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HomeMy WebLinkAboutMiscellaneous - 91 WOODSTOCK STREET 4/30/2018.b -- 10000 Date TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .un,�,� 7 , ,} has permission to perform plumbing in the buildings of .. .act ��,1 ��'. • , . • ......... . at .... .! ,u f1:2.yt L 1` ... . • . , , . , North Andover, Mass. Fee . .. Lic. No. '�. R-12 g.. /✓% ............... .. . Check # PSP PLUMBING INSPECTOR ,rn, 5�2-113 P TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY r'_� MA DATE / (PERMIT # JOBSITE ADDRESS OWNER'S NAME OWNER ADDRESS 1 TEL FAX OCCUPANCY TYPE COMMERCIAL 0I EDUCATIONAL Q NEW: EJ RENOVATION:0 REPLACEMENT:,a FIXTURES 7 FLOOR BSM BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR /AREA DRAIN INTERCEPTOR (INTO KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET WASHING MACHINE CONNECTION WATi j WATER OTHER HEATER ALL TYPES RESIDENTIAL& PLANS SUBMITTED: YES [0 NOEj 10 1 11 1 12 1 13 1 14 I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES R'N0 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYP F COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND M 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 0I AGENT J� SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate 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. PLUMBER'S NAME° -�—LICENSE # SIGNATURE MP 0 JP 0— CORPORATION 0# __ PARTNERSHIP0#� -� • LLC a _ j COMPANY NAME ;ADDRESS J _-- _ CITY _ ,y1 } STATE � � ,` al � ZIP I I d` $'y TEL 9;q — // FAX ;CELL EMAIL oF-1 z N Eld } w CL Cd w LL ti The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): Address: City/State/Zip: 1)1,5- y PhoneS-/y 3X 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).* have hired the sub -contractors 2a 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. ❑ Building addition 10. F1 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roofrepairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they aie 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 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 Name: 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. Ido hereby cerp under thepainMndpenalties ofperjury that the information provided above is true and correct, Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone #: 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 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 bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial .Accidents Office of Investigations 600 Washington Street Boston., MA. 02111 Tel, # 617-72.7-4900 ext 406 or 1-877rMASS.ATI Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia -y :'O [L H -i F IVI ISSACHUSETTS PLUi LUMBERS AND GASFITTERS LiCEN8ED AS A JOURNEYMAN°"P.LUN4901 f ISSUES THE ABOVE LICENSE TO: LEDAND4' GUT_MAN Id LlPPoLD ST sN a HEIAUEN . MA 0 1844-5130 Y t 3.1728 01:/01:14 1'r115, .<z r� i Date... r TOWN OF NORTH ANDOVER ON PERMIT FOR WIRING This certifies that ....... x1a tp...... ............ t has permission to perform .......... .................................. wiring in the building of ........(..`.Y...0..0...................................................... at .... ....... 7. :Torth Ando er ass. . ..... Fee.� ............ Lic. No. .............. LECTRICAL INSPECTOR Check # 4- 5 o" I &07=M5'4Z?W 617 '00414xent 4 ;Vu6&& 54a 4 BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Official Use Only Permit No. t Occupancy & Fee Checked APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00 (Please Print in ink or type all information) Town of North Andover The undersigned applies for a permit to perform the electrical work described belowJ-. Location (Street & Number { / W d Qd J � (—,I( P Owner or Tenant LaJIL 0 Owner's Date jti a3 To the Inspector of Wires: Is this permit in conjunction with a building permit Yes IV No ❑ (Check Appropriate Box) Purpose of Utility Authorization Existing Service Amps �Voits Overhead Pe Undgmd ❑ No. of Meters New Service Amps Voits Overhead ❑ Undgmd ❑ No. of Meters Number of Feeders and Ampacity f �� O Location and.Nature of Proposed Electrical Work OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent NO = haves ed valid roof of same to the Office YES= NO = ff you h ve ca�ked YES please indicat the type of cover a by hecking the appropriate box Aq"S—U = BOND = OTHER = (Please Specify) � �� bvn7 MP &j / © Gi If (Expiration Oate) Estimated Value of Electrical Work$_ Wnrk to Atart Inspection Date Resquested Rough Final LIC. NO. Z — � � ry PJ rl e(/r _ Signature ���,✓^�� LICA. NO. Z qL T 7� C% L/ if � ,[� Bus. Tel No. Address ! � T Alt Tei. No. OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusepp General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) Telephone No. PERMITTEE $ ' (Signature of Owner or Agent) Total No. of Lighting Outlets No. of Hot fuse No. of Transformers KVA Above ❑ In ❑ No. of Lighting Fixtures Swimming Pool grnd ❑ grnd ❑ Generators KVA �%' No. of Emergency Lighting No. of Receptacles Outlets v' No. of Oil Burners Battery Units No. of Switch Outlets No of Gas Burners FIRE ALARMS No. of Zone No. of Detection and Total No. of Ranges No of Air Cond Tons Initiating Devices j Heat Total Total No. of Diposal No. Pumps Tons KW No. of Sounding Devices No./ of Self Contained ' No. of Dishwashers Space/Area Heating KW Detection/Sounding Devices ❑ Municipal ❑ Other No. of Dryers Heating Devices KW Local Connection No. of No. of Low Voltage No. of Water Heaters KW Signs Bailases Wiring No. Hydro Massage Tuds No. of Motors Total HP OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent NO = haves ed valid roof of same to the Office YES= NO = ff you h ve ca�ked YES please indicat the type of cover a by hecking the appropriate box Aq"S—U = BOND = OTHER = (Please Specify) � �� bvn7 MP &j / © Gi If (Expiration Oate) Estimated Value of Electrical Work$_ Wnrk to Atart Inspection Date Resquested Rough Final LIC. NO. Z — � � ry PJ rl e(/r _ Signature ���,✓^�� LICA. NO. Z qL T 7� C% L/ if � ,[� Bus. Tel No. Address ! � T Alt Tei. No. OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusepp General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) Telephone No. PERMITTEE $ ' (Signature of Owner or Agent) Name Name: Location: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print City Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity F1I am an employer providing workers' compensation for rry employees working on this job. Company name: Address City Phone #: Insurance. Co. Policy # Company name: Address City: Phone # Insurance Co. Policy # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the 'unposition of a mmnal penalties of.a•fine up to $1,500.00 and/or one years' imprisonments vefiLas_evil.penalties in-thelmnicia-STDP VVDW9PJ)EP and a fine9f-(,31110.)D)-ajiay againitme 1 understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. l do hereby certify miler the pains and penalties of perjury that the /reformation providers above is true and caorred Signature Print name Official use only do not write in this area to be completed by city or town official' City or Town PermitUcensin4 El Building Dept E]Check if immediate response is required . El Licensing Boars( E] Selectman's Office Contact person: Phone # Health Department El Other ' V N2 3'11 7 Date..4... ......................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that j ......................................................... ............:.................. a has permission to perform . r ...........:.....:. .,. wiring in the building of ............ ... 2 ........................................................ r at . ......... C ......- .. !1 :4�.. , North Andover, Mass. Fee . ...... ~...... Lic. No.. ....... �.......0-�^-�:.................... ELECTRICAL INSPECTOR Check # WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Y (3-0 I n I The Commonwealth of Massachusetts "" Use /O`Y Perric No: Department of Public Safety f Occupancy & Fee Checked/U-n . BOARD OF FIRE PREVENTION REGULATIONS S27 CMR 1200 3/90 heave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed In accordance with the Macsachuserts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFOION) Date Z © I City or Town of. OT`}� 6�L I To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Stree Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: . Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization NO. _ Existing Service 1 Q Q Amps_ / Z Ll4olts Overhead 6J/Undgrd ❑ No. of Meters ^L— New Service 200Amps j of © / y© Volts' Overhead 191/'Undgrd ❑ No. of Meters__ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work C cl ep T e ke V t n G No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures SwimmingPool Above In- grnd. ❑ grnd. ❑ Generators KVA No. of Receptacle Outlets No. of Oil Burners No, of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No, of Zones No. of Detection and Initiating Devices No. of Sounding Devices No. of Self Contained Detection/Sounding Devices Local ❑ Municipal ❑Other Connection No. of Ranges No. of Air Cond. Total tons No. of Disposals No. of Heats Total Total Tons KW No. of Dishwashers Space/Area Heating KW No. of Dryers Heating Devices KW No. of Water Heaters KW No, of No. of Signs Ballasts Low Voltage Wiring No. Hydro Massage Tubs No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirement;s of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES ❑ NO E] .I have submitted valid proof of same to this office. YES ❑ NO If you have ecked YES, -please indicate the type f cover ge by checking the appropriate box. 7 INSURANCE BOND ❑ OTHER ❑ (Please Specify) �f^ V ocle, C i Expi ation Date Estimated Value of Electrical Work $ Work to Start , 15- 04 Inspection Date Requested: Rough Final Signed under the penalties of perjur FIRM NAME (� LIC. N0. Licensee i -f C �/� Signature LIC. NO. 2-11'72-t 1�} e �R `''l ✓1/� © O Bus. Tel. . Address No - Alt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub- stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) Telephone No. PERMIT FEE S h/V Signature of Owner or Agent Location No. 7 Date \�) �` l/ NORTH TOWN OF NORTH ANDOVER D o Certificate of Occupancy $ HUs t� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # :r I Building Inspector ' TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: C Building Commissiond/Inspector of Buildings Date SECTION 1- SITE INFORMATION 1. l Property Address: 1.2 Assessors -0 qJ Map Number Map and Parcel Number: © 0Z Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.Q. 54) Public ❑ Private ❑ Zone 1.5. Flood Zone Information: Outside Flood Zone 0 1.8 Sewerage Disposal System: Municipal 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Name (Print) � � Add ess for Service: Signature Telephone 2'2 Owner of Record: • Name Print Address for Service: Signature Tele hone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: N N5. tl 0 Li ensed Construction Supervisor: , W . n Address re Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor 91, EWJ2L)LitDLl Not Applicable fl �j Q /o q3 83 Company Name —Z-, V SY N �j Registration Number c A,dL9/ dre Expiration Date Lure Telephone M M X Z O SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result -f tha ti„iidino hermit. Signed affidavit Attached Yes ...... No ....... 0 SECTION 5 Description of Pro osed Work check all applIcs New Construction ❑ Existing Building ❑ Repav Accessory Bldg. ❑ Demolition ❑ Other Brief Description of Proposed Work: Aene _ JlC ;rh �D�1T tJJF}��Sy �Ei Ct! *t �C..-k SECTION 6 - ESTIMATED CONSffRUCTION COSTS Item Estimated Cost (Dollar) to Completed by permit applii 1. Building a o 2 Electrical 7- � 6 J 3 Plumbing 4 Mechanical (IIVAC - 5 Fire Protection 6 Total (1+2+3+4+5 SECTION 7a OWNER AUTHORIZATION TO BE CON OWNERS AGENT OR CONTRACTOR APPLIES FOR I I, Hereby authorize My behalf. in all matters relative to work authorized by this b Si nature of Owner SECTION 7b OWNER/AUTHnORIZED AGENT DECLA I, property Hereby declare that the statements and information on the -for and belief Print AAM Si ire of ( Wmer/A ,ent NO. OF STORIES BASEMENT OR SLAB SIZE OF FLOOR TIlvMERS 1 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS lU{IGl1'f Ul� I�UUNUA'1'IUN SIZE OF FOOTING MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND ,.. (, 1 rwrc IS IMU.DINU C (JNNl:t- I nU i v 1`It11 ul-- . ble (s) ❑ I Alterations(s) Addition ❑ ❑ Specify 'T ..cJ�� ge w 7 , L t- A, > �� � rear al t= c *� QFFICIAL,USE ONLY ant (a) Building Permit Fee Multiplier (b) Estimated Total Cost of Construction Building Permit fee (a) x (b) I Check Number PLETED WHEN JUILDING PERMIT as Owner/Authorized Agent of subject property to act on .iilding permit application. Date RATION ,as gs"WAuthorized Agent of subject :going application are true and accurate, to the best of my knowledge Date SIZE 2 11 DCKNESS X 3 0— // LP V/O'I77/I➢t092[�/PCLGfII ✓� (d�UOCI(6 BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR a , Number: CS 058245 Birthdate: 03/24/1943 Expires: 03/24/2002 Tr. no: 18312 Restricted To: 00 KENNETH B KEEN 21 HEWITT AVE N ANDOVER, MA 01845 Administrator �k & HONE IMPROVEMENT CONTRACTOR 10 Registration: 108383 Expiration: 8/18/02 Type: DBA KEEN CONSTRUCTION CO. Kenneth Keen ADMINISTRATOR 21 Hewitt Ave No. Andover MA 01845 1 Town of North Andover Building Department ti . 27 Charles Street _ North Andover, Massachusetts 01845 978)688-9545 Fax 978 688-9542 q °� aN1[tMWNR DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and a condition of. Building permit # the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL cl 1, s150a. The debris will be disposed of in /at: Facility location p Sig f plicant �--- Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. name: ia jC*iDrl `` /Lc'NN CtLi �En1 1 location: `Z/ ./7' erku r I—r 4a6- .. press: 61y:. hone # incur,knrn en Failure to secure coverage as required under Section 25A of NIGL 152 can lead to the imposition of criminal penalties of a fine ul one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I understand that a ! do hereby certify under the 04ins and penalties of perjury that the information provided above is true and correct. 01 Signature Date -`Gi� 7` rr Print name ENAI E tr • If C EAJ _..�. _. phone # � 7' b -691 "SZ00 official use only do not write in this area to be completed by city or town official ,_.:....._ city or town [] check if immediate response is required contact person: (revised Il95 PIA) permit/license # rlBuilding Department []LiceosingBoard - - []Selectmen's Office []Health Department phone #; nOther 1 w 7) N vUU O � z r O .z 7 v ro U � PQ a m U W w u x U w a w m O r cn L V) c c m c ' o O y 0 4L vv Q C ev ;= o r: o H :CCL '~" y o 3AL E c .o j Cf �mm co m 3 ' s c y = _O m Amo aL)a`� c c : o C _ r : IE �.. or- =r CIDo v y o V: c Q mYc CL `mc o = m :ID c N a �-- o •• v' m •• _ W CO -;;LD R O c O F- A �a= - Z r O CD ED LLA U a o- on = In .0 g .!d 3 o f- 2 2o.em > 0 S TV �-V do 0 E 0 CC z O D H ca CD L CD C O co 0 _m FL y 0 CA C O V O .0 _O C. CO) i O Z Cl) C. CO) C CD 3� �o co L O C' 0. C 4-0 C C cc O O 4-0z CD C. CA C 0 U) U) w W IrW VJ . Location Of/ tPooA40 C-'( No. //b �, Date r TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 16L� _ `� Building Inspector A 7 TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING k NUM, �. IME BUILDING PERMIT NUMBER: �Z DATE ISSUED: 1_,3 _ SIGNATURE: L Building Commissioner/I ctor of Buildings Date SECTION I- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Numbef 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage 11 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Re uired ---4Provide Required Provided Required Provided 30 J ZS 7, 1 3 Signature 2.2 Owner of Record: Name Print Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: ZL N Address re Telephone 3.2 Registered Home Improvement Contractor l-/-,cE�) 6"o,�sf2,�c`����J Company Name 2,1 /� C&u 1. 1T I�✓ c �1. tq . Address for Service: Not Applicable 0 ,�'S Z))Y� License Number . Z y' T Expiration Date Not Applicable 0 /o 2 3 � 3 Registration Number Address Expiration Date M M z 0 0 z M 0 aanr Q M _r Z 0 1.7 Water Supply M.G.L.0 40. 34) N 1 1.5. Flood Zone Information: 1.8 Sew a Disposal System: Public &I"', Private 0 Zone Outside Flood Zone ❑ Municipal On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record / fel ND JJ Name (Print) Address for Service Signature 2.2 Owner of Record: Name Print Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: ZL N Address re Telephone 3.2 Registered Home Improvement Contractor l-/-,cE�) 6"o,�sf2,�c`����J Company Name 2,1 /� C&u 1. 1T I�✓ c �1. tq . Address for Service: Not Applicable 0 ,�'S Z))Y� License Number . Z y' T Expiration Date Not Applicable 0 /o 2 3 � 3 Registration Number Address Expiration Date M M z 0 0 z M 0 aanr Q M _r Z 0 SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this. application. Failure to provide this affidavit will result in the denial of the issuance of the building nermit. Signed affidavit Attached Yes ....... No ....... 0 SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition Accessory Bldg. ❑ Demolition A Other ❑ Specify Brief Description of Proposed Work k /D X I SECTION 6 - ESTIMATED CONSTRUCTION CO. -,TR I Item Estimated Cost (Dollar) to be Com leted b ermit a licant 1 ,y = �} �uSEO �4`" ffe� y r z 5PI� 1. Building UQ (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 PlumbinE Building Permit fee (a) x (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number 3M -11111v /a UW1vr,K AU 1HUK1LA11U1N 1U lir: CUMFLr YED WREN OWNERS AGENT OR CONTRACTOR APPLIES FOR'BUI.LDING PERMIT 1, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building pennit application. --Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, l'(ri 1a+QMa=0Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are trite and accurate, to the best of my knowledge and belief /- Si ire of jr/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS I' 2 ND3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE KEEN CONSTRUCTION CO. 21 HEWITT AVE. N. ANDOVER, MA 01845 (978) 691-5201 Cano, Cheryl & Mel 91 Woodstock Ln. N. Andover, MA 01845 (978) 794-4892 Contract # 1531; Appendix A Date: 3-28-03 Dining Room Addition: • Demolish & remove existing sun room • Demolish & remove existing front stairs (if not solid concrete) • Excavate & pour foundation for @ 14'x 21' dining room • Saw -cut existing to create egress to crawlspace • Supply materials & frame addition as per prints leaving existing exposed brick chimney • Open wall between kitchen & dining room • Supply & install Harvey Majesty windows & Andersen Frenchwood door as per prints • Supply & install vinyl siding and roofing to match existing • Insulate exterior walls and install vapor barrier • Hang blueboard and skimcoat plaster to smooth finish on walls and ceiling • Supply & install trim on door, windows and base to match existing • Replace baseboard in kitchen to match existing • Supply & install underlayment in kitchen to flow through dining room • Supply & install thresholds into hallway and living room • Paint walls and ceiling (2 coat finish, 2 neutral colors) • Stain and urethane door, windows and trim to match existing • Supply and install vinyl flooring ($500.00 installed. allowance) • Deck on back of addition to be quoted at a later date and shall not be included in this contract Electric: • Supply & install outlets to code • Supply & install one phone (Cat. 5 wiring) and one cable outlet • Supply & install switching for customer supplied ceiling fixture Plumbing: • Supply & install one zone of forced hot water baseboard heat off existing boiler Total Price:$48,400.00 (forty eight thousand four hundred dollars) �Oop7 , - g1 a .P v+ J u a m PIPE FN D. N82 4742"E DRILL HOLE FN D. 4O+ \F WOOD STAKE PIPE FND. PLAN OF LAND A 7LAN77C ENG/NEER/NG & IN SJR -V ----Y COJNSs .!/ TANT5 1,AIC N ANDOVER, MA 97 TENNEY STREET -SUITE 5 - GEORGETOWN, MA 01833 DA TE- SEPT 14, 2001 SCALE 1 " = 30 FT. FOS NO. A0107-04 THIS PLAN IS FOR THE EXPRESS PURPOSE OF INDICATING THE MONUMENTATION J❑HN B. FOUND OR SET AS PART OF THE PROPERTY PAULS❑N LINE SURVEY PERFORMED. No. 31725 THIS PLAN IS NOT TO BE USED FOR OBTAIN— ING BUILDING PERMITS OR FOR RECORDING AT THE REGISTRY OF DEEDS. SEPT.?I4, 2001 I do hereby cert under the lii� aV penalties o perjury that the information provided above is true and correct. i ignature l% � ,L7 ` �✓((� }�� Date Print name S N,4 3- T h X i w . ...... _ _ _..._ _.. Phone # official use only do not write in this area to be completed by city or town official ,... ...._ ..___ _ city or town: - permit/license # -Building Department check if immediate response is required oLicensingBoard'❑Selectmen's Office 0Health Department contact person: phone #; -Other `- ✓l e �a�v�noou��e� o�'��aaaac�uaeCta BOARD OF BUILDING REGULATIONS j License: CONSTRUCTION SUPERVISOR E, Number: -GS 0582:45 I i Birthdate: 03/24/1943 ! sExpkes,: 03/24/2004 Tr ono: 20021 Restricted; -00 i I KENNETH B KEEN 21 HEWITT AVE N ANDOVER, .MA 01845 Administrator. I ✓rze V� anirreoouuP,a�� °� /�czclucaeC�a Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Re_ glstration: 108383 Expiration 81'1'8/2004 TYk.DBA KEEN CONSTRUCTIOWCO. Kenneth Keen 21 Hewitt Aver No. Andover, NIA 01845 Administrator FORM U -'LOT RELEASE FORM Add` `� a 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 or requirements. *****************************APPLICANT FILLS OUT THIS SECTION APPLICANT (. Wo , �� 2y �, OIL PHONE LOCATION: Assessor's Map Number 0 q,!: PARCEL V0Z,! SUBDIVISION LOT (S) STREET _/ % ST. NUMBER ************************************OFFICIAL USE ONLY************************** R� ECMENDATIONS QF TOWN AGENTS: 'ATION ADMINIVRATOR COMM DATE APPROVED DATE REJECTED M TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR -HEALTH DATE APPROVED DATE REJECTED COMMENT PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT rI RECEIVED BY BUILDING INSPECTOR DATE_ Revised 9\97 jm �il 1 x w w A LEcn V p H w Z z w 0G U _ x O a v� r� CO w H w �' u W C04 c�i C u. 0 U z O c� C w w d Q 7 cn cn cn o D c :AL c 5 ko� �L �N p�O�Oo :� C� n ti • g CD •o 0 0 C I r: Hr •�i LEQ q m o 2 i 2. m a4 ,o n C ` u CM m c • n �, E mm� C N H O � L •O c O N O C O Eco CD 0 N m ; cc O CI CCM N Q is S ci c c Q Q H nc o m S m OR eC+ p N F— o � o �•-� m �.. CO) nz O C Z oc E V.0vco) o U a 5 z U) � C, C F— C $ nim O 0 y CD LA ._ �E m L- 0 co I.— = CL L � .0 3� O � � O !D o Q CL Q y C C 4- C M .v C ' CO V y � C �C C d .y D LLI 0 L1J If Lij Lli Cc LLJ LLJ Cf)