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HomeMy WebLinkAboutMiscellaneous - 91 BELMONT STREET 4/30/2018i - Town of North Andover D.S.A. — Zoning Compliance Form 978-688-9545 This form must be reviewed with the Inspector of Buildings. Office Hours are Monday -Friday 8-10 am, and 1-2 pm Monday -Thursday. Name of Business: .� � GCGcth Addres's of Business: j/ &� Zoning District : Map. 0 (3 Lot 1-7 Phone: Email ,� / Nature of Business: Itl GlneA— Do you own this property? Yesy If no, written permission is required from your landlord. Will you have clients coming to this property? Yes No Will you have any employees? Yes J No Will you have any major deliveries? Yes NoyJ Description of Business Activity (Must be Completed) C� //a /7 Signature of Applicant For Signage Refer to North Andover Zoning Bylaw Section 6 The proposed use is an allowed use in this zoning district. Issued By ate 05 l �-l�- North Andover MIMAP May 17, 2017 5�C 69 SUTTON ST 0 r 5��� f Lawrence 67 SUTTON ST 13 McCABO 65 SUTTON ST 013,E 0 06 115 McCABE Cq rr __ 46. Q5 McCABE CT BE CT r' a 7 MCCABE CT 8 MCCABE CT 12 McCABE 2 M CABS CT' '•� 013.0-0034 4 C MCABE GT 'BE L- 12 !PC C Il Cc- BE ti + 87 BELMONT ST I'S 013.0-0007 ` 87 BEV -N ST 87 BELMONT St 105 BELMONT ST 008.0-0003 t e� 01'3:0 0_02 74'BELMONT 008.0-0004 �e\C�0 (W MARBLEHEAD ST 0.13.0.-0029 82 BELMUNT ST 8 MARBLEHEAD ST 88 BELMONitT SIT 94 ois.o-ooss 300 BE ... ST 0) LM � f;013:0�0033�1 008.0-0005 - N 0 MVPC Be Zoning Overlay Zoning ® Municipal Boundary B Adult Entertainment Oistric E3 Machine Shop Village Ove ! Busine 0 Busine a 1 District s 2 District – Rail Une Interstates 0 Watershed Protection Dist 0 Historic Mill Area 0 Busine 0 B.alne, s 3 District 4 District Horizontal Datum: MA Stateplane Coordinate System, Datum NAD83, Meters Data Sources: The data for this map was produced by Merrimack = Interstate — Major Road 0 Medical Marijuana Downtown District 0 Gainer Planne s Business District Dev �iOR7M f O +mac , a,N < r aa� 00 Valley Planning Commission (MVPC) using data provided by the Town of North Andover. Additional data provided by the Executive Office of Environmental ARairs/MassGIS. The information depicted – Roads l i Easements Historic District trio L7 Osgood Smart Growth (40 0 Hydrographic Features 8 @ Corritl 0 Cortidg 0 Conido I, Development Dist Development Development Dist Development Dist p I 1 District �� p A, N M on this map is for planning purposes only. It may not be adequate for legal boundary interpretation. THE TOWN LI NORTH ANDOVER MAKES or NO MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING ❑ Parcels – Streams :n Industri 12 Distrix i THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY r- Wetlands 0 Industri 13 District �o * {r OF THESE DATA, THE TOWN OF NORTH ANDOVER DOES NOT R Exempt Lands p 0 Industn Reside I S DisVic[ i District �� •• ,,�a Qj, ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION 6 ce Reside aB Reside ce 2 District ce 3 District S$A�MUSE de ce 4 District - 1 _ 74 ft n '�j} •dece Y 6 District .• vn,ege esidential District NORTH ANDOVER BUILDING DEPARTMENT 27 CHARLES STREET Tel: 978-688-9545 Fax: 978-688-9542 DATE:— NAME— ATE:NAMEJZx ko C 4 ,c—, ADDRESS ...._ ZONING DISTRICT: Z- TYPE OF BUSINESS: t L,) � U BUILDING LAYOUT PROVIDED: YES x NO AVAILABLE PARKING SPACES: y ZONING BY LAW USAGE: YES NO BUILDING INSPECTOR SIGNATURE Location No. 6) Ec5 "`1 Date 2 3 Check # 3-,�e 285 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee �N $ 30 TOTAL $ �11 A .. . � Build,IK6In pector i r w LU 0 cl 2 z w 0 z LL 0 z 0 OVER * *3� 0 4% U) o O = cu —J Ao O.L 46 U) C,e)�: cle) = cu —J C\l CY) co m E 00 c .0) @ cu (9 op cu a- Cl) Ln _0a) O E C) 0 0 0(D CU 0 0 LU cn 0 NCAcu cu C: F— E C.2 Im �5 CL OM > L- U) FE 0 0 a) a) a. LU m 0 Q 0) ICU C: cn cu > E z X U-) 0 cn 0 cn 0 ch L 0 iE U) a) z A) a) > 0 = 0 > U) 4— ci cy C: r— CO 0 < CY) 4- M .2 -t� 0 0 z caa) (D -r 06 -a — Cf) 0 z 06 a) c- C: clS C: CU LLI a -cu (D 6 0 4z z 2 -FH m CU < 4- a) 4— 0 co 0 CD a) E cu o5 o Lp LO t: 4� a) . It CO 4-- N o 0 T— C) CN E U) E CY) C%j Lo T— -I.- C: 0 C: cy) N ui 0 E CD 0 — (D U) C> cu CD z -6.1 =e- 0 0 00 W co 0 r , 00) o L— bi 2 .— < ui EE N > ca 0 75 0 a. 0 0 UO) U C3 0 G M 0 '6 9 W Z- :3 6 Fd ® ao0a o, eC � s m.I°a 0 0 en �Oa���'o o v 0 'v �0 v � b QJ •N m iL•+ r C 5Cc N ea as CL � t o � � o a c� iii O CLa CL tUCL O �► A as rCL d O rJ G M 0 '6 9 W Z- :3 6 Fd ® ao0a o, eC � s m.I°a 0 0 en �Oa���'o o v 0 'v �0 v t E I z ffjy� pai o�� ° . o O a i as ® C.i m o a c� iii O t E I z ffjy� pai Xg - Pig� 7j; _ �� � \ \ 0 , M CL CL 10 � \� \ . .� . LO Xg 7j; 0 M CL CL 10 LO co X co m C-4 3-545 r Date...... . I ........... NORTH TOWN OF NORTH ANDOVER 0 0 PERMIT FOR MECHANICAL INSTALLATION �9SSAC MUSEtI( This certifies that . . ........ has permission for mechanical installation,2. in the buildings of. .......................................... at a ............. No h Andover, Mass. Fee ? s -4t� Lic. No.,,,2.1.� .... _I .......... GA INSPECTOR WHITE: Applicant CANARY: Building Dbep�t. PINK: Treasurer Commonwealth of Massachusetts Sheet Metal Permit Date: 162- / *_ N Estimated Job Cost: $ lf� Plans Submitted: YES NO Permit # Permit Fee: $_23H, Plans Reviewed: YES NO Business License # 211 Applicant License # 13 y O H Business Information: Property Owner / Job Location Information: Name: Cel[kQh fI�C CrP .�� ��v�_j Name: /� 1 idSy 4113` Street:-?( &60(t,. S -t Street: q1 1905-/o 15�, City/Town: City/Town: /Ifr, lot, Telephone: (� 7if 1 %�9 �a3 i Telephone: Photo I.D. required / Copy of Photo I.D. attached: YES NO Staff Initial J-1 / I-11 ,-' nrestricted license J-2 / M -2 -restricted to dwellings 3 -stories or less and commercial up to 10,000 sq. ft. / 2 -stories or less Residential: 1-2 family AV Multi -family Condo / Townhouses Other Commercial: Office Retail Industrial Educational Institutional Other Square Footage: under 10,000 sq. ft.over 10,000 sq. ft. Number of Stories: Sheet metal work to be completed: New Work: Renovation: HVAC _Metal Watershed Roofing Kitchen Exhaust System Metal Chimney / Vents Provide detailed description of work to be done: SFeI/gIF0 6&d 400 a(r -i Air Balancing INSURANCE COVERAGE: I have a current liabilitv insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes ta No ❑ If you have checked Yes, indicate the type of coverage by checking the appropriate box below: A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box[], I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General L 's. Duct inspection required prior to insulation installation: YES NO Date Date By Title City/Town Permit # Fee $ _ Inspector Signature of Permit Approval Progress Inspections Comments Final Inspection Comments Type of License: ❑ Master ❑ Master -Restricted ❑Journeyperson Signature of Licensee ❑ Journeyperson-Restricted License Number: ! 4W6.1 -t ❑ Check at www.mass.gov/dpl OP ID: PS "' CERTIFICATE OF LIABILITY INSURANCE DATE TYPE OF INSURANCE 10/311/2014/2014 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 is an ADDITIONAL INSURED, the policy(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 endorsement(s). PRODUCER Foster Sullivan Insurance 163 Main St. North Andover, MA 01845 Sullivan CONTACT Pete Sullivan HONE a/c No Ext :978"686'2266 n/c Na :978-686-6410 -MAILStephen DDREss: psullivan@fostersullivangroup.com [A— RODUCER CALLA -1 CUSTOMER ID #: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: LIBERTY MUTUAL INS CO 23043 INSURED Callahan A C and Heating Services, Inc. Kate Callahan INSURER B: GUARD INSURANCE COMPANY INSURER C: 91 Belmont Street North Andover, MA 01845 INSURER D: INSURER E: PERSONAL &ADV INJURY $ 1,000,00 INSURER F: GENERAL AGGREGATE $ 2,000,00 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED 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 CLAIMS. INSR LTR TYPE OF INSURANCE ADDLr UBR POLICY NUMBER POLICY EFF MMIDD/YYYY) POLICY EXP I(MM/DD/YYYYI LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE Fx_] OCCUR CONTRACTUAL LIAB CBP4016154 09/25/2014 09/25/2015 EACH OCCURRENCE $ 1,000,00 PREMISES T Ea occurrence $ 100,00 MED EXP (Any one person) $ 5,00 PERSONAL &ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GENT AGGREGATE LIMIT APPLIES PER POLICY rXJERC0j LOC PRODUCTS - COMP/OP AGG $ 2,000,00 A AUTOMOBILE LIABILITY ANY AUTO BA4544035 09/25/2014 09/25/2015 COMBINED SINGLE LIMIT $ 1,000,00 (Ea accident) BODILY INJURY (Per person) $ X ALL OWNED AUTOS BODILY INJURY (Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE (PER ACCIDENT) $ X HIRED AUTOS X NON -OWNED AUTOS $ $ A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE CU8809334 09/25/2014 09/25/2015 EACH OCCURRENCE $ 5,000,00 AGGREGATE $ 5,000,00 DEDUCTIBLE $ B RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVEY/❑NN OFFICER/MEMBER EXCLUDED? (Mandatory b ander If yes, describe under DESCRIPTION OF OPERATIONS below N/A CAWC586931 09/25/2014 09/25/2015 $ WC STATU- OTH- TORY LIMIT X ER E.L. EACH ACCIDENT $ 500,00 E.L. DISEASE - EA EMPLOYE $ 500,00 E.L. DISEASE - POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) fax # 978 688-9542 i`CDTICIr`ATG LIAI - _ _ _ _ _ TOWN OF NORTH ANDOVER BLDG. DEPT. 1600 OSGOOD STREET BLDG. 20 / SUITE 2035 NORTH ANDOVER, MA 01845 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 Izfaa-ZUU!J ACUKU CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD Page 1 Residential Heat Loss and Heat Gain Calculation 12/17/2014 In accordance with ACCA Manual J Report Prepared By: Callahan A/C & Heating For: Franciosa Builders (First Floor) 91 Boston Street North Andover, MA 01845 Design Conditions: Lawrence Indoor: Outdoor: Summer temperature: 70 Summer temperature: 87 Winter temperature: 70 Winter temperature: 0 Relative humidity: 50 Summer grains of moisture: 95 Daily temperature range. -Medium Building Component Sensible Latent Total Total Gain Gain Heat Gain Heat Loss (BTUH) (BTUH) (BTUH) (BTUH) Infiltration 3,809 5,540 9,349 22,709 Ceilings 6,615 0 6,615 11,975 Windows 10,698 0 10,698 10,720 Floors 1,773 0 1,773 10,342 Duct 0 0 0 6,412 Walls 1,231 0 1,231 4,184 Fireplaces 0 0 0 1,996 Glassdoors 1,546 0 .1,546 1,790 Doors i 119 0 1 119 403 Skylights 0 0 1 0 0 Misc i 1,200 0 11,200 0 People 1,500 1,150 2,650 0 Whole House 28,491 6,690 35,181 70,531 (3 tons I HVAC -Calc Residential 4.0 by HVAC Computer Systems Ltd. 888 736-1101 Load calculations are estimates only, actual loads may vary due to weather and construction differences. Page 1 Residential Heat Loss and Heat Gain Calculation 12/17/2014 1 0 0 In accordance with ACCA Manual J 1,500 1,150 Report Prepared By: Floors 0 0 1 0 0 Whole House Callahan AIC & Heating 5,633 26;715 42,639 ( 2 tons ) For: Franciosa Builders (Second Floor) 91 Boston Street North Andover, MA 01845 Design Conditions: Lawrence Indoor: Outdoor: Summer temperature: 70 Summer temperature: 87 Winter temperature: 70 Winter temperature: 0 Relative humidity: 50 Summer grains of;moisture: 95 Daily temperature range:Medium Building Component Sensible Latent Total Total Gain Gain Heat Gain Heat Loss (BTUH) (BTUH) (BTUH) (BTUH) Infiltration 3,082 4,483 7,565 15,184 Walls 2,877 0 2,877 9,779 Ceilings 4,157 0 4,157 7,098 Windows 9,466 0 9,466 6,701 Duct 0 0 0 3,877 Skylights 0 0 I 0 0 Glassdoors 0 0 j 0 0 Doors 0 0 0 0 Misc 0 0 0 0 Fireplaces 0 0 1 0 0 People 1,500 1,150 21650 0 Floors 0 0 1 0 0 Whole House 21,082 5,633 26;715 42,639 ( 2 tons ) I I I HVAC -Calc Residential 4.0 by HVAC Computer Systems Ltd. 888 736-1101 Load calculations are estimates only, actual loads may vary due to weather and construction differences. 1 I I I J sem. Callahan A/C & HEATING SERVICES 91 Belmont Street North Andover, MA 01845 www.callahanac.com 978-689-9233 TO: JOE FRANCIOSA 8 NEWELL FARM ROAD WEST NEWBURY, MA 01985 PROPOSAL PROPOSAL M 1.10010 DATE: 12/17/2014 i REP: KJM JOB LOCATION: 91 BOSTON ST. NORTH ANDOVER, MA DESCRIPTION Total INSTALLATION OF NEW HEATING AND AIR CONDITIONING SYSTEM (GAS PIPING AND ELECTRICAL NOT INCLUDED) CONSISTING OF THE FOLLOWING:(FIRST FLOOR) A_GOODMAN MODEL #GMSS968004C GAS FIRED 96% HOT AIR FURNACE 80,000 BTU B_GOODMAN MODEL #GSX13361 13 SEER 36,000 BTU CONDENSER (R410A) C_GOODMAN MODEL #CAPF3636C 36000 BTU COIL D_FREON LINE SET E_ELECTRICAL BY OTHERS F_GAS PIPING BY OTHERS G_PVC FLUE AND COMBUSTION AIR PIPING THROUGH SILL PLATE TO OUTSIDE H_30 x 30 CONDENSER PAD [PRECAST] I_CONDENSATE PUMP AND PIPING J_INSULATED DUCTWORK WITH FLEXIBLE BRANCH LINES TO REGISTER K CENTRAL RETURN REGISTER FOR FIRST FLOOR L_APRI , AIR HEATING AND COOLING MODEL # 8463 DIGITAL THERMOSTAT M SUPPLY REGISTER FOR EACH ROOM INSTALLATION OF NEW HEATING AND AIR CONDITIONING SYSTEM CONSISTING OF THE FOLLOWING:(SECOND AND THIRD FLOOR) A_GOODMAN MODEL #GMSS9606043B GAS FIRED 96% HOT AIR FURNACE 60,000 BTU B_GOODMAN MODEL #GSX13241 13 SEER 24,000 BTU CONDENSER (R410A) C_GOODMAN MODEL #CHPF2430B COIL D_INSULATED DUCTWORK WITH FLEXIBLE TAKEOFFS E ELECTRICAL BY OTHERS INCLUDING LOW VOLTAGE WIRING PAYMENT TERMS SEE PAYMENT SCHEDULE Total All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. All covered by Workman's Compensation Insurance's. Equipment warranty by manufacturer. Contractors labor warranty for one year. AUTHORIZED SIGNATURE: DATE: CUSTOMER ACCEPTANCE: DATE: * * A signed copy of this proposal and deposit must be received for us to schedule this installation. (This proposal may be withdrawn by us if not accepted within 30 days.) Authorized dlaire` Partner in Comfort -f' Page 1 r Callahan A/C & HEATING SERVICES 91 Belmont Street North Andover, MA 01845 www.callahanac.com 978-689-9233 TO: JOE FRANCIOSA 8 NEWELL FARM ROAD WEST NEWBURY, MA 01985 PROPOSAL PROPOSAL M 110010 DATE: 12/17/2014 JOB LOCATION: 91 BOSTON ST. NORTH ANDOVER, MA REP: KIM DESCRIPTION Total F_NEW APRIL AIR DIGITAL HEAT/ COOL MODEL # 8463 THERMOSTAT G_SUPPLY REGISTER FOR EACH ROOM H CENTRAL RETURN REGISTER I_B-VENT FLUE THROUGH ROOF J_GAS PIPING BY OTHERS K_PERMIT .BY PLUMBING CONTRACTOR L_REQUIRED DRAIN PAYMENT TERMS SEE PAYMENT SCHEDULE Total All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. All covered by Workman's Compensation Insurance's. Equipment warranty by manufacturer. Contractors labor warranty for one year. AUTHORIZED SIGNATURE: DATE: CUSTOMER ACCEPTANCE: DATE: * * A signed copy of this proposal and deposit must be received for us to schedule this installation. (This proposal may be withdrawn by us if not accepted within 30 days.) Authorized rilairee Partner in Comfort Page 2 ,f Callahan A/C & HEATING SERVICES 91 Belmont Street North Andover, MA 01845 www.callahanac.com 978-689-9233 TO: JOE FRANCIOSA 8 NEWELL FARM ROAD WEST NEWBURY, MA 01985 PROPOSAL PROPOSAL #: 110010 DATE: 12/17/2014 JOB LOCATION: 91 BOSTON ST. NORTH ANDOVER, MA REP: KIM DESCRIPTION Total PAYMENT SCHEDULE: _ FIRST PAYMENT DUE UPON COMPLETION OF THE ROUGH 14,825.00 BALANCE DUE UPON COMPLETION 4,800.00 PAYMENT TERMS SEE PAYMENT SCHEDULE Total $19,625.00 All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. All covered by Workman's Compensation Insurance's. Equipment warranty by manufacturer. Contractors labor warranty for one year. AUTHORIZED SIGNATURE: DATE: CUSTOMER ACCEPTANCE: DATE: ** A signed copy of this proposal and deposit must be received for us to schedule this installation. (This proposal may be withdrawn by us if not accepted within 30 days.) Authorized A0111aire. Partner in Comfort Page 3 Date ... 3! f. ........ / TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .6 el4-74C / � has permission for gas installlatii n in the buildings of . �`'Ct-�r/?'�.. /f ...................... at ... %" ..^ ........ ,North over /M ss.1 Fee.?' Lic. No. fSZ%Z.. ... ........ . GAS INSPECTOR Check # SOS13 8431 { The Co7nrizonwealth ofMassachitsetts ' Department of Industrial Accidents i17, Office of Investigations �r-�'�__, 1 � 6dll �rnshingimz 5"h'et"t �\ r 4oston, Mei 02111 \ wwjv.rrzass.gov1d!a Workers' Compensation Insurance Affidavit: Builders/Contractoa•s/I:lectriciaus/Plumbers Applicant Information Please. Print Legibly NTt1.Ille (Business/Orguiization/Individual): Address: CS ; 1/,//tf 7iLlIf/'ihone #:ip: _City/State/Z Are you an employer? Check the appropriate box: 1. 1 am a employer with 5' 4' ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors �. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. slip and have no employees These sub -contractors have working for me i1 any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 3. ❑ 1 am a homeowner doing all work officers have exercised thein myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] I, J .] 2„ Type of project. (required): 6. ❑ New construction 7. ❑ Remodeling, S. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs oi- additions 11.[ Iumbing repairs or additions 12. ❑ Roof repaixs 13. ❑ Other -____ *Any applictult that checks box #1 must also fill out the section below showing their workers' compensation pulicy information. 1 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those cnlities have caaployees. If tite sub -contractors have employees, they must provide their workers' comp. policy number. I ant an employer that is providing workers' corrzpensation iazsurance for my employees. Below is rife policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: 7 () (2 Expiration Date: Job Site Address: A t,`ootj Ciiy/State/Zip:�r •/�/Vyt'k2s(Z Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required raider Section 25A of MGL c. 152 can lead. to the imposition of criminal penaliies of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties i1 the form of a STOP WORK OR DER 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 lavestigations of the DIA. for insurance coverage verification. Ido herebh cert under the pains and penalties ofperjury that the information provided above is true and correct. Y- 2 7 -mac'// Phone #: f _� ,�',s' - j OJfu al use only. Do not write in this area, to be completed by city or town official City or Town: Permit/t.i� ease # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. 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A [i �,�..�-_ � � .- j 1. � i 1 � j 1' � ,i f� � � . � \� �V l� .__-� -�""_ � p . t r �1 � 1 I 1 1 Town of North Andover D.B.A. – Zoning Compliance Form 978-688-9545 This form must be reviewed with the Inspector of Buildings. Office Hours are Monday -Friday 8-10 am, and 1-2 pm Monday -Thursday. 5/ - /7//7 Applicant Name of Business: /2 JX,M4?A Address of Business: Ilro177`� ��� Zonin District Map, (3 Lot d Phone ,? 6f9 e,2,,0 Email'mo i //,/, /W? al Nature of Business: AL' AlIn.')` K ej— 61/ Do you own this property? Yesy If no, written permission is required from your landlord. Will you have clients coming to this property? Yes No Will you have any employees? Yes !! No Will you have any major deliveries? Yes NoyJ Description of Business Activity (Must be Completed) ,era 1r- Ga /2 Signature of Applicant For Signage Refer to North Andover Zoning Bylaw Section 6 The proposed use is an allowed use in this zoning district. Issued By ate 0 � l-`- North Andover MIMAP May 17, 2017 CjC.Cee� 69 SU ON ST Lawrence 67 SUTTON ST 13t.MCCABE'C1 65 SUTTON ST ,r.. 013.0=0006 15fm&C BE Cl 5 MCCA VCTz 6'•McCABE-CTr 7 1E).CT 8 MCTA%E, CT` .12, ZCABEECI 2-McCABE'CT 013.0-0034 4 MCCABE;CT .12 MCCABE CT` 3 MCCABE+CT 87 BET ST IIis 0:13.0-000/7 87 BELMONT ST 87 BELMONT ST 105 BELMONT ST 008.0-0003 °lye°°27 74 BEL'MON,, °��5�<e 008.0-0004 8 MARBLEHEAD ST [O 31�Oo0029 ' f82 BELMONT STS `' 8 MARBLEHEAD ST 88�_0:NT ST" ;. R4 (013 0-0031 100 BELMONT ST 013:0 0033 008.0-0005 � N (008.0- 06} [j MVPC So Zoning Overlay Zoning 13 Municipal Boundary 13 Adult Entertainment Distric ❑ Machine Shop Village Ove ." Busine Q Mine s 1 District s 2 District Horizontal Datum: MA Stateplane Coordinate System, Datum NAD83, — Rail Line ® Watershed Protection Dist 0 Historic Mill Area R Busine ■ Businei s 3 District Meters Data Sources: The data for this map vias produced by Merrimack Interstates = Interstate — Major Road E3 Medical Marijuana © Downtown Overlay District 0 Historic District Y Genera O Planne V Condo s 4 District Business District Commercial Dev Development Dist NOWTI{ Of 'ut c, q� ? 4�� r� •e 00 Valley Planning Commission (MVPC) using data provided by the Town of North Andover. Additional data provided by the Executive Office of Environmental Affaim/MassGIS. The information depicted an this map is — Roads i r Easements Osgood Smart Growth (40 Hydrographic Features a Comdo C Cortido Development Dist Development Dist 3 O --• - �' L 1a A for planning purposes only. It may not be adequate for legal boundary definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING ❑ Parcels Streams Streams '-: Industri i in I 1 District 12 District * i « * THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY OF THESE DATA, THE TOWN OF NORTH ANDOVER DOES NOT Wetlands N Indusiri 13 District +� o ��� ! ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF + Exempt Lands N Induslit Reside 1 S District ce 1 District _ �w 'Tf °wwr�o �����,� �SSAGMUSEt THIS INFORMATION Reside ce 2 District R? Reside ce 3 District de 4 Dist 1 " = 74 ft de ode erict s D1sstrlc ce 6 District 1 } tk f rrt Y �I a e:Je e e e r v tai y� at div i ❑ MVPC Bo Interstates Interstate — Major Road Roads t-# Easements I Parcels 1"=40ft Horizontal Datum: MA Stateplane Coordinate System, Datum NAD83, Meters Data Sources: The data for this map was produced by Merrimack t 14ORTN q Valley Planning Commission (MVPC) using data provided by the Town of O e e tiNorth Andover. Additional data provided by the Executive Office of •p. OO Environmental Affairs/MassGIS. The information depicted on this map is L for planning purposes only. It may not be adequate for legal boundary to definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY c+ ♦ OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT \o ' • ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF 40�. THIS INFORMATION 1