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HomeMy WebLinkAboutMiscellaneous - 93 AUTRAN AVENUE 4/30/2018I/ BUTTERWORTH & O'TOOLE, INC. P.O. BOX 8294 SALEM, MA 01971-8294 ADJUSTERS/APPRAISERS FOR INSURANCE COMPANIES ONLY TELEPHONE (978) 741-5731 October 12, 2006 FAX (978) 740-9109 FORM OF NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B TO: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectmen City/Town Hall ADDRESSES North Andover, MA 01845 RE: Insured: Edward Antonelli Address: 93 Autran Avenue Policy No.: Citv/Town Hall North Andover, MA 01845 North Andover, MA 01845 F0117036 Loss of: 10/10/06 File or Claim No.: 060-1475 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Massa Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Ch. 139, Sec. 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. If no reply is received from your office within ten days, we will assume you have no liens of any type against this property and we will recommend to the insuring company that this claim is paid. Member of National Association of Independent Insurance Adjusters Paul Dionne Adjuster BUTTERWORTH & 01TOOLE, INC. P.O. BOX 8294 SALEM, MA 01971-8294 ADJUSTERS/APPRAISERS FOR INSURANCE COMPANIES ONLY TELEPHONE (978) 741-5731 FAX (978) 740-9109 October 12, 2006 FORM OF NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B TO: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectmen Citv/Town Hall ADDRESSES North Andover, MA 01845 RE: Insured: Edward Antonelli Address: 93 Autran Avenue Policy No.: City/Town Hall North Andover, MA 01845 North Andover, MA 01845 F0117036 Loss of: 10/10/06 File or Claim No.: 060-1475 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Ch. 139, Sec. 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. If no reply is received from your office within ten days, we will assume you have no liens of any type against this property and we will recommend to the insuring company that this claim is paid. Paul Dionne Adjuster rrs Member of National Association of Independent Insurance Adjusters April 7, 2015 THER7OP81fOd06f���C-0 fEARlli P GROU U FORM OF NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B Building Commissioner, or Inspector of Buildings c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Board of Health or Board of Selectmen c/o City or Town Hail 1600 Osgood Street North Andover, MA 01845 Fire Department or Arson Squad c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 RE: Our File No.: P1592326 Insured: EDWARD P ANTONELLI Address: 93 AUTRAN AVENUE, NORTH ANDOVER, MA Policy No.: F0117036 Loss Date: 04/06/2015 Loss Type: Building or Other Structure Damage A claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Ch. 143, Sec. 6 to be applicable. If any notice under Mass. Gen. Laws, Ch. 139, Sec. 3B is appropriate, please direct it to my attention and include a reference to the captioned insured, location, policy number, loss date and claim or file number. If no reply is received from your office within ten days, we will assume you have no liens of any type against this property, and the claim will be paid in our customary manner. Sincerely, Marie J. Landers Property Claim Examiner 1-800-688-1825 x1136 NORFOLK & DEDHAM MUTUAL FIRE INSURANCE CO. DORCHESTER MUTUAL INSURANCE CO. FITCHBURG MUTUAL INSURANCE CO. z222 Ames Street, P.O. Box 9109, Dedham, MA 02027-9109 Telephone: (800) 688-1825 0 Fax: (781) 329-1818 April 4, 2014 THER9CIRfFG0.06(I'�fll1EllHAfiAGROUP@ FORM OF NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASS. GEN. LAWS, CH. 139, SEC. 36 Building Commissioner, or Inspector of Buildings c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Board of Health or Board of Selectmen c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Fire Department or Arson Squad c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 RE: Our File No.: P1472507 Insured: EDWARD P ANTONELLI Address: 93 AUTRAN AVENUE, NORTH ANDOVER, MA Policy No.: F0117036 Loss Date: 03/04/2014 Loss Type: Building or Other Structure Damage A claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Ch. 143, Sec. 6 to be applicable. If any notice under Mass. Gen. Laws, Ch. 139, Sec. 3B is appropriate, please direct it to my attention and include a reference to the captioned insured, location, policy number, loss date and claim or file number. If no reply is received from your office within ten days, we will assume you have no liens of any type against this property, and the claim will be paid in our customary manner. Sincerely, Marie J. Landers Property Claim Examiner 1-800-688-1825 x1136 NORFOLK & DEDHAM MUTUAL FIRE INSURANCE CO. 222 Ames Street, P.O. Box 9109, Dedham, MA 02027-9109 DORCHESTER MUTUAL INSURANCE CO. Telephone: (800) 688-1825 FITCHBURG MUTUAL INSURANCE CO. Fax: (781) 329-1818 Date...��... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........... ....... li .. !� ...................................... has permission to perform ........ 4- zz, ... n ................................................... wiring in the building of ..... z . ................................................................. at / ...... C .............. . North Andover, Mass. ....................... Ege.. 4 ............. Lic. No . ............. z .......... f�� ..... ............. 4�.. .......... ELEcTRICAL INS-PECTOR Check # --) 0 61 8971 Jz. Commonwealth of MassachusettsEPerrnitNo. fficial Use Only Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Fee Checked aveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 52OwORK (PLEASE PRINT W INK OR TYPE ALL INFORIIIATION) Date: City or Town of: NORTH ANDOVER °� By this application the undersi ed To .the Inspect o Wires: gn gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 9 �j �u f /-,4 ,v i9 V C Owner or Tenant Owner's Address S,ATelephone No. .saQ• �i/f� Is this permit in conjunction with a building permit? Purpose of Building_ lD��l N5 Yes � NO � (Check Appropriate Box) Utility Authorization No. Existing Service 76PO Amps (2° / 'Lj/� Volts New Service Amps Overhead � Undgrd ❑ No, of Meters _ / _Volts Overhead ❑ Undgrd ❑ No, of Meters Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: No. of Recessed Luminaires Com letion o the ollowin table may be waived b the Inspector of Wires. No. of CeiL-Sus No. of p. (Paddle) Fans Total No. of Luminaire Outlets No. of Hot Tubs Transformers KVA No. of Luminaires Swimming pool Above ❑ In- Generators KVA o, 11 o mergency tg g — . No. of Receptacle Outlets d d No. of Oil Burners BattUnits No. of Switches FIRE ALAII!M_S No. of Z Wines No. of Gas Burners o, of Detection and No. of Ranges No. of Air Cond. Total Initis * Devices No. of Waste Disposers Tons Heat Pump Number ons ICW No. of Alerting Devices No. of Dishwashers o, of elf -Contained Totals: __. __ _ _ — Detection/Alertin Devices Space/Area Heating KW Local ❑ Municipal ❑Other No. of Dryers Heatin A g ppliances KWSecurity Connection Systems: o. of Water ICS' Heaters No. of o of No. of Devices or E uivalent Sis Ballasts Data Wiring: No. Hydromassage a Bathtubs g . No. of Motors Total Hp No. of Devices or Equivalent Telecommunications Wiring: n7'aru • No. of Devirpe n. r ........ 1.._a Estimated Value of Electrical Work: Attach additional detail if desired, or as required by the Inspector of Wires. Work to Start: (When required by municipal policy.) d in INSURANCE COVERAGE: Unless Inspections waived by the owner, o Permit fo the perfonnace with NMCncelof oe tc upon completion. the licensee provides proof of liability insurance includingal work may issue unless undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing of6ceuivalent coverage or its substantial The CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penaltiesof perjury, that the information on this application is true and complete. FIRM NAME: vZZ© F t`eC7 ✓'l G Licensee: _ �jJ /� �7-� LIC. NO.: `277 5A (If applicable, enter exempt " in tqlicense number line.) Signature / LIC. NO.: %ZA%3Z Address:VD�Bus. TeL No.:_�7� 3 7.*Per M.G.i c 14 i, s 57 61, seork requires D 7 Alt. Tel. No.: Mf • 6&Z- 77 ,Fv OWNER'S INSURANCE WAIVER: I am aware that the L,icens a doles not havety 'the liability L'c. No. required by law. By my signature below, I hereby wive this requirement I am the (check one) ❑ownercoQ wneo agent Owner/Agent Signature Telephone No. PERMIT FEE: $ ;F-7 5-, ") q � I El Ll The Common wealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 414shington Street Boston, MA 02111 www nzassgov/die MI -kc -ant InfOriitBtinn . Workers' Compensation Insurance Affidavit. Builders/Contractors/Eiectriciants/Plumbers Nanle (Business/organization/Individual): Address: 10 fT- City/State/zip: /VO- j4rPo-,t'r l} - F th Phone #:_ . �7�' 317- % 3/ 7 Type of project (required): 6. ❑ New construction 7. []Remodel I ing 8. Q Demolition 9. (] Building addition 10.❑ Electrical repairs or additions I I. ❑ Plumbing repairs or additions 12.[] Roof- 13 -0 Other `Any applicmthat checks bot; # I must also fill out the section below showing their workers' compensation pohcy atton t homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 4C—im ractots that check this box must attached an additional sheer showing the trema of the sub-connctors and their wosicers' com _ [i ininsdoa. p Policy ma I am an employer that is pr1?W&ng:worhers' compensation insurance for informamy. employees: Below is the policy Job e tion Insurance Company Name: Policy # or Self -ins. Lic. 9: Expiration Date: Job Site Address: City/State/zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under �f ff e pains and penalties of perjury that the information provided above is true and correct one #: / M IV' Y3) 2 Official ase only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # 20 Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Cleric 4. Electrical Inspector 5. Plumbing inspector 6. Other 11 Contact Person: Phone #: Are you an employer? Cheekthe appropriate box: 1. ❑ I aro a employer with 4. ❑ 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 ori the attached sheet t ship and have no employees These su&contractots have working for me in any capacity. [No work=' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its ' required.] 3. D I am a homeowner doing officers have exercised their all work right of exemption per MGL Myself [No -workers' comp. a 1.52, § 1(4), and we have no • insurance required.] t employees. [No workers' comp. insurance required ] Type of project (required): 6. ❑ New construction 7. []Remodel I ing 8. Q Demolition 9. (] Building addition 10.❑ Electrical repairs or additions I I. ❑ Plumbing repairs or additions 12.[] Roof- 13 -0 Other `Any applicmthat checks bot; # I must also fill out the section below showing their workers' compensation pohcy atton t homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 4C—im ractots that check this box must attached an additional sheer showing the trema of the sub-connctors and their wosicers' com _ [i ininsdoa. p Policy ma I am an employer that is pr1?W&ng:worhers' compensation insurance for informamy. employees: Below is the policy Job e tion Insurance Company Name: Policy # or Self -ins. Lic. 9: Expiration Date: Job Site Address: City/State/zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under �f ff e pains and penalties of perjury that the information provided above is true and correct one #: / M IV' Y3) 2 Official ase only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # 20 Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Cleric 4. Electrical Inspector 5. Plumbing inspector 6. Other 11 Contact Person: Phone #: Information a nd 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 includirikg the legal representatives of a deceased employer, or the recerver or trustee of an individual, partnership, association or other legal entity, employing employees. 'However the owner- of a dwelling house having not more that, 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 Icovemae 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 toyour situation and, if necessary, supply =6-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 Deportment 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, notthe 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'ticense number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Deportment 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 >f 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 Departt nent of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 Ext 4.06 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617-727-7744 www.mass.gov/dia 0 6F - /r - - - �/� Date .............. TOWN OF NOR-TH ANDOVER 1� ,,- PERMIT'FOR PLUMBING SACMUS k, ........ ......... ...... This certifies that ............ -Z, has permission to perform plumbing in the-13uildings of ................................... at North Andover, Mass. Fee7. ...... Lic. No .......... .... ... Check # PLUMBING INSPECT �R 8171 Y ,:*u ','MASSACHUSETTS UNIFORM APPLIC TION'�F'OR PERMIT TO DO�'RLUM'SING ' (Print or Type) MASS. Date � Building �T � ~� � Permit # � Location _ rAy rGn Atte- Owner's C Name New ❑ Renovation ❑ Replacement ❑ Plans Submitted: Yes ❑ No ❑ FIXTURES Building Permit No. I I I IH I I ( lZl Q I I i I> wl Nlzl� I.� O = ZI !Ln 1-I .z I ID �o l7 Zf Z a -a IQICC OiN'w N f I= U F Ulw QQ I I V11Q F,,, 'n Ise I� of a Iz z d X x W I 0. O 1 i Q W < Q W I?' O I Q I Z aIQ I Q I J �y w = ~ ~ I W 1 3 '^ 1 m 3 iF- 0. O I Z I J N i ac Y n Q F- Q Z Y Z 0 W Q F O LL I " Y of W 0 Q 1- QQ Q = v' H 3iY OIJ Q Q 3 O I Q 1 1" j SIh�NILL Q It7 a K 0 K Q Q 31o.'im O Q 1- O ..l�mlv�I� SUB-BSMT. I I I I I I I I I I I I I I I I I I I I I I I I I I I i— BASEMENT I I I I I I ( I I I I I I I I I I I I I re I I I I III 1ST FLOOR 2ND FLOOR I I I I I I I I I I I I I I I I I I I I I I I I I I I I 3RD FLOOR I l l l l l l l l l l l l l f l l l (l l l l l l l l l 4TH FLOOR I I I I I I I I I I IIII I I I IIII I I I I STH FLOOR 6TH FLOOR I I I I I I I !III I I I IIII I I 7TH FLOOR _I 8TH FLOOR I I I I I I I I I I I I I I I L I I I I I I I I I I I Check one: Certificate Installing Com any Name ��'� Ulii�o �r ❑ Corp. Address �� �o—o ��' ' ❑ Partnership ❑ Firm/Co. Business Telephone —� Name of Licensed Plumber 1 a`►P�S W INSURANCE COVERAGE: Check one I have a current liability insurance policy or its substantial equivalent. Yes ❑ No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. 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 Chapt r 142 of the M . General Law , n hat my signature on this permit application waives this requirement. 0 Check one: Owner ❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information 1 have submitted (or entered) in the above 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 provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / v. Fee �j a— � Check # lgnature of Licensed Plumber ,J Date License Number —21 2:73 — APPROVED (Office Use Only) Type or Plumbing License: Master ❑ Journeyman This certifies that 9.9 - A 14� has permission for gas in7.t�llation in the buildl"S� of ..... ............................... at ........... North Andover, Mass. Fee-�� ..... Lic. No�� .... ............ ............. GASINSPECTOR Check # , — —Z.� —(e 7 68,01 Date..................... OORTH TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that 9.9 - A 14� has permission for gas in7.t�llation in the buildl"S� of ..... ............................... at ........... North Andover, Mass. Fee-�� ..... Lic. No�� .... ............ ............. GASINSPECTOR Check # , — —Z.� —(e 7 68,01 G MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) Date (0 20 TOWN OF OWNUM Massachusetts AT. Location New ❑ Renovation ❑ Replacement ❑ Permit # d �� Building Owner's /� f Name E3 , rl4o o d b Type of Occupancy: Plans Submitted: ❑ Yes ❑ No (Print or Type) Installing Company Name 3k e/. LJ ► � 1 t! �. Address 7 G (o (,.,,(It,•tm S - Business Telephone Check One: ❑ Corp. ❑ Partnership ❑ Firm/Company Name� Licensed Plumber or Gasfitter Certificate I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. I have inf the owner or his a t that I do not have liability insurance including completed operations coverage. Signature ofOWner/AgenT- NOTES: Notice: It is the Plumber or Gasfitter of Record to arrange for Inspections. Notice: A Re -inspection Fee of $50.00 will be charged for failed work or missed inspections. NO other inspections will be scheduled until the fee has been paid I have a current liability insurance olicy to include completed operations coverage. ❑ Signature of Licensee: LICENSE TYPE: 15(Plumber ❑ Gasfitter ❑ Master 'Journeyman License Number U � BELOW FOR OFFICE USE ONLY FINAL INSPECTIONS 101143 APPLICATION FOR PERMIT TO DO GASFITTING NAME & TYPE OF BUILDING LOCATION OF BUILDING PLUMBER OR GASFITTER PERMIT GRANTED DATE 20 GAS INSPECTOR it 6 Date.... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............ Pa 7- 2- 0 Z-�ZZ�71-2rf .......................................................................... has permission to perform .......... A/07.7�6 ........................................ wiring in the building of ........ 4.41�& 6 ................................. q worth. Andover, Mass. at . .. .......... Fee.Y��... Lic. No. 7 0 Fj sp M - 'di I �C, 1, L cro? Ch'eck # 1� 3- 7568 ,t .� Commonwealth of Massachusetts Official Use Only {` Department of Fire Services Permit No.� Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (72// 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 9 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) q32-/Prr-t /,-/ live. Owner or Tenant Owner's Address a' SA lC Telephone No. Is this permit in conjunction with q building permit? Yes ❑ No E5"'- (Check Appropriate Box) Purpose of Building f)V-V-' ( i ti Eb Utility Authorization No. Existing Service (00 Amps (_79 1 L% -Lo Volts Overhead ®� Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity No. of Meters tom/ No. of Meters Location and Nature of Proposed Electrical Work: Co,41r) e j-foi -r fo Completion of the following, tahle may he waived by the to—ertor of wir— No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of V Total V Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. grnd. o. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump Totals:Detection/Alerting Number I Tons..KW No. of Self -Contained Devices No. of Dishwashers Space/Area Heating KW Local[E] Municipal ❑ Other Connection No. of Dryers Heating Appliances Kms, Security Systems:* No. of Devices or Equivalent No. of WaterKW Heaters No. of No. of Si ns Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 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 cover ffi ge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:) I certify, under t7he and penalties of perjury, that the information on this application is true and complete. FIRM NAME: i1 LIC. NO.: (Z7-7 g/+ Licensee: _"�Mu 11U-� Signature LIC. NO.: F- 2-73 7,3 (If applicable, enter "oxen: t - in the license number line.)Bus. Tel. No.: i7P-�,r 7 5�3 i % Address: __ fc7 z� vt j .� l- 1�1d. ^-ptx-f"'- /yiq- p/� y 1- Alt. Tel. No.14 - &&2 -?7 d Q *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No.PERMIT FEE. $ 4 . The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Avvlicant Information _ Please Print Legibly Name (Business/Organization/Individual): U2 Address: G��- �,;. S I City/State/Zip: 110 4V Vvu't I� Phone #: � 3 ( -7 Are YOU an employer? Check the appropriate box: L ❑ I am a employer with 4. ❑ I am a general contractor and I mployees (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. employees and have workers' [No workers' comp, insurance comp. insurance.t required.] 5. We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp, right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' :Any applicant that checks box #1 must also fill out the comp, insurance required] section below showin #- Type of project (required):. 6. ❑ New construction 7. ❑ Remodeling 8. C] Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12 - El Roof repairs 13.[] Other Homeowners who submit this affidavit indicating they are doing all work ana Ir d then hire outside musation st submit new affidavit indicating such. tContmctors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' co mp. Policy number. man a player rear is providing workers' compensation insurance for my employee& Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. M 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 cnv"anP ..ora,. ,«: _ 1 do hereby certify under the pains penalties ofperfuy thatthe information provided above is true and correct —I---, Date: L l D Phone #: [Contact ficial use only. 7olerea, to be completed by city or town ofJlclaL ty or Town• Permit/I.icense # uing Authority Board of Healthment 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Other Person: Phone #: } Information and Instructions y Massachusetts General Laws chapter 152 requires `all e mploy�o inrthe service of another under any contractorkers , comp ns ti or their no�fllure,s oye pursuant to this statute, an employee is defined as "...every p express or implied, oral or written." er egal or any two or An employer is defined as "an individual, pend p, the legal representativons corporation or es ofla deceased �employers or the re of the foregoing engaged in a joint enterprise, to employees- However the receiver or trustee of an individual, partnership, association or other legal entity, emperein, or loying yang occupant of owner of a dwelling house having not more than todoma�m�tenancentsaen onstructind who eor repair work on such dwelling house dwelling house of another who employs persons 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 buildin renewal of a license or permit to operate a business or to construct ecce t ble evidence of compltan a with thesIn the iusurancemcmoveragelth for requiredy applicant who has not produced p Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall f public work until acceptable evidence of compliance with the insurance enter into any contract for. the performance o requirements of this chapter have been presented to the contracting authority. Applicants Please fill out the workers' compensation affidavitss completely, bychecking numbers among with their aply to o You e(s) of on and, if necessary, supply sub -contractors) name(s), a ( ) phone 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 e coverage. Also be sure to sign and date the affidavit. The affidavit d uld Accidents for confirmation of insuranc be returned to the city or town that the application for the permit or license is being requested, not the Dep . Industrial Accidents. Should � have any questions n�>>� hosted below. Self-insurelaw or if you are d to should enter their . a workers'. compensation policy, please cP artment atself-insurance license number on the appr nate 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 Pe� license apcense plications n aer which ny given year► need only submit one affidavit indicating current l be used as a reference number. In addition, an applicant that must submit multiple perms PP_(city or policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (ty town)." A copy of the affidavit that has been officially stamped or marked by the city or town maybe provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone -and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Invesdgations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext.406 or 1-877-MASSAFE Fax # 617427-7749—­ Revised 17=727-7749— _Revised 11-22-06 www.mass.gov/dia 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: IMA,(( Building Commissioner/InSetor of Buildings Date 2 SECTION 1- SITE INFORMATION 1.1Iro erty Address: 1.2 Assessors Map and Parcel Number: Map Nun t Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: —oy0 I Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required ProvidedRec •red Provided t- 1.7 Water•.Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Pablic ❑ `ftvate ❑ Zone Outside Flood Zone 0 1.8 Sewerage Disposal Municipal ❑ System: On Site Disposal System ❑ SEC^'I'IQN 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 OwV,-of,ecord ` Name (Print) ff 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: Address Signature Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature 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 rmit. —Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description o4 Pro osed Work checkallapplicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: S k--) (-`C C �� �'l t c: �CB �' (�� eyy , Ct_ G P) o Hca rv� SF.CTI(]N 6 - F.STYri4ATVn rnNCTUFTrTTnN CnCTQ Item Estimated Cost (Dollar) to be Completed b ermit a licant, s� E�l M�� kON00 .. n..... ...:,,� x 1. Building�.., (a) Building Permit Fee Multi lier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number ar,a.ilvl'q /il VW1rL�i(AUltiVM_MI!•Al1VP1 Lll ISE l,'VMrU lE'll WIM.N OWNERS, AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, Eck wCe U "� kct � as Owner/Authorized Agent of subject property Hereby authorize to act on My be u all n ers atuv to wor orized by this building permit application. Si nature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, 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 r Location 61-e No. 1-3s Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ 2 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 146 *41 4 Buildi-ng Inspector 4 ` TOWN OF NORTH ANDOVER BUILDING DEPARTMENT 1.2 Assessors Map and Parcel Number: Map Num Parcel Number APPLICATION TO CONSTRUCT REPAIP., RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING ;Qyt Mz-Cx.:e BUILDING PERMIT NUMBER: J� � DATE ISSUED: 1.6 BUILDING SETBACKS ft Front Yard Side Yard SIGNATURE: Required Provide ReqWred Building CommissionedIn for of Buildings Date t 2 Re red Provided a0EU11V1N 1- SilR UirORMA ILO 1.1 etty Address: n t ) ' ( f�✓l 1.2 Assessors Map and Parcel Number: Map Num Parcel Number j7 v J -e c ` VU A 1.3 Zoning Information: ZoningDistrict Proposed Use 1.4 Property Dimensions: �I; Advo /va Lot Areas Fronla e ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide ReqWred Provided Re 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 Ownereoff ecord lam`" C�vc c G 117,7 1�C �(l �y la c4 4 Name (Print) Q Address for Service: -C��— (o y 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. Address Signature Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Tele hone 89 M X ic Z O z M 90 0 mn M rM z Q P SECTION 4 - WORKERS COMPENSATION (NLG.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 .......0 No ....... 0 SECTION 5 Description of Proposed Work check atl applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. . ❑ Demolition ❑ Other 0 Specify Brief Description of Proposed Work: ' Ct k(9 seco,nS >°��r.5 0 c�a q fess Vic' G� c-, 0 n C' �ko rV\ SFCTTON 6 - RSTiMATRD C0NCTR1TCT1nN rM.T.Q. Item Estimated Cost (Dollar) to be >Epy� Completed b permit applicant x 1. Building (a) Building Permit Fee �-� ` Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) ^ �� a J 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number JLC l lluf4 '/a UWiNJEK AU 1'riUKiZA'I'IUN TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUELDING PERMIT I, %_" ce C `� <<`� ��zl f' as Owner/Authorized Agent of subject property Hereby authorize to act on My bell, n all ers ativ to wor �thorized by this building permit application. �f Si nature of Owner 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 r Signature of Owner/Agent Date i NO. OF STORIES SIZE ( p Q S 4-- BASEMENT OR SLAB -` SIZE OF FLOOR TFVMERS 1 2 3 SPAN DRAENSIONS OF SILLS DIMENSIONS OF POSTS DM ENSIONS 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 D M O z W w � o m c c v 4qO N C V V d C R R 1 di M m E I L m .2 40 C Ica Ec zCO3 1y o Z' 3 QE1 C C � ._ m R Go R N 1 � � is E0 K CS1 CO CD 1� C O �t � ' ams W y O 1 SOL Z o � a m N m C = O m_CL..+ 3 1 � o N m$� W CO Z r C w ~ •N Gt R C Lcr-�� u 'FE c31 co, �m 06 om a VD CD O � Z R � H *M.Oy� 5 cm H w E CL a� s C C2 CD C.3 cc CL H C Q .a H C cc 0 .0 _cc 0. CO) L Cl ts co CL COD COC W V/ C 0 a- co m 0 U) crW w w U) o o w a a, cn O Or. o w °�° o C2 T -� U � a w a U �' o u: c w O w U W o w v v) i�, p C7 o w � a u. w a 4 ra o cn cu o cn w � o m c c v 4qO N C V V d C R R 1 di M m E I L m .2 40 C Ica Ec zCO3 1y o Z' 3 QE1 C C � ._ m R Go R N 1 � � is E0 K CS1 CO CD 1� C O �t � ' ams W y O 1 SOL Z o � a m N m C = O m_CL..+ 3 1 � o N m$� W CO Z r C w ~ •N Gt R C Lcr-�� u 'FE c31 co, �m 06 om a VD CD O � Z R � H *M.Oy� 5 cm H w E CL a� s C C2 CD C.3 cc CL H C Q .a H C cc 0 .0 _cc 0. CO) L Cl ts co CL COD COC W V/ C 0 a- co m 0 U) crW w w U) . t ru..,p Town of North Andover '• ' Building Department p 27 Charles Street t North Andover, MA. 01.845 D. Robert Nicetta s.sACHUS4ti Building Commissioner (978) 688-9545 688-9542 Fax Please print / DATE �,q_ Ci JOB LOCATIOP "HOMEOWNER Number Name PRESENT MAILING ADDRESS City Town HOMEOWNER LICENSE EXEMPTION (� Street Address Map /lot Home Phrone Work Phone State Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings of two units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. (State Building Cade Section 108.3.5.1) DEFINITION OF HOMEWOWNER: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures ac- cessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned "homeowner' certifies that he/she understands the Town of No. Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures ai HOMEOWNER'S SIGNATURE I APPROVAL OF BUILDING OFFICIAL MORTGAGE INSPECTION FLAN NORTHERN ASSOCIATES, INC. 401 SOUTH BROADWAY, LAWRENCE MA.01843-3522 TEL:(978) 837-3335 FAX:(978) 837-3336 MORTGAGOR: EDWARD ANTONELLI LOCATION: 93 AUTRAN AVENUE CITY, STATE: NORTH_ANDOVER MA DATE: OCT. 96, 2000 LOT 59 0 0 F, LOT 99 45.00' LM LOT 52 "51Q0 s ff ;a ,2 story/ / wood// #9 j 45.00 AUTRAN AVENUE CERTIFIED T0: HOMESTEAD MORTGAGE CORP. Flood hazard zone has been determined by scale and is not necessarily accurate.Until definitive plans are. tissued by HUD and/or a vertical control survey is performed, precise elevations cannot be determined, NOTE. This mortgage Inspection was prepared specifically fir mortgage purpose only and is not to be relied upon as a land or property -04t"_A444 line survey, used for recording, preparing deed YN Of Aq descriptions, or construction. No corners were 4A� sot. Building location and offsets are approximately located on ground and are shown specifically for zoning determination c CARMEN A. . only and are not to be used to establish rt Q limes. The matters shown hereon are based o y TEs*rA client -furnished information and may be subject 0. 1846 Q to further out -sales, takings• casements and rights 01 flF p p of way, and other matters of record and preserptiv¢ toor other �rSTEP� � responsibilityshere nhto land oumer orn Associates, r occupant assumes /Ohtl LAN�S�P, accepts no responsibility for damages resulting from said v reliance by anyone other than the said mortgagee and it assignsd in connection with its proposed mortgage financing to said mortga or. 0 0 0 0 DEED REF. 3964 / 200 PLAN REF. 8 / 406 SCALE: I"=20' JOB #: 200/.06697 LOT 53 This mortgage inspection was prepared in accordance with the Technical Standards for Mortgage Loan Inspections as adopted by the Massachusetts Board of Registration of Professional Engineers and Land Surveyors 250 CSCR 605. I further state that in my profissional opinion that the structures shown conform with the local zoning horizo dimensional setback requirements at the time of corulruct are exempt under previsions of M.G.L. CH. 40-A Sec. 7. 1 1. Pro,perty/House is not in Flood Hazard. 7! 2. Property/house is in a Flood Hazard Area. (] 9. Infirnration is ins-ufficent to determine Flood Hazar Flood Hazard determined from latest Federal Flood Insurnce Rate Slap Panel 'Z SOD C po ADO � C ... /4" 9_C/3 - ,,.—t.,r--._.