renovation: Lq Replacement: ❑ Plans Submitted: Yes ❑ No ❑ FIYTI IRFC INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes tR No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy �J 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 Owner ❑ Agent ❑ Siqnature of Owner or Owner's Aoent I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: C_ Title 29 Plumber Signature of L censed Plumber Ci /Town i9 Master City /Town APPROVED (OFFICE USE ONLY ❑iourneyman License Number: 3 Li DEDICATED z SYSTEMS W 1-y Z O jA%A > Y Z 4A V1 F Y Z H Q jA y J 2 U asc ya w 4A l9 a: Uj O Z � Z ax O. W V) C Z cc W H � H Z I.- WCd a a V) Y V1 G to O Z n X N Q x Vaf J W W ~ Q Q Q -j LA.. H Q H C W 3 D Q LL W z ;;J 3 W {�/ Z :.� C d LL d. 011 3 W W a LU Y 2 Q Q 2 0 d 0 o o Z Q Q a o= a o Y Q Z to a H a F— W a u I a Q } H o'wa Q m m 0 C LL x Y J J 'A jA 3 3 3 o a 0 G 3 SUB BSMT. BASEMENT 1' FLOOR r% FLOOR Ti FLOOR 4' FLOOR FLOOR FLOOR FLOOR 8' FLOOR r r- Installing GA ;A k C Check One Only Certificate # Company Name: d V V ►�►� U.n • Q/ Wcorporation L 6 ff Address: ?,0. 13 c>>C 1-701 City/Town: 1--3�1pu2 iLL State: jj4&. — ------ ---------------- -� Partnership Business Tel: Q 7 37 3 Fax:'1 i Cr 5 (— 4 (3 ( ❑ Firm/Company Name of Licensed Plumber: INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes tR No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy �J 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 Owner ❑ Agent ❑ Siqnature of Owner or Owner's Aoent I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: C_ Title 29 Plumber Signature of L censed Plumber Ci /Town i9 Master City /Town APPROVED (OFFICE USE ONLY ❑iourneyman License Number: 3 Li z 0 U W a C7 O cG a, O a+ � 3 z � o a 0 0 ❑ m a z � w a w z 0 F U x W U p" H z z w .-A 9814 Date ... /..Z .......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............ ................................ .... ............................. has permission to perform ... . ........ ¢4............................. wiring in the building of ... .............. do - a T!.:5.. ....... :-5 .............. ....... 5............................ at..., — ... . ............................................... North Andover, Mass. . ......... .. .......... .. ......... ic. Noyk ......... 3-57 910, Fee ..................... EucrucAL I Nsrecroa Check -� COMMOnwealth Of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Occupancy and Fee Checked tev. 1/071 (leave blank) ��— APPLICIATION FORwork to be Perfonnedt PEaccorRnMIT TO PERFORM ELECTRICAL WORK ce with he Massachusetts Electrical Code (MEC), 527 CMR 12.00 N<(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER— To the Inspector of Wires: \ r.\ By this application the undersigned gives notice of his or her intention to perform the electricalwork described below, rI Location (Street & Number) caner or "tenant A . - - r/ 01 Owner's Address Is this permit in conjunction with a building permit? yes C Purpose of Building , t �y E •t" / U S Telephone No. No u (Check Appropriate Box) Utility Authorization No. xis tsig Service Zy!/ A ps %1v�12 y e Volts Overhead ❑ New Service Amps / Volts Overhead ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: No. of Recessed Luminaires No. of Luminaire Outlets No. of Luminaires No. of Receptacle Outlets 7 No. of Switches No. of Ranges No. of Waste Disposers No. of Dishwashers No. of Dryers Heaters KW No. Hydromassage Bathtubs OTHER: r -r,_ Completion of the No. of Celt.-Susp. (Paddle) Fans No. of Hot Tubs Swimming Pool Ve ❑ u_ grnd grr No. of Oil Burners No. of Gas Burners No. of Air Cond. ota Tons eaOt ump� 1 u�m e�r ons Totals: t Space/Area Heating KW Heating Appliances KW No. o 0.0 Signs Ballasts No. of Motors Total HP Undgrd 9 ---No. of Meters Undgrd ❑ No. of Meters 72-r(/arr.,7 t•in table ma • be waived hothe Ins eetor o Wire. o.O Transformers Ota KyA Generators KVA ❑O. O—Tl�ij a enc i - t ng Q -t _.... rr-_'- ALARMS No. of Zones No, of Alerting Devices Local ❑ tvi u Cot ecurity yyst -- No. of Del Data Wiring: No. of Dei e ecT common, No. of De` Attach additional detail iJ'desired, or as reyttired by the Inspector of Wire Estimated Value of Electrics! Work: Work to Start: (When required by municipal policy.) 2 - U 3 l Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless 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 OND ❑ OTHER ❑ (Specify:) C certify, under the pains and penalties of perjury, that the information on this application is true and coniplet� FIRM NAME; /% a -- LIC. NO.: yy33 Licensee: G��:--.�`�s� Signature - i ti ut,l,lic,ehlr. n r r-trmpt �n the license number line) LICA�--N--O.: 9 3 3 Address: S 1 Bus. el. d _O.: *Per M.G.[. c. 147, s. 5 -61, security work requires Depaitm of Public 5a�ty "S" License: �It. Lecl. No.: OWNER'S INSURANCE WAIVER: l am aware that the Licensee does trot have the liability insurance coverage normally required by law. fly my signature below, 1 hereby waive this requirement. I am the (check one) ❑ owner owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. S • /I ELECTRICAL PERMIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR - DOUG SMALL 1. ROUGH SPECTION: Passed — v Failed — ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) Date -,,O 2. FINAL INSPECTION: Passed — [ ] Failed — [ ) Re -inspection required ($50.00) - Inspectors' comments: (Inspectors' Signature - no initials) Date e- 3. UNDER GROUND INSPECTION: Passed — [ ) Failed — [ j Re -inspection required ($50:00) - [ ) j Inspectors' comments: (Inspectors' Signature - no initials) Date 4. INSPECTION — SERVICE: DATE CALLED NATIONAL GRID: NAME: Passed — [ ) Failed — ( ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) Date r 5. INSPECTION - OTHER: Passed — [ ] Failed — ( ] Re -inspection required ($50.00) - ( ] Inspectors' comments: (Inspectors' Signature - no initials) Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE -INSPECTION OF $50.00 IS TO BE CHARGED. Location qO � Y1 5 r— No. Date` v TOWN OF NORTH ANDOVER o Certificate of Occupancy $�Cf� MUS Building/Frame Permit Fee $ —' Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # v� 23669 Building Inspector TOWN OF NORTH ANDOVER t APPLICATION FOR PLAN EXAMINATION Permit NO: ' I I Date Received Date Issued: F1 —5 7-( d IMP ORTANT:. LOCATION ( 4pp f� must complete all items on this red Al &(&e� ,wt d 1d"t5 Print MAP NO: �b PARCEL:a_ ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building /One family I VAddition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other SepticWell ❑#FToodpl ❑ Wetlands p tWatershed District ; VWater/.Sewer DESCRIPTION OF W OKK 1 U Bh FhK-V UNNI i): Cons � Q SCAJo �DO/Y� to Gti�Q tvl�e�r �IcGk. I S (/z4g o-ff o/ hoar - I l ode) . or OWNER: a�� ata-sg8� Address: QO Avpl e n 54yee f - vA o a 45 (2►-0,0le-y COr\S L C -1&\ 9M Gtkf) Ph �e (\C, CONTRACTOR Name: C1 I& A?5?-493Z Address: '' Lo(q PQ -54u< Qct—. Qt'RC� V � 2 O l B45 Supervisor's Construction License: 51211 Exp. Date: Home Improvement License: ARCHITECT/ENGINEER Address: I tL4[-Sq C�- a7--1 --) Exp. Date: " (� Phone: Reg. No. FEE SCHEDULE: BULDING PERMIT., $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COSTBASED ON $125.00 PER S.F. Total Project Cost: $ 'oi)�rJ �%� • �U FEE: $ d I -q— Check No.: 3 ej 0-- Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the gu 4anty fund Plans Submitted 1� Plans Waived ❑ Certified Plot Plan Q 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 -� `�Lly 62 7- e COMMENTS (2flje-r�1 �Dl�e- ©" ���y� �� CONSERVATION Reviewed o COMMENTS . % /I. HEALTH # � 1 COMMENTS ' .viewed on Signature 4 Zoning Board of Appeals: Variance, Petition No: ` Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Co Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signa FIRE DEPARTMENT - Temp Dumpster on site yes. Located at 124 Main Street Fire Department signature/date COMMENTS Located 384 Osgood Street no Dimension Number of Stories:_ Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or servicedroprequires approval of Electrical Inspector Yes DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine NOTES and DATA — (For department use ;'r-r� ® Notified for pickup - Date Doc:.Building Permit Revised 2008 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: 7 IMPORTANT: Applicant must complete all items on this page LOCATION Ao Appi -bi T�Wj Al *(&M W 6 1 � 5 Print MAP NO: PARCEL: f ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building VOne family Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Q Septic ❑Well ❑ FFloodplain `D Wetland's 0 Watershed D' .- , Cvl'Water/Sewer . DESCRIPTION OF WORK TO BE PERFORMED: (,dnS-SCQJ'Orl �DOm In Gti�a c�he��' �IcGI� l5 �/Z�! 0-i� 0� hoz4,1o1, �e� or, OWNER: Name: -JVa�3-5980 Address: C) A-pQI��n 54yee f - Ko- Apiwu, vAy a z{6 CONTRACTOR Name: C►vw,e'y cbos�ac�&\ O� 6i� Ph �\c k( Address: 54 (1,q pc&- < Supervisor's Construction License: 5g I 1 Exp. Date: a?- a -7 r1 �) Home Improvement License: ARCH ITECT/ENGINEE 1lLitg4 Exp. Date: Phone: Address: Reg. No. 'i- I)-11 FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ r 51-5 • oo FEE: Check No.: 3 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the gu •anty fund m m X m //mom/� V/ m v m v y d GO Co) 'O O CD n Z y CD r O �� =?o CL y CD 0 o p Q� O Q CD cc C O av y o to C S v CO) O Z o CD 0 CD I C 0 0 Z o, O O _ U2 O r� C/) co C CD n CR c?�o m 2 C. y <. m o W y m PC� n m a MnCD ? a -4 O O 'Go* O o1 O GO CDO .0 O C2 M co O Z�.co O LA. W s= . ay CL ,..' ... o a - mmya CL N 02 y 0Q 0 mavy cc N ,� _ �9 CD w .drt. , = m coy a M GO) �\ WO V C. R �. s� _C .-F CO) CD 02 mow: dam: CL -0, j n d _ca- C O _CD s, o l' o - ro � z �' o trl l I w o ro '' w o aGc o 5 CL � y o a. tv O x Eye z O W omq 0 9 . PL � OM 1 Ct r% o� � 3 Lr, P � E a e - cl� ool .j 46 ...,.. , 3.1 -, '--- rage I O ? uaLe: "'r11Z0I L' 04.33 FlIVI Page:1 of OP ID: BW CERTIFICATE OF LIABILITY INSURANCE oATE;nIramDnvvv; DOCUMENT WITH RESPECT TO 'AIH CH THIS 1?01!10 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTP.ACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the poiicy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endoraement(s)• PRCDLCER 978-459-8681 DONTACT NAME. Francis ProvencherInsuranc=978-454.9343 FAX A enc , Inc. g y -1 arc Na Exc - (AX, Nol>___-_ ----- ;1zh�—----- --— 570 Rogers Street g : ADDR=ss: PRODUCER ---- Lowell, IIIA 01852cL'srel�=�Ioa:GROWCOI ^ --- _ NSUR.ER(S)_AFFORD W. i LOVERAGE NAIL CINSURED - Crowley Construction General I INSURER Northland Insurance Co. -- —--+----- ' Contracting Inc. — SOD Lr 54 Long Pasture Road suRBRB — --- ---- .ir--' i Jr .CDUL:r, ai,IfO'e� - — msuRER C r--- ------- - --- ---- �------- --- N. Andover. MA 01845 i N FES AU", C, INSURER D: I NSURER E----� 7 UMSRELLALIAB L^ INSURER F : - EXCESS LIMB COVERAGES CERTIFICATE NUMBER: tiNIr.FDep• THIS 15 TO CERTIFY THAT THE POLICIES OF INSLRANCE LISTED BELC0 HAVE BEEN ISSUFD TO THE INSURED NAMED AEOVE FOR THE POLICY PERIOL INDICATED. NOn,'U(THSTANDING ANY REQUIREMENT, TERM OR CONDITION OF Arlt CONTRACT OR OTHER DOCUMENT WITH RESPECT TO 'AIH CH THIS CERTIFICATE MAY 5E ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHO)AN NIAYHAVE BEEN RFDL!CED BY PAID CLAIMS. — THE EXPIRATION DATE THEREOF, NOTICE MILL BE DELIVERED IN ILTR TYPe OF INSURANCE -T3tSL�SL16r; --- c — TOLICY EFF Ir R. N POLICY NUMBER tMMIDDIYYY, 1 (MM1DD!YYYY) LIMITS �GENERAL LIA9ILIT Fa :H O CI R EP ry , 11000,000 A IX COWVEPCIAI GENERAL LIA3LIT1 WS053237 12(25109 12/23/10, ` I fir l l - --- - -- - 2u,1 � u; 50,000 f CLq'�"S-n,�� SIO CIJ�tIED r<=(/ y r p } EXCLUDE IJ Cr.cr,x e iI: rI -1;-! P, 1,000,000 --2„00_7,000 --- i I OPTL nuGREGA?= LIN11T APDL ES PER. ! -- - - c PRoJJCT,-col:; F.°T,++— 2,000,000 r-- -�j POU' -Y 11 11 — AUTOMOBILE LIABILITY— : r,e!a,iNED SPJ�='_E LIMIT , �.bIY AUT — SOD Lr ---- .ir--' i Jr .CDUL:r, ai,IfO'e� i N FES AU", C, I i 7 UMSRELLALIAB L^ EA11-:140'.CLF==r CE r EXCESS LIMB RETEN'ThC)"I I --LV'---- -i a V`,:RI:ER$COMPENSATION !! — '-� ! AND EMPLOYERS' LIABILINYJ N ANY PRnPRIETrRI ART cGr>FC!..I:E iJFf:_ T1EIRr-u i-, �C NIA, -I-arUr DE (Mandatory 11.1 NH) .1i e c c ,l .. }.. E_ -I S — EL D,.5 -ASE UESCRIPTION OF OPERATIONS! LOCATI°ONS!'dEHICLES (Attach ACORD 101, .Additional Remarlis Scnedule, if more space is reauiredi — CARPENTRY THE WORKERS COMP CERTIFICAT E WILL BE ISSUED DIRECTLY BY THE COMPANY WITHIN 2 BUSINESS DAYS t CERTIFICATE HOLDER r'AMrP:i I ATInnl NANDOVE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE MILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH TME POLICY PROVISIONS. 120 Main Straet I N, Andover, MA 01845 ALrrHOR.I;.EDREFRESEPITATIVE f ACORD 25 (2009109) G 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print'Leaibly Name (Business/Organization/Individual): Address: '�Lf Lo f) A,& �V q UOLOG . ("+A C 6n onGael C«\J-ra(�nq, Ittic, V.CI City/State/Zip: u% Ale\& • WOr W45 tr45 Phone #: 9 l V 26� 44 3 z' A re u an employer? Che the appropriate box: The Commonwealth of Massachusetts 4.9 I am a general contractor and I Department of Industrial Accidents have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. # Office of Investigations 'ai `{ �' / 600 Washington Street workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its Boston MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print'Leaibly Name (Business/Organization/Individual): Address: '�Lf Lo f) A,& �V q UOLOG . ("+A C 6n onGael C«\J-ra(�nq, Ittic, V.CI City/State/Zip: u% Ale\& • WOr W45 tr45 Phone #: 9 l V 26� 44 3 z' A re u an employer? Che the appropriate box: 1. I am a employer with 4.9 I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. # 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.] officers have exercised their 3. ❑ I am a homeowner doing all work 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. r❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.nOther *Any applicant that checks box # I 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. tContractors 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' kers' compensation insurance for my employees. Below is the policy and job site information. C,J t.b Q k Insurance Company Name: Policy # or Self -ins. Lic.p#: Expiration Date: Job Site Address: �� il`IA1 ` City/State/Zip: 1 41 Attach a copy of the workers' compensation policy declaration page (showing the policy numLr 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 c ti under the pains a andpenalltiiesofpef jury that the information provi/Fde/d above is true and correct: CianntnrP• �1.�JU_,,�. T e4A-�IA A Date -Z//// /! / / D Offlcial 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 #: 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 oviner 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 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 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 surethat the affidavit is complete and printed legibly. The Deparhnent 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 pen-nit/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,meed 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 pen -nits 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. y The Department's address;, elephone and fax number:,_ The Commonwealth of Massachusetts : Department of Industrial Accidents ' Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.govldia Stephen Crowley CROWLEY CONSTRUCTION 54 Long Pasture Road North Andover, MA 01845 978-258-4932 tele/fax crowlevconstruction@comcast.,net Estimate Prepared For: Dr. and Mrs. George Boutselis Dale Street North Andover, MA 01845 978-273-5884 Scope of Work: Construct a 16 ft. wide by 12 ft. long Addition in area where deck exists; we need to remove railings off existing deck and remove mahogany decking boards in area where Addition will be constructed; we will construct a completely new frame floor in area of existing deck; this frame will be constructed out of 2x10 flooring joyces (16 on center) which will enable both floors (in existing bedroom and in new sitting area)to be perfectly flush with each other; we will install a 3/4 in. tong -n -grove plywood glued to new flooring joyces for new Addition; the plywood floors in new Addition will meet the old plywood floors in existing bedroom so once new hardwood floors -are installed they will all be at the same height; framing off with 2x10 flooring joyces (16 on center) and using the existing ones underneath will give us a larger depth so it enable us to install more insulation in floor; the underneath part of deck will need to be insulated; we will install 12 in. of insulation in floor prior to installing plywood under deck for maximum protection of plumbing pipes; this will also allow the sitting area to be well insulated to save on heating expenses. Construction of Addition will consist of 2x6 exterior walls (16 on center) for maximum insulation purposes; we will use 1/2 in. CDX plywood on all exterior walls; looking from inside Addition to rear yard we will install two Anderson windows which will have a rough opening of 34.5 in. by 49.5 in.; we will space those windows out on wall which will allow for a space between both windows for wall television unit; to the right side of Addition we will also have two windows in the center of that wall which will be mulled together; windows will be the same size as the two on other wall (65 in x 49.5 in.); left side wall will have a thermo-true door installed which will be 36 in. wide and 82 in. height which will be all glass and divided light; this is an insulated, vinyl door with aluminum sill. Back to Construction of Addition: The framing of roof will consist of 2x8 ceiling joyce (16 on center); also the construction of roof will consist of 2x10 roof rafters with 5/8 exterior plywood for roof; all perimeter edges of roof will have aluminum drip edge installed and entire roof will have water and ice shield installed; where roof meets existing home we will install all flashing in said areas and install a 30 -yr. architectural shingle to match existing roof. Exterior of Addition will have Tyvek house wrap installed on all exterior walls prior to installation of any windows or doors; after Tyvek and the windows are installed we will wrap around all windows with water and ice shield; prior to installing door on top of Tyvek we will also install water and ice shield; prior to installing any exterior wood corners on house we will wrap the corners with water and ice shield to allow for maximum protection; exterior siding to match existing siding on home; it will be a pre -primed siding to match existing siding; on area of deck where existing deck meets new Addition that entire area will have water and ice shield installed up against existing ACORD. CERTIFICATE OF LIABILITY INSURANCE 11 /0312010 EACH OCCURRENCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS EXCESS LIAR CLAIMS -MADE CERTIFICATE DOES 140T AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. $ THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING IPISURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. RF-ENTION y IMPORTANT: If the certHicate holder is an ADDITIONAL INSURED, the poilcy(ies) moat be endc mad, If SUBROGATION 13 WAIVED, subject. to the y terms and conditions of the policy, certain Policies may require and endorsement A statement on th1E oertificato does not confer rights to the '.NC STATUTORY LIMIT$ OTHER certificate holder In lieu of such endoresment(s). WORKER'S COMPENSATION AND PRODUCER CONTACT NAME: 6210/2011 = L. EACH ACCIDENT PHONE FAX ANY PROPERITOR/PARTNER/EXECUTIVE Y FRANCIS E. FROVENCHER 5 ikC, No, Ext): FAX $ 100.000 (A'C, No): 530 ROG.ERS STP.EET EMAIL (Mandatory in NH) ADDRESS: S 500,000 PRODUCER LOWEL.L, MA 0185" CUSTOMER ID#: DESCRIPTION OF OPERATIONS celcw 226F9G INSURERS) AFFORDING COVERAGE NAIC tt INSURED INSURER A: TRAVELERS INDEMNITY COMPANY INSURER B: THIS REPLACES ANY ?RIOR CERTIFICATE ISSUED TO THE CER T IIICATE HOLDER AF'FI'C TING 4YOR CROWLEY CONSTRUCTION GENERAL, CONTRACTING INC INSURER C: INSURER D: 54 LONG PASTURE ROAD dNSURER E: NORTT3 ANDOVER, MA 01845 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS ISTO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAYS BEEN ISSUED TO THE INSURED NAMED AUOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION CF ANY CONTRACTOR OTHERDOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAT PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DE.CRISED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDLSUBR POLICY EFF DATE POLICY EXP DATE TYPE OF INSURANCE POLICY NUMBER MM'QDYYYYI (MPA 001YYYY) LIMITS LTR INSR WYD GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED CLAIMS MADE OCCUR. PREMISES (Ea.cxcmmmrs) MED EXP (any ane person) PERSONAL && ADV INJURY $ GEN'L AGGREGA'E LIMIT APPLIES PER.: GE14ERAL AGGREGATE POLICY PROJECT LO -1 PRODUCTS (';Q. MP:OP ACG S AUTOMOBILE LIABILITY COMEiNED S!NrLE $ ANYAUTO LIMIT (Ea accidert) ALL OWNED .AUTOS BODILY (N.iLIRY $ SCHEDULE AUTOS (Par person) HIRED AUTOS SODILS' INJURY $ ;Per accident) NON-OAINED AUTCS PROPERTY D.ANIAC•_ (Per accident) UMBRELLA LIAS OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMS -MADE AGGREGATE. $ DEDUCTIBLE $ RF-ENTION y y '.NC STATUTORY LIMIT$ OTHER WORKER'S COMPENSATION AND EMPLOYER'S LIABILITY YIN UB 012ON430-10 0211612610 6210/2011 = L. EACH ACCIDENT S 100,000 ANY PROPERITOR/PARTNER/EXECUTIVE Y E.L. DISEASE - EA FIAPLOYEE $ 100.000 OFFICEWMEMSER EXCLUDED? (Mandatory in NH) E.L. CISEASE - POLICY LIMIT S 500,000 (I yea. ds-mit1A Under DESCRIPTION OF OPERATIONS celcw DESCRIPTION OF OPERATiONSiLOCATIONS/VEHICLES.'RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY ?RIOR CERTIFICATE ISSUED TO THE CER T IIICATE HOLDER AF'FI'C TING 4YOR E;.' S COMF COVERAGE CERTIFICATE HOLDER TOWN OF N ANDOVER 120 MAIN ST N ANDOVER. NIA 0i845 ACORD 25 (2004109) CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Charles J Clark 1988-2009 ACORD CORPORATION. Al I rights reserved. NOV-03-2010 08:48AM FROM -FRANCIS PROVENCHER INSURANCE 1-978-454-9343 T-578 P.001/001 F-009 CORD. CERTIFICATE OF LIABILITY INSURANCE 11/03/x010 THIS CERTIFICATE Is IssuED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder lean ADDITIONAL INSURED, the ppjlcy(lea) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the Polley, oortaln polloloa may roVUlro and ondoraemonL A atatomont on this Certificate does not confer rights to the oertilicate holder In Bou of cUch andorsement(s). PRODUCER CONTACT NAME: PHONE FAX FRANCIS E. PROVENCHER IN (A/C, No, ext): FAX (AIC, No); 530 ROGERS STREET LOWELL MA 01953 36f9G INSURED CROWLEY CONSTRUCTION GENERAL CONTRACTING INC 54 LONG PASTURE ROAD NOR'T'H ANDOVER, MA 01845 E-MAIL ADDRESS: PRODUCER CUSTOMER IDS. INSURER(S) AFFORDING COVERAGE INSURER A: TRAVELERS INDEMNITY COMPANY INSURER B: INSURER C: INSURER D: INSURER E: INSURER F: COVERAGE'S CERTIFICATE NUMBER: REVISION NUMBER: THISISTO CERTIFYTHAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE INSUREDNAMED ABOVE FOR THE POUCV PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACY OR OTHER DOCUMENY WITH RESPECTTO WHICH THIS CERTIFICATE MAV BE rBSUED OR MAY PERTAIN. THE INSURANCE AFFORDED By THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAWS. INSR TYPE OF INSURANCE LTR GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR, OEN'LAGOREGATEi LIMIT APPLIES PER: POLICY PROJECT LOC AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULE AUTOS HIRED AUTOS NON -OWNED AUTOS UMBRELLA LIAR OCCUR EXCESS LIAR CLAIMS -MADE DEDUCTIBLE RETENTION $ ADOLBUBR POLICY EFF OATF POLICY EXP DATE POLICY NUMBER (MMIDO'.YYYY) (MKZDIYYW) MR WVD LIMITS EACH OCCURRENCE DAMAGE TO RENTED $ PREMISES (Ea occurranca) MED EXP (Any one per3on) $ PERSONAL 88 ADV INJURY S OENERALAOOREOATE $ PRODUCTS - COMP/OP A00 $ COMBINED SINGLE 7 LIMIT (Ea accident) BODILY INJURY $ (Por person) BODILY INJURY $ (Per aeeldent) PROPERTY DAMAGE $ (Per accidenq EACH OCCURRENCE AGGREGATE WC STATUTORY LIMITS OTHER NAIC v WORKER'S COMPENSATION AND EMPLOYER'S LIABILITY YIN UA -0120N430-0 02/10/2010 02/1012011 E. L. EACH ACCIDENT $ 1001000 ANY PROPERITOR/PARTNER/EXECUTIVE Y E.L. DISEASE • EA EMPLOYEE $ 1001000 OFFICERIMEMSER EXCLUDED (MmlOelory In NH) E.L. DISEASE - POLICY LIMIT S 5001000 It yea, decvlbe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERA-nGNWLOCAnoNS/VEHICLES/RESTRiCTIONSIsPECIAL ITEMS TIUS REPLACES ANY PIUOR COtTIFICATE ISSUED TO TILE CER'I'I):IC:A'IT! HULOLIG AIA7L•CIYNO WORKERS COMM CUVaKAw, CERTIFICATE HOLDER CANCELLATION TOWN OF N ANDOVER SHOULD ANY OF THE AGOVE DESCRBiED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE 130 MAIN ST WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE N ANDOVER, MA 01845 Charlcs J Clark ACORD 25 (2009/09) 1088-2009 ACORD CORPORATION. All rights mserved- 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: 6rloof?,Ic, Phone LOCATION: Assessor's Map Number Parcel Subdivision Lots) 1 Street St. Number �b ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Conservation Administrator Comments Town Planner Comments 'g�/Date Approved Date Rejected Date Approved Z qL Date Rejected Date Approved Food Inspector -Health Date Rejected Date Approved Septic Inspector -Health Date Rejected Comments Public Works - sewer/water connections driveway permit Fire Department Received by Building Inspector Date home and new Addition prior to installing new flashing both against new Addition and flashing will be put under new mahogany deck prior to siding exterior walls. Exterior of Addition is totally complete, all mahogany decking is refashioned to Addition; we will go inside to finish construction. Interior of Addition will have all necessary electrical installed for plugs, switches and television; we will also install CAT 5 telephone wire which will all for phone and internet connection; the cable television lines will also provide for internet access; we will install reset lighting in Addition. We will install an outside light next to exiting door on deck which can be controlled from exiting door and entering room; reset lighting will also be controlled entering and exiting room. Interior of Addition will have 11.5 in. of insulation in floor (1138), 61/4 (1121) insulation on all exterior walls and 9 1/5 in. (1138) of insulation in ceiling; we will remove door which divides bedroom from sitting area; entire Addition will have 1/2 in. blue board installed on all walls and ceiling; we will install a skim coat plaster on all walls and ceiling; we will match existing ceiling texture in bedroom to sitting area. Where existing door is entering new sitting area - that entrance way will become the cased opening - and we will install all necessary finished work around that entrance way and all windows and exterior doors exiting Addition. We will install a 2 1/4 in. Bruce hardwood floor in entire sitting area; we will have the floor sanded and finished; floor to match existing floor finish in master bedroom. Entire Addition to be completely finished both exterior and interior. We will also install 2 hearing lines in new Addition; 2 hating lines in sitting area under both areas of windows which will be facing the back yard and to the right side of Addition. At these location we will put a 10 in. x 12 in. flooring vent (2). All debris to be removed from site. All necessary permits to be obtained. Notations: The only question for exterior is time -line and getting the exterior painted; we will install larger footings to support deck and Addition of room. As evident by the signatures below both parties have read and agree to the above estimate. Stephen Crowley is fully licensed in the State of Massachusetts. Member of the Better Business Bureau. Total Cost $21,750 CO) 10 CD C7 CD O CL r a� O o p CL Q CD O L M) 0 CD O rrt CD m CD y CD CO) ti T z D r P b 0 C7 N -n rn rn `-J �A ' (o �q O 07, 0 fD 0 M d y w G z H � wGw ? P--4 M y o z ro rC/) z 0 n i ::3 GG x QL c �° OG �O °'" x CD to x x omq 0 9 0 c ! CIA yJ �Y i ! CIA I t— +z+ i wf 1 s ! l i } { r- i y" ice! F t— +z+ i wf 1 s ! l i • kj i t— +z+ , y 1 ! l 90 sow s� MINIMUM BUILDING SST5.4,,, L INE . ....... .. .. 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Date NORTh TOWN OF NORTH ANDOVER •6 OOH A Certificate of Occupancy $ MW Building/Frame Permit Fee $ Foundation Permit Fee $ DLJ, U sACHuat Other Permit Fee $ Sewer Connection Fee $ 6 Water Connection Fee $ -TOTAL Building Inspector 6651 Div. 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LL co, o R O p= Q Z VpZ>NZoQ Np F-Z0V Z= VQ Q F_ z V :E d .n SQoe �(�O W Z NI o � 0 w Z J O 1L d Q O i N N O O S Z >? 1 N LL Z i)00 � m W m Q 0 W ed 0 W �- if) 0. t0 3 m����8 n m� 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: U -A A -C 0>h -A CQ \ Phone G %C ok D LOCATION: Assessor's Map Number Parcel Subdivision )) y/%..,�✓�pr� ��t% Lots) Street �6�-/z (� Q St. Number — ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: k AAzAn. AA AA -� I Date Approved F '-- __ `ti Co servati n Administrator Date Rejected Comments :a r 11:k�Q Date Approved 1 Tnwri-Plannet3 Date Rejected Comments La vn�:t Food Inspector -Health *=� Septic Inspector -Health Date Approved Date Rejected Date Approved Date Rejected Comments 70- w U `- 6 ) 45K Public Works - sewer/mer_ connections S5 16114 r,6 driveway permit L SSU to J J Fire Department ' t. Received by Building Inspector Date OCT 1 51993 FJ 14 r Ci Oj > -0 C:) 171 m " n :r fit ul > —4 f— CD M L4 ni m -A _0j-) 0_ z 00 nt PA z_" > M c. C) CD > r- ni > z A (A cn m ;u 00 C: I'll 0,0 m ch n -n 0 C) > A z Z mIn rn cj 4_4 0 C) cn C 0In -n 0 0 0 "Z 0 u co r Ci Oj > n " n :r fit f— CD M L4 ni IT] 00 nt m > M c. C) CD z X r- > z A cn m ;u C: I'll 0 ch n -n 0 C) > A z Z mIn rn 0 cn C 0In -n 0 0 0 "Z 0 u co j,.4 r- C) r Ci iL 5 In tm ni IT] 00 nt c. 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In, l.6 1 -ti Al: l n; I t3 Ir jet T"i Iii r'I I5 IT i., I1 I 17" JA ♦ ItaN I..-, I, t. lo O'b. 01. 4i L Ir jet Iii r'I I5 II I1 I t. lo O'b. 01. 61 - Ir T z D C') O z cn m m D 0 z v CO) C � O CO)10 0 CD C'7 0 Z N2 CD O �_ C r C')� O CL q CA -0 da cm _ O —•y o Q y C2. O S. CD .0 CA =tCD n CCD Cl) 0 H o CL T Z W • O� = . * CD C •1l =r CD .�•► =r d = y CD O CD CO) O O CD � CD = o �� c CD ca m O of • c CD n a CD O i4 o CD 0 co 0 Er Nit CD CCD CDCD H ca C � O p� y : Q C IC2 >.Cluzl),; H CD O n 6 O ca o rp CD CD ED O�c E oma: CD Z= w .pow �. Co o' 3 � � z 7 n y � o a y � Q' C (D o � �'UQ Ciy r 4 y � w o r 0 �n 0 Q o G Q rt [ t� ( O 12 rt o C CL x 9 O 16 to z I", 0 0 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: 610t)17AC, A. -t t 1 ' LOCATION: Assessor's Map Number Phone Parcel Subdivision Lot(s) S Street -A a (/ t_4yl 5y��� St. Number b ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Conservation Administrator Comments Town Planner Comments Food Inspector -Health Septic Inspector -Health Comments Date Approved Date Rejected Date Approved Z Q"► Date Rejected Date Approved Date Rejected Date Approved Date Rejected Public Works - sewer/water connections _ driveway permit Department Received by Building Inspector Date Location , , ,� I No. � -Date f MORTm TOWN OF NORTH ANDOVER 'Certificate of Occupancy $ 47), y Q i ; x r Building/Frame Permit Fee $ Foundation Permit Fee $ UU lJ 0 t S1CMU5E _ Other Permit Fee $ --�-"— "° Sewer Connection Fee $ Id1)6 Water Connection Fed TOTAL $ . �► v C� l / f Building Inspector 150.00 RAID ' 7211 Div. Public Works Location Je� 5r /D f -5- N0. - Date P No v 6923 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL s Location % (� r..r VV �No. Date�� r.z 04 NORTH TOWN OF NORTH ANDOVER A&L• Op Certificate of Occupancy $ Building/Frame Permit Fee $ s'? CH t<� Foundation Permit Fee $ ue Other Permit Fee $ O& Sewer Connection Fee $ . Wa�gi-dbnnection Fee T lLt ��3% bbilding Inspector 6496 Div. Public Works t ._. P&Arr i=o. M�/Jv— APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. s • A r PAGE 1 MAP INU. LOT NO. '`: 2 RECORD OF OWNERSHIP iDATE BOOK 'PAGE ZONE SUB DIV. LOT NO. LOCATION � � � F - PURPOSE OF BUILDING ,- p� ���ll ince- OWNER'S NAME NO. OF STORIES I,qo SI`ZEJ /&, )S W15-0, OWNER'S ADDRESS BASEMENT OR SLAB y��p YI f Q2ND ARCHITECT'S NAME d V yh- IISSTII'''fC� 10 2X k C)((DvY' SIZE OF FLOOR TIMBERS c. 1 Jl 1 BUILDER'S NAME K �,U1Licl Il Q i p` gho SPAN I L DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS f)( 1- G n DISTANCE FROM STREET _ 11 POSTS DISTANCE FROM LOT LINES - SIDES REAR '. GIRDERS I1 �/�1p,L) AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION e7)II THICKNESS )0'( IS BUILDING NEW WC J* .7 SIZE OF FOOTING 11430 /I % IS BUILDING ADDITION I� �V MATERIAL OF CHIMNEY U 6- A -s i � tj vv IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILL/E'D LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE es IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION, IF ANY INSTRUCTIONS IS BUILDING CONNECTED TO TOWN SEWER ye IS BUILDING CONNECTED TO NATURAL GAS LINE SEE BOTH SIDES a 1..� ...) m Cmczi —0. O V PAGE 1 FILL OUT SECTIONS 1 - 3 Lo Rn a o. O PAGE 2 FILL OUT SECTIONS 1 - 12 m"—Pfa 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_ C4 (S OF OWNER OR AUTHORIZED AGENT FEE /.SAO PERMIT GRAN E 19 I jp 4 ! lER TEL. y8� ��3 aS� �A R. TEL. H �OaS- 6`►-.- 2 TR. LIC. # V 42110k -C I MAY - Q 1994 3 PROPERTY INFORMATION LAND COST lZo G 00 - EST. BLDG. COST EST. BLDG. COST PER do. &0ou EST. BLDG. COST PER ROOM /% SEPTIC PERMIT NO. 4 APPROVED BY BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN b (/0 4 It?, /� BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY STORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES_ LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA - APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. r BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY STORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES_ LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA - APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. `r t CONSTRUCTION 2 FOUNDATION CONCRETE I �yh 8 INTERIOR a PINE HARDW D _ PLASTER DRY WALL UNFIN. FINISH I 2 13 _ _ _ CONCRETE BL K. BRICK OR STONE PIERS 3 BASEMENT AREA FULL FIN. B M'T' AREA '/ 1/2 1/ FIN. ATTIC AREA _ N_O B M FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS II 9 FLOORS CLAPBOARDS B _ 1 ��_ 2 3 _ _ DROP SIDING WOOD SHINGLES ASPHALT SIDING ASBESTOS SIDING CONCRETE EARTH HARDW D COMMCN ASPH. TILE VERT. SIDING _ STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY BRICK ON FRAME ATTIC STIRS. & FLOOR I_ CONC. OR CINDER BILK. WIRING STONE ON MASONRY STONE ON FRAME SUPERIOR I� POOR ADEQUATE NONE 5 !20F 10 PLUMBING GABLE HIP BATH 13 FIX.) AZ GAMBREL MANSARD TOILET RM. )2 FIX.) 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 II 11 HEATING WOOD JOIST PIPELESS FURNArE FORCED HOT AIR FURN. TIMBER BMS. & COLS. Y STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING _ RADIANT H'T'G UNIT HEATERS GAS 7 NO. OF ROOMS OIL ELECTRIC NO HEATING B'M'T 2nd _ 1st I 3rd `r t -n m m Irl =1 o 0 0 ii CD z (n z 0 m 000 X z C m r -4 Ch x T 3NII ONOIV OIOJ o I X z m m x -u 0 Z -n 50 -n m m Irl =1 o 0 0 ii CD z (n z 0 m 000 X z C m r -4 Ch x 3NII ONOIV OIOJ () m 0 a 0 n 0 z m z j -n m m, m o C", > -n. > ONS --1 77 z x 0 o z Z >Z M m 0 0 Z z Zn co ca m m -n r q A) > I z m o m 0 C) < > Z 0 > m N 1 0 m m Ln T -4 0 0 5 z m m z It 3NII DNOIV GIOA OZ z > cz K -7r BCW Z cY W Z Cl) 0 > x 0 z z o z o 0 > < z > m 0 c 0 � T --1 C) z pm 0 C: m M mozz M z -0 WZ -D --� > z 0 0 �n > � M --, c 0 MKZ CD CHARLES KATSIKAS 32 POWER AVENUE RYE NH 03870. Doa05-03-49 LICIV05KSC49031 03-26-1993 'CLASS OPR-MC END. Exv.05-03-1996 REST. / ' 'i SEX M NGT. 5.11 �Lj+•��� ss.N 031.38.0432 ■ Omr Uj j �'�x�orn o -A -4 xA (A � 3 0tjr�-( D(D m-( tjgzgmr rrn� i O�zm� o�o�o (P + f.? �' 0 ZNz 4�ON� rnA�rm Of 0 Cr �o v S1 r m 0 z N —f rn o-� d��oti AALg SU11,DING S IW -UX30, I W tj VI I N �J T 1�-27 m� � rn X Z XLa d R N rn N fit .„ z �U o o cf) � z Orn m Lorn m rn D d rn m> N 7 ' m zD Z no Q W N N m m m or Z N q* NX. M a C V v m U \m m d �= • N O CS y 0 CD `y nO OM n nn 3 CD M= p• T CL •• m CD o �m CD x O co H —� 0lb Z�•CD O y C7 n � o �cm o Com: CD GD H �o� . CL CD CA H .� tU Ccm � Q C r CD d <� H CD H � it � O cc O CD 0 COAR o m C o` CD 0) b. ;. O to CD w- cn O7 p CD UQ rD rD 1 z z o cm w -'p (D o ° p. rt x z � y w � � -n J I Z3 C-) O D r n Z p O y -2 CL r c'J o = Q �• y O 0CD v CD CrCL =r O CD n CCD O CCD C) WW C• CD a y cn DO =C CD CO) i C) cm CD z — � CO) � o T CCD Z O CD � z C ,\ CD m m or Z N q* NX. M a C V v m U \m m d �= • N O CS y 0 CD `y nO OM n nn 3 CD M= p• T CL •• m CD o �m CD x O co H —� 0lb Z�•CD O y C7 n � o �cm o Com: CD GD H �o� . CL CD CA H .� tU Ccm � Q C r CD d <� H CD H � it � O cc O CD 0 COAR o m C o` CD 0) b. ;. O to CD w- cn O7 p CD UQ rD rD 1 CT o cm w -'p (D o ° p. rt x Q WQ� s a 1 z 0 omi 0 9 0 P=h Cl) o � x ; 20 0 CD 0 0 N > va z 0 PATRICK J. DONOVAN ASSOCIATES, INC. claim and Foss . `f�'cljustments P. 0. BOX 110 WAKEFIELD, MA 01880 TEL. (781) 245-5540 — FAX (781) 245-7016 August 14, 2002 Building Commissioner City or Town Hall North Andover, MA 01845 Insured : George A & Antoonia Boutselis Property Address : 90 Appleton Street, North Andover Insurer : Merrimack Mutual Insurance Company Policy Number : HP2087104 Type of Loss : Water Damage Date of Loss : 8/9/02 Our File # : WAP33828 Claim has been made involving loss, damage or destruction of the above -captioned property, which may either exceed $1,000 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 file number. 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. Vern Laws, Adjuster VL/so DP INDEPENDENT INSCR.ANCR MUSTERS of Massachusetts D OmO-0M Z3 O zr3 z m rCiOrr�t -F-( � •"' �ZN�DmO O TomrE- 0 N NDO-4� �Dr 2m DALE zh_� S� Zrm��•Di� MINIhtUtK gUII.D'� 5E18A j 0 D �;' z N N l K�-.Z I rnDo"� rn-- crIjLAAAA $ w 0 J f� - � �� 387 o O m si �7 / 0 n D� �0 - rz 3:NZ Ul DI 4 ('Z-( N G pttl D �1 T�D� N z �' NmOD z r cNn �mE-4 in�_� O �+ co rnrZm I> A g Z - m 70 O 4 rr -t3p 7- rnz O (0 N r NDN m r Z D.- 0 0 r o z m 0 - . d 0 -4 --t ( o (P m p o �� Z R N � (-p4M ul � g 0 rn � m � � m T- � lu iTi .� rn V J m m 1--• r D m m c . 2 —I N N r n� V• -�r n O Ill D , � � � .�" W 70 -D z ti o -0 r o n� � 1 ^'' �i"+:�,V�'^�••-r^�y��.s s�-:..:-�..�a-„7.+�-.,..�„kp`"a�:nq-�;..:-....,, � ;.�„ an„}s:r...r .. . `r Location �2./ No) g Date N TOWN OF NORTH ANDOVER G'\0 , Certificate of Occupancy $ "-"'--- • : Building/Frame'Permit Fee $ s�CHuse Foundation Per it Fee $ Other Permitgee $ �.��o d Sewer Connection Fee $ Water Connection Fee $ 6 �.J-) y TOTAL $� U /g Building Inspector ry _ 66!63 Div. Public Works _ V'iF _� ....-.+'?ms's.-..i •.:;r `Ww�'�'�="�.�.3y:.-s.-. :.r as"ti ..,xPMEMEMPEN �i.n" Location ���� f O�c l "' 57;, 't2FT— No. 400 ; r--9 Date g p I i° - 7483 Building Insp v� Div. Public Works TOWN OF NORTH ANDOVEFF Certificate of Occupancy $ Building/Frame Permit Fee $ 3 vt'S"b Foundation Permit Fee Other Permit Fee $ —" Sewer Connection Fee $ 70 Water Connection Fee $ m TOTAL $ Building Insp v� Div. 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Z,a NZ ZU �nlf Q OU OUma -111 ISI ' I I I I� N �I -0 O t7 W p mTTI — O Z w 2 O I I QaWU L) t; W Z °Z_ �o� N m Q a o u= S V F p = V Z Z u 0 Z LLLLLL: °' Owi°a" a Y F Zd'w m Z � Z W OC W�Z �QyOv�FWpo I \ � O Z _Z N _Z Z Z LL �% CO O° O°=NQ,v�ni°V�OOUZONv 0n 0000 V 00 Z°Z w 0UVVVZOOo3: !» ,Q= ZIS U°3QQiNv,)uN Z f s 0 O O d L FORM U - IAT 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: U4 A-5 Cum C. Phone G %r �� � LOCATION: Assessor's Map Number Subdivision , Street Parcel Lot (s) St. Number ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Date Approved l q Cb1iservAi n Administrator Date Rejected Comments Y� Date Approved Town Planne Date Rejected Comments C 1 Food Inspector. -Health �10A --i- Septic Inspector -Health Date Approved Date Rejected Date Approved Date Rejected Comments 7' L)eo/li' c,�-- Public Works - sewer r- connections - driveway permi I _ SU?� Fire Department Received by Building Inspector Date u OFFICES OF: APPEALS BUILDING CONSERVATION HEALTH PLANNING NORTH ANDOVER ✓` DIVISION OF' PLANNING & COMMUNITY DEVELOPMENT KAREN H.P. NELSON, DIRECTOR 120 Main Street North Andover. Massachusetts o 1845 (617) 685=4775 r %. In accordance with the provisions 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 111, S 150A. The debris will be disposed of in: -(IZcation of Fadlity) 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. /Ad ;PA C�z n 0 z cn m 0 z z D C2 CO) 'v CD C � d 'v O n Z CO) E O 'v CL r 0 C O ? C d �• CO) �M c v CD CDCLO O cr CD CD O CD C O rA Qv y cc CD F v CO) O CD Z o CD 0 CD = _ d -•N O Q N eco y am C) fG O 0 C2 •� M D N CL CD Z =r.0 H ..4_ O G TI ,••. 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