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Home My WebLink AboutMiscellaneous - 95 PEMBROOK ROAD 4/30/2018Location No TOWN OF NORTH ANDOVER Z Certificate of Occupancy $ ,ssACNUSEt�Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 17323 -8-uilding Inspect 1. Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 0 0VQ.-I Signature Telephone 1.3 Zoning Information: Zoning District Proposed Use 2.2 Owner of Record: 1.4 Property Dimensions: Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Regaired Provided R aired Provided 3.1 Licensed �Supervisor: �lConstruction 1.7 Water Supply M.G.L.C.40. 54) Public ❑ Private ❑ Zone 1.5. Flood Zone Information: Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Name (Plint) Address for Service: Signature Telephone 2.2 Owner of Record: `a s Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed �Supervisor: �lConstruction Not Applicable /D Licensed Construction Supervis A/ //y License Number Addr �J -&7j / Expiration Date Signature Telephone R 3.2 Registered Home Improvement Contractor m s3,sC,� AW )�� Not Applicable ❑ Name a Company 10I A /,� �D, "�� (%� Registration Number � /_ /j gate Address 64��ExpiC�ion Signature Telephone m�. 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:.. l i i i I SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item 1. Building Estimated Cost (Dollar) to be Completed by permit applicant QFF4ICIAL �;; (a) Building Permit Fee Multiplier USE QNI,y 1"op rv;• 2 Electrical (b) Estimated Total Cost of Construction�Q� 3 Plumbing Building Permit fee (8) X (e) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on My b a f, in 1 r Mwork authorized by this building permit application�� Signature of Ownffr 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 Si ature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR T MBERS iST 2 ND 3RD SPAN DIN ENSIONS OF SILLS DINIENSIONS OF POSTS DRAENSIONS 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 A NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9! DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in properly licensed solid waste disposal facility as defined by MGL Chapter 111, S_ 150 A. The debris will be disposed of in: ti (Location of Facility) , ql-,,Wll-�Z4 Signature of Permit Applicant of � Df Date NOTE: Demolition permit from the Town of North Andover must be obtained for this projeo through the Office of the Building Inspector The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02911 Workers' Compensation insurance Affidavit Name Please Print Name: Location:9� /pie-P�/ City )141%Q UIQ% %� Phone # g7e-76kf —61,,72-7- I am a homeowner performing all work myself. am a sole proprietor and have no one worldng in any capacity' I am an employer providing workers', compensation for my employees woridng on this job. Company name:. Address ow. Insurance. Co. /—RA/0 /y)r-/2 )� //Y, �(/ Policy Company name: - Address: . tit ja: Phone* * Failure to secure coverage as required under Section 25A or MGL 152 can lead to the irripasifion chriminatpenanimor.alk arKVor one years' imprisonmentas_we9-asA%A.pxaafties foe-dA$;Il M)-aliay understand that a copy of this statement may be forwarded to the Office of InWestiiatiorls of the DIA for coverage verirrcmon. / do hereby owW Me Va Wils and penalties of penrjury the the agurnxiboa provi led above is hue and correct CGnn!zhirrs Print name W91,�l all%(z k -t)iz . . P # �7��0�� Official use only do not write in this area to be compk ted by city or town dfiic iar I z IING REGULATIONS -ION SUPERVISOR . 22.680 Tr. no: 26824 i � � ✓�ie Two�n��ta�ruuP,a�i o� �.aaaac�7,��"�""" Board of Building Regulations and Standards r 9 ROME IMPROVEMENT CONTRACTOR 1 Registration 103358 i ' =_ t Ex irafion t P � 7f7J2004 t Type Private Corporation . A. JASONS,INC/LSH & 4 Arthur Wal§h,Jr. r 55 Pleasant Sty N Andgver MA 0:1845, (' Ad i"ktratnr a rA rij tvi pq �°. Cl) O v c° U x° O a0 s C —co W x 0 w c z 0 1 co ,r s C .L" N 6 O O om 3MA O N �� o .� Cos O O Em a8 � m N O ' = _ O Of C O Q �_ N ®.� cc V hO O 0 � CO CL � c Q O m c •O ® m O N CD m •N e-. AD is co �E O. = C c, .o w Z CS Lu C.3 CD o,. ®_� C42m� FE A 210 m ® N �' .. O_ a CL� �mm I coO co O O v co C. O y C O cm CA O O � LA O O �E m m CD CD Lft CD G3 o M® a CL c� c ev cd Vco J .� A. O *., CO3 2c C.3 co CL C.) CO) cc C c d N Y/ W W W U) yt MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print //or Type,)) Mass. Date 9-1-k . 19 9/ Permit # ` Building Location ��/ AWZ4%C� Owner's Name �Type of Occupancy G New Renovation ❑ Replacement ❑ Plans Submitted: Yes❑ No ❑ Installing Company Name �% �5 �G - °�1�-- Check one: Certificate Address 70 ❑ Corporation ❑ Partnership Business Telephone 373- / ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE: I have a current �I'a�r'lity insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes L �' 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 Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner❑ Agent ❑ Signature of Owner or Owner's 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 issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Ge a al Law By T e of License: _ Plumber SignatuRe of cense umber or as fitter Title asitter Master Mastter License Number / d City/Town Journeyman APPROVED (OFFICE ONLY) . V/ , 30 4r N (A ¢ W �A N N Y U Y ¢ N h ¢ N ¢ O O N S F W W N ¢W O H U m H S 7! _ O o f a a¢ ¢ _ O O O ZZ r ¢ W O d C 0¢ N V A W S = ¢ y ¢ = a ¢ ¢ W 0 �.., a W f, W = N ¢ C7 Z f- a = W J a z ¢ F- — W W >. to O m > Z W O F 2 U a J O �. N W I a W > W 7 2 a ¢ a a O O W O w H SUB—BSMT, BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR eTH FLOOR 7TH FLOOR - 8TH FLOOR Installing Company Name �% �5 �G - °�1�-- Check one: Certificate Address 70 ❑ Corporation ❑ Partnership Business Telephone 373- / ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE: I have a current �I'a�r'lity insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes L �' 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 Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner❑ Agent ❑ Signature of Owner or Owner's 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 issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Ge a al Law By T e of License: _ Plumber SignatuRe of cense umber or as fitter Title asitter Master Mastter License Number / d City/Town Journeyman APPROVED (OFFICE ONLY) . V/ , 30 4r Q s y z N m A -� Q a M t .i �_ D r z N 9 m n I -1 O 2 s 4 N , m n x m '^ ' r. _ m s i� c A m _ ; s m s =� v O m a 7D r O z � .p n O r a � s m ,� m -+ r m o 0 ,' c v► a � 4 m o 3 = p a 77 r�i� A � 9 ZO 1 _ 9 � a Li � � ; n 7 �" a m f � c m O � o '" 0 c o = a s � J � I "'� � I A i v ! a O a ; m y I i y 9 m A �_ O .._ . - Z i �_ E� a �r'Date."�.:..1.. j NORT1y _ T6WW OF NORTN ANDOVER' - ot,�Eo ,gtio r '•Ir?"PERMiT i fx O AS INSTALLATION A. FO ��9SSACHUSEt�hf This certifies that.. . %', .,+ . .� ..1 has permission for gas installation ...... in the buildings of ..`r .. ........ .. . at North Andover, Mass. Fee.. I' ..--'.Lic. No. j' :,�.. . ...... ...;. t GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD File