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HomeMy WebLinkAboutMiscellaneous - 92 FRENCH FARM ROAD 4/30/2018 (2)Location ! %' 0 Nc•. Date l / �oR,h TOWN OF NORTH ANDOVER 3:0��„•O- •,MOL n Certificate of Occupancy $ Building/Frame Permit Fee - $ CMUs <�' Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ f Water Connection Fee $ TOTAL $ `� r / Building Inspector 45/17/99 14:02 25-00 PAID Div. Public Works N F yC A 4 z w � z � J i z � � w A c w W x z � o z F C F GO V1 z C p O _ F� o � w o 0-0O z O O c O O Ow e Z z w w w V O F W N 4 z GO C C q w to G F� C O O Ar aa, o w U x e O O 9z v � ww o w C2 z M i z F z O O z d F� z "t O � a L] Z U ' `" �' w x U U U w C C C �c F z a= z z z o_ F z w z v 0 c F t x � 0 �~ z z LM O 4 z N O � F 0. 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Co CL i.1 A 0 a. o V o 0 C CO) D L O v CL CO) C CD CM C 0 -- CD .CD 0 m m 0 co H = 3 � co D 0 0. om < 10 � cv 0 0 Z CL CO) C 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 or requirements. *****************************APPLICA-NT FILLS flUT THIS SECTION********************"** APPLICANT'-�IW-C� 5@1040L' PHONE LOCATION: Assessor's Map Number PARCEL v SUBDIVISION LOT (S) STREET �'h`� c� �Q-"t "� ST. NUMBER I RECOMMENDATIONS OF TOWN AGENTS: CO ,TION ADMINISTRATOR COMMENTS TOWN PLANNER COMMENTS FOOD INSPECTOR -HEALTH SEPTIC INSPECTOR -HEALTH COMMENTS USE�ONLY**********/*1***o***** f 1`QmoV-a N8 1 DATE APPROVED DATE REJECTED. DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE a Revised 9197 jm ti d S4 k .! Date/4/h TOWN OF NORTH ANDOVER op PERMIT FOR PLUMBING SScHusE This certifies that .................... has permission to perform ... 7 tti ............................ plumbing in the buildings of .. 5.d.�!.Y f Y- ................... . at .. `.�.q. F. n r t . c (.. 1--I: A ! _ ................ North Andover, Mass. Fee. 2. �'..... Lic. No. ... .............................. PLUMBING INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type Ago /Z6741/�l LA?,41" Mass. Date e ' 19L Permit # 3 Y .. Z Building Location 6,rYN VOwner's Name"// L Dbe/7' bzden 14U6 /J 46 f v+ 2d Type of Occupancy 2t 5 + D E Iv 1i r2� L_ New - ❑ Renovation ❑ Replacement i5d" Plans Submitted: Yes ❑ No ❑ Installing Company Name � O r3Ee r A - -ram AAA -r A e 7 Check one: Certificate Address ') f`? C`C AC H m r� f, ) /, � ) ❑Corporation Ir E Tqi _ n Al A 0 a VL/ ❑ Partnership Business Telephone -&f Z -i9-7 1 ❑-A" Name of Licensed Plumber '�4 f� e3 i=e T fry • . S54 mmr4 req ep. INSURANCE COVERAGE: I have a current I�'ability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ ' If you have checked yes, please /Indicate the type coverage by checking the appropriate box. A liability insurance policy ld Other type of indemnity ❑ Bond ❑ OW*NER'S INSURANCE WAIVER:_ I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issu for this application will be in compliance with all pertinent provisions of the Massachusetts State Plum ' g oDde andrr7 of the era[ laws. By Title re of Licensed Plumber— City/'Town um rCitylTown Type of License: Master % Journeymab E]0 - APPROVED OFFICE U NL License Number_ D3 10 c ao to m r O 3E In O S O A m c CA m O Z Check # Building In�cfor Location ° No. ' Date M00VTN TOWN OF NORTH ANDOVER Certificate of Occupancy $ �'�s'•••° E<� -2 CRUS Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 'J Check # Building In�cfor 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: BuK#g Commissioner/I for of Buildings Date - SECTION 1- SIT ORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required— Provided R 'red Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record 4006 SVItioC)II&I Name (Print) Address for Service: Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: ( 104- Addr /` l f" n re Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor U "- /,n Not Applicable ❑ Company Name -- Registration Number A Expiration Date na ure Telephone 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 permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work(check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: �^ ��C � rtri% J //✓ �r SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 ©O d Check Number SECTION 7a OWNER AUTH IZATI N TO BE COMPLETED WHEN OWNERS AGkNT OR RACT S FOR BUILDING PERMIT as Owner/Authorized Agent of subject property H — y authorize to act on My a , all rn s t e work authorized by this building permit application. Si weer Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Signature of Owner/Agent Date MEMO 11ii:lllill ON IN NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINIBERS 1 ST2ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS DIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE V The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print Name: �7'✓ Ity l !" Location: �rIe lVel /7-/ City Nr /1�1/0o ,--, Q 1-2- Phone F7am a homeowner performing all work myself. 01 am a sole proprietor and have no one working in any capacity © I am an employer providing workers' compensation for my employees working on this job. Company name: Address % Ztu) ` ' Cityrzo e7L Phone #: Company name: Address City Phone #: Insurance Co. Policy # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify ungo-Me paiq��ry that the information provided above is true and correct. Print name ��/f Phone Official use only do not write in this area to be completed by city or town official ❑ Building Dept ❑Check if immediate response is required Building Dept ❑ Licensing Board ❑ Selectman's Office Contact person: Phone A ❑ Health Department ❑ Other FORM WORKMAN'S COMPENSATION V i HOME 1"PROVEnBT CZ`::TRACTC2 t RIgistraiiOD 106577 =1C TrR, - 10PIOUAL E%piratiol 07721+00 3Ott1I :1. 11Cl AHO,, G�ceN,�oftta}. BOX 8185 AOW,V,SWTOR TRO :.IL! "A ?1630 �%/ie Co�iimonurrtrltJ o�; �l�juacluivel�i BOARD OF BUILDING REGULATIONS _ n License: CONSTRUCTION SUPERVISOR li Number: CS 059995 lBirthdate: 04/14/1959 Expires: 04/14/2002 Tr. no: 22640 Restricted To: 00 JOHN W MCMAHON PO BOX 237 TEWKSBURY, MA 01876 Administrator L- M 1 �¢ x A x v -0 O w v U) o P-' z z A o O w w O w' G U cz G w aa O p aG coW G w O wx u U p u2 y U) G w o u w z G O cz co w W d w A 7 co 6 U) Q cn x CIO W H x W C#* x H 0 c O E ID CL co ea . � o m c o � C y o c C.2 v •ate :ac c o CD0 Ea D o _ t5 o c. N :0= m c .ate �3 'cam CIO iv = C N W = N E CD mo N O m �cCIO�a 0 Z •� C � O O a aw O oS~ ,O 4-'o r '= O C as � R cm O = = O y O -= 0 � E N M 0 cm N C R 0 cc Q! c m 0 Of C �C N CD t 0 g O C/) r U 0 z O U CO 1� O co O O - 0 o s Z o CL O H 0 C CD C c y C .0 O y O O E m m C ~ " 3� O � i � O d im- vsQ = C� .3 J .fl CL O ,� C Z CD C.3 y O C C■— CL ev CO) G 0 LLJ U) W W Ir LLJ ffLU^ vJ Town of North Andover Building Department 27 Charles Street North Andover, Massachusetts 01845 (978) 688-9545 Fax (978) 688-9542 DEBRIS DISPOSAL FORM t%ORTH q O tiLso �6� ti� OL 0 y 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 c11, s150a. The debris will be disposed of in /at: Sr w( Facility location Si re of Applicant Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector.