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Home My WebLink AboutMiscellaneous - 95 JOHNSON STREET 4/30/2018TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .... A— - S � 1.11!i/: A0I/— /%? I! ............... has permission to perform ....1) ... ....................... plumbing in the buildings of ... ....................... at ...G? .5 .. J. (o. r. 4 ?.... ........ ,North Andover, Mass. Fee. 4. .. Lic. No.. 7�' ... ...... ��. . ` .--,.......... . / PLUMBING INSPECTOR Check # 5073 MA:'SACNUSE1TS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) Mass. Date . e _20c / Permit # Building Location �$ /Owner's Name -JV e Type of Occupancy t+ 7 E ti i I r1 LN New ❑ Renovation ❑ Replacement (H"" Plans Submitted: Yes ❑ No ❑ FIXTURES Installing Company Name 7 40c 1 Check one: Certificate Address_ �� 0 C0 !4 c N MA 0 /- � j ❑ Corporation Ir E L4 u Fn yy1 Ay / Lj ❑ Partnership Business Telephone__ 11 � _ X97 I 2-i!Fi—rrn/Co -- Name of Licensed Plumberr v3r r ,�,' • SA,yi,if,g rrCl tic"` INSURANCE COVERAGE: I have ayes curre;'lability insoua ce policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. 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 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 anent Owner El Agent C3 w1„lr U l4e a+ u+use aeMIS 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 pegormed under the permit issu for this pertinent provisions of the Massachusetts State Plum in a and apter of the eral Lawplication will be in compliance with all �vL L Title re o Licensed Plumber City/Town Type of License: Master Journeymah ❑ MPRCVM O IC US ONL License Number c� � Y • MEET M OMEN MEN MEN MEN ME NONE MEN SOMEONE MEN monsoon ENO MENNEN 0 NONSENSE ONEEMMEMMONNO on Installing Company Name 7 40c 1 Check one: Certificate Address_ �� 0 C0 !4 c N MA 0 /- � j ❑ Corporation Ir E L4 u Fn yy1 Ay / Lj ❑ Partnership Business Telephone__ 11 � _ X97 I 2-i!Fi—rrn/Co -- Name of Licensed Plumberr v3r r ,�,' • SA,yi,if,g rrCl tic"` INSURANCE COVERAGE: I have ayes curre;'lability insoua ce policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. 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 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 anent Owner El Agent C3 w1„lr U l4e a+ u+use aeMIS 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 pegormed under the permit issu for this pertinent provisions of the Massachusetts State Plum in a and apter of the eral Lawplication will be in compliance with all �vL L Title re o Licensed Plumber City/Town Type of License: Master Journeymah ❑ MPRCVM O IC US ONL License Number c� � J z O W N W U U. L6 O m O 3 O J W m t7 Z m J a • O G O i - z z O W -� z a c tt m _J O 4. O m z W t� O a O ~ cc G W V ~ m J• W t � tL t z J 4 lV !G N N Location qc -- _ IO/1tisU�j SJ�— No. Date NOR7M TOWN OF NORTH ANDOVER O 0 R 9 Certificate of Occupancy $ Building/Frame Permit Fee $ sNCNust Foundation Permit Fee $ Other Permit Fee $ TOTAL $ -3 Check # Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING SE Lf R2 ., . BUILDING PERMIT NUMBER:DATE ISSUED: SIGNATURE: Building Commissioner/I ctor of Buildings Date �r a 1vi� 1- X711 L lull r vIMIVIA l 1v1-4 q1.1 Property Address: I� joky -re -u% s T*, 1.2 Assessors -9/�? Map Number Map and Parcel Number: - - Parcel Ntknber " 4/ _may /} ...vo 14 / 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 Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zone 0 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSEMAUTHORIZED AGENT 2.1 Owner of Record Name (Print) Address 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: Licensed Qonstruction 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 p SECTION 4 - WORKERS COMPENSATION (XG.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 all applicable) New Construction ❑ 1 Existing Building 0 1 Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ I Demolition ❑ I Other ❑ Specify Brief Description of Proposed Work: I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I Item Estimated Cost (Dollar) to be Completed by permit applicant ; � I IL>(ISI " t%" v.Y.xxsK a'w �:J� rxX"m;;�' nt,.z "JNV T A� y s Si *� yNs�re.."�:��`�T'� .uF<l.b� .,S ,amu*` 1. Building Q,O (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) Dr �-- 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number Or,%-X1VP1 /a VWF4JVMAU111VK1GA11ViV 1V tfLCVMYLElL�ll WtiL1V OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION t, ,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 of Owner/. Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINMERS 1 2 ND 3 RD 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 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print 'Name: Gt*l /BMJ ��yJ Y Location: ! 1, L,�� ,,,3 C J7 City _ M2 Atti06✓6-r-L.- Phone 0 am a homeowner performing all work myself. 0 1 am an employer providing workers' compensation for my 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 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 under the pains and penalties of perjury that the information provided above is true and correct. Signature Date Print name Phone # Official use only do not write in this area to be completed by city or town official' ❑Check if immediate response is required Building Dept Contact person: Phone #: FORM WORKMAN'S COMPENSATION ❑ Building Dept ❑ Licensing Board ❑ Selectman's Office ❑ Health Department ❑ Other Town of North Andover Building Department 27 Charles Street North Andover, Massachusetts 01845 (978) 688-9545 Fax. (978) 688-9542 DEBRIS DISPOSAL FORM & µOF?r" q �O� i ti y� COC [W KA I.L�oR�1TlD PP¢.t't� 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 c1'1, sI50a. The debris will be disposed of in /at: AP"n,, Facility location Signature ofApplicant Date NOTE: A demolition permit from the Town ofNorth Andover must be obtained for this project through the Office of the Building Inspector. WD WD 0Oj 4.1 L v cn 0 N w a c •v o w o w x U ao w o � w aw c� c a w" a u a w o a ci � w" a � o a c w z w cra z cn JA ° cn = o •CD c o IA4: Q I 2 = L `. O N v �O C *4-.R ci 40 c ms I c La :mm o my N cp =mcc O C O O �oKCS w o s � o os Va COL ca V•�Z O _ O O Om v O 0.0 c r.+ •tii CIE -.S Z :03 m .y C V� •m ® m c CO3 CL IDg _ w m 0 A C aCl CL� go 0 CO2 co CO) U CD CL CD O co Q _cc CO2 O CL CO2 0 C _R Cc - COD r� LLJ 0 U) U) Ir W CCW U)