Loading...
HomeMy WebLinkAboutMiscellaneous - 96 FARNUM STREET 4/30/2018IV PERJIIT NO. I APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 MAP NO. I LOT NO. 2 RECORD OF OWNERSHIP iDATE BOOK PAGE ZONE SUB DIV. LOT NO. I LOCATION PURPOSE OF BUILDING OWNER'S NAME ` NO. OF STORIES SIZE .. OWNER'S ADDRESS BASEMENT OR SLAB ARCHITECT'S NAME BUILDER'S NAME SIZE OF FLOOR TIMBERS 1ST 12ND 3RD V SPAN �A DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREETNo n POSTS _ }�// DISTANCE FROM LOT LINES — SIDES 'f tf REAR `^r- GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X 10 IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE { ^rfJ /1 IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION, IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS SEE BOTH SIDES PAGE i FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED PERMIT GRANTED 9/5Y �3 19 3 PROPERTY INFORMATION LAND COST .'s EST. BLDG. COST / C-0 EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN eft C V 7,- � BUILDING INSPECTOR v 'NV1d 101d S3OV1d3H SIHl 'a3SOdW12i3df1S '013 'S30VN -VE)'S3H0N0cl H11M 'SONIa1If19 d0 SNOISN3WIa 1OVX3 aNV S3N11 101 WONA 3ONV1Sia aNV lO1dOSNOISN3WIa lOVX3 MOHS1.Sf1W N01103S SIHl 31 aa033b JNIa11n9 ONIIV3H ON _ I Pic I j51 DISID313 P"z 1. W.9 li0 SWOOa dO SV0 S831V3H 11Nn 91.H INVIOVM ONINO110N0O 211V _ Sd31dVM (JOOM OdVA 210 M.1,M IOH -S10D V 'SW9 13315 WV31S 'S10:) V 'SW9 2139WI1 ind 81V IOH (13JMOd 3OVNMnd SS313dld 1SIOf 000M ONIIV3H LL oNIWVMd 9 210013 3111 S36n1X13 N4300W M3MOHS 11V1S ON19Wnld ON NNIS N3HO11>I haO1VnV1 13SOID M31VM CXld L) 'WM 131101 'XId EI H1V9 ONlewnld OL 3NON 31yn030V 800d I MOIM3dnS ON 1211 M 210014 T SnS DI11V 3111 'HdSV NONJW07 sMOOId 6 N3HDIDI NM300W WOOM 0V3H S3OVld 3MH 1. W.9 ON V18V DI11V 'Nld % 1/1 'A V3MV ,1.W,9 'Nld lln3 V3MV IMMSV9 £ N13Nn IIVPA AMO M31SVld SM3 _ 0.M0MVH 1d 3NO1S MO X0IM9 3NId 'X,19 313MJNOD E L 1 9 313MDNOD HSINId MO11131N1 8 NOliVdNnod Z N011Of1HISN00 SiN3WIdVdV S3O13d0 AIIWVWVd I1lnW S31M0!S AIIWVd 319NIS .IONVdn000 L 13AVMO '8 MVI 31VIS S30NIHS DOOM S3I9NIHS 1lVHdSV 03HS 1Vld OMVSNVW13HWVJ dIH 319V0 dooa 9 X19 M30NID 210 ':)NO:) 3WVMd NO )IOIM9 AMNOSVW NO )IDIa9 3WVMd NO OJJn1S AMNOSVW NO ODJn1S ON101S 'iUA ONIOIS SO1S39SV ON101S 11VHdSV S3IONIHS DOOM `JNI01S dOM(J SGMV09dVl:) S1lVM 17 Date..?-.. - 0 q ... ........................ 4, TOWN OF NORTH ANDOVER IL # PERMIT FOR WIRING This certifies that.......... ........ 4� .................................................... ........ has permission to perf orm ....................... ........ .. wiring in the building of --a ..... R-1.1 ............................................ at ... 7A ........ .ir'l...... North Andover, Mass. Fee -3-5 ............... Lic. No. 7A?. .5 ................. 17ELECTRICAL Check -Z/-- M �L\ Commonwealth of Massachusetts Official UseOnly AN EKM Department of Fire Services Permit No. O.3o S c�5 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date:. 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) f�dz /v b 44 Owner or Tenant b P,4 61 &-), p iy- e Telephone No. Owner's Address nt L ?'—"r4 0 tt! U A . ( Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building �D W 2 I Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 3 S;�'AZ a AJ PTC) AA,_ — _( ANS r A �fpcf 0(,C- Completion `t,C Completion of the followino, tahlp mm, ho wniveil h„ the Tna—mr of w;-. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- F] rnd. rnd. o. o Emergency Lighting Batte Units No. of Receptacle Outlets G No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiatin Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump Totals: Number Tons " -'I KW """""".....""' No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs 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: ' '- Z Z—p'& 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 coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE eBOND ❑ OTHER ❑ (Specify:) I certify, under the ains and penalties i erjury, that the information on this application is true and complete. FIRM NAME: 4A Pvo N Yr r T LIC. NO.: '74 S�, Licensee: oPt Ul&A-N- (� 'r Signature.--- LIC. NO.: 7.4, s ` f} - (If applicable, enter "exempt" in the li ense nymber line Bus. Tel. No.: 1� 8 ` 6 g 7 30 3 Address: o2 'I C8 IV - 7- ` ►V( Alt. Tel. No.: f7 t - 7C y- 94' 3y *Per M.G.L c. 147, s. 57-61 ecurity work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCEWAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law By my signature be w, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Age Av" Signature _ Telephone No. PERMIT FEE: $ �j` E9 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name Address: t -0-z PV S r— City/State/Zip: 4 A w eVl p Z y zL Phone 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 2.0-1 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. [No workers' comp. insurance required.] 3. ❑ 1 am a homeowner doing all work myself. [No workers' comp. insurance required.] t workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. E1,11temodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs 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 are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am 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. I do hereby cAtify under the pains and penalties of perjury 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 # ?7— 2 2 —b-6 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 Location No. <5��f Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee TOTAL Check # 1, �/ 9-3 1 8L-5 L/ Building Inspector "' TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REP RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE:2A Building Commissioner/ffispector of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 4"/71 S14 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area / Fronts R 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Re4pired Provide ReqWred Provided ReqWred Provided 1.7 Water S M.G L.C.40. 54) 1.3. Flood Zone Information: Zone Outside Flood Zone ©- Public I Privato !�L a 1.8 Sewerage Disposal System: / Municipal 0 On Site Disposal System EY SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT I c F Ct. i^ ; F10 2.10 of Record Ll 1114 Name 'iitj"--- . J Address for Service Si na r6 r Telephone 2.2%Owner' f ecord: Nam rint..) r o "�. Addr s for Service: q 7F / Si atur6 Telephone SECTION 3 - CONSTRUCTION SE VICES 3.1 Licensed'eonstruction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable 0 Company Name Registration Number Address Expiration Date Signature Telephone SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 f 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 hermit. Si ed affidavit Attached Yes .......0 No ....... 0 SECTION S Description of Proposed Work check se a ble New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) 7TIMtion 0-1 Accessory Bldg. 0 Demolition 0 Other ❑ Specify Brief Description of Proposed Work: uz/ W,'/) /]� 'n'A4"'�� e '�) a J-)� cc-) 'Ale i' /I i .S'J 7 I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I Item Estimated Cost (Dollar) to be Completed b t applicant OFFICIAL USE ONLY :.. 1. Building f �D (a) Building Permit Fee Multiplier property 2 Electrical (b) Estimated Total Cost of Construction b f 3 Plumbing Building Permit fee (a) x (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number bZU11Ur is UWALK AU inUMIZAHUN TU BE CUMPLETED WHE14 OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, a i' q /= 4- ®'J /9--q as Owner/Authorized Agent of subject property x Hereby au orize / -tok llAw! �tr / to act on My - f, in.all m relati�authorized by this buildGh permit application. Si is 'e ofer Date SECTION 7)b OWNER/AUTHORIZEI) AGENT DECLARATION I,4 i V A-elG `�' as Owner/Authorized Agent of subject property Hereby f e that the statements and information on the foregoing application are L*ue and accurate, to the best of my knowledge and heti ''") 1 14 Pr' f`Nani Si6a&rd/otbwner/Aii6t Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIlaERS 1 Yr 2 NEI 3 RD SPAN DM ENSIGNS OF SILLS DIN ENSIONS OF POSTS DIN ENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHDANEY 1S BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE firr, dl� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 11; `AA4,,r V I A! 0!N V e Owner: )11190f /fi(MOL Date of kupection: t j zt (ay SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) '" ,; <11_W4 r7l' revised 9/2/98 Page 10 of 11 3 5&43ON NAX# Ar30v� v)e► ve" y ri FORM U- LOT RELEASE FORM 3( I t IV S 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 LOCATION: Assessors Map Number v /4 SUBDIVISION STREET t ly 1-1W I)I JI ` OFFICIAL USE ONL DATE APPROVED DATE REJECTED CO TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS `F OD I CTOR TH DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PHONE-D21&IV PARCEL gE LOT (S) ST. NUMBER PUBLIC WORKS - SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE R*vWW X197 Jm 3 2X8 DECK JOIST 16".O.C. —� 2X10 CANTELEVER WITH 4X4 POST— csAURDRAIL HIEGHT 36" 5ALUSTRATE 5" O,C, HANDRAIL HIEGHT 34" POST TYP, \—(5) 2X12 STRINGERS EQ, SPACED -GAURDRAILHIEGHT 36" 5ALUSTRATE 5" O.C. HANDRAIL HIEGWT 34" POST TYP: 2X8 DECK JOIST - (5) 2Xi2 STRINGERS 16" O,G. �. ` ° r=(2, SPACED 2x10 CANTELEVER WITH 4X4 POST ELEVATION &GALE: 1/4" • P-0" 6'-411 O 12" O O 4 T7 "v in O O O FOUNDATION PLAN r1Xll r O ci r z I , X X X (1Xm 0 m 4 -4 A rt mAA � 0 0 v N n d 6 PARNHMM STREET RESIDENTIAL NORTH ANDOVER, MA P.O. BOX 5 . MORTGAGOR DEED REF, ADDRESS OF PRINCIPLE BUILDING P fo PG. —jy •-- ��£► rcltlM �i' PLAN REF. DATt OF INSPEO-nON * 4ce. -, r n:: cl0' r:� �Arin1 vr� NOTE:•'� Rite mortaaq• fnsnectian re,� o►r+oer..1 ,�'%� �N 1' I FURTHER SATE THAT IN uY pR7rVkq-arwji be rdledd a "or m6mpd9e PUPPo•a and IN not to _ on es o wryd OPINION the y+ F3f SUItVt;Y T. � Drfnctple etrvotu►. a and 000.r. no rapen Itty for dwno u °°`'fit' AUDCI outbuIldfrigs, �ore:}�c� 4 rallQncs bY'�Y�e Ot?leP on the 101d No. 36669 *1th the htboc* �—+ and fb assf9n• caonn�ctlon o r0n� ►�quwmanis of Eta• ictal M009a9• finonohiq to "Id moatp gor, ��. � ffCISf[9. cf major knP+0VwnMU that ho enofiroachminte T1i1GAi10N TQ Prop" "nee exr pt Of �!�Y varoos i i I Thls c.rtlrttalEon N basod on the t ■1 P ' Y GI hot Al o flood tioxor,d ,� : f e t h ", end d ph. ■ . 4 �� _ _. , ocutlon a r VWVO to orWV L7 z pr P*" is In o flood HCM Wd Ara.. f °° North Andover Building Department Tel: 978-688-9545 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 a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: (Locatio�lof Facility ' ignature of -Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector A f NORTH TOWN OF NORTH ANDOVER OFFICE OF p BUILDING DEPARTMENT > ; + 400 Osgood Street North Andover, Massachusetts 01845 D. Robert Nicetta, Building Commissioner HOMEOWNER LICENSE EXEMPTION Please print DATE:? JOB LOCATION: U Number Street Address HOMEOWNER Name PRESENT MAILING ADDRESS City Town Telephone (978) 688-95454 Fax (978)688-9542 Map/Lot /�/ /�.�q,o�,o q7�-���iy�9g7f- me Phone Work Phone Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings to 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 (Code Section 108.3.5.1) DEFINITION OF HOMEOWNER 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 structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned "homeowner" assumes responsibility for compliances 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 dover Building Department minimum inspection procedures and r cements and/t);af6e7 }fie will comply wi said procedures and requirements. ! / , kAIall JI 'LlM:7&IMZG1 APPROVAL OF F;OARD OF APPEALS 688-9541 CON SFRA' \TION 698')530 IIFALT11 689-9540 PLANNING 688.9535 H- O H o CD o cA x O ` a O p. Z O w a w° C4 U w a a°' w a a Q' w a°' w A 0 vii H- O H �� Z O co Do O c■ L CD z h O — I C C CD cm O ca ca O O ■ ca CC CD Z O� O O � O CC ® a cmQ CA c ev v � ■v d O ca Z � C CD CL v y � c c— ■� C Cos LLI 0 UI LLI U) Ix W cz LLIW N CD o cA O ` O p. Z O �o� J• Ly mO Q' �• Q CO ID C w 41 `S CP� 0 mc� E m � COL m X�3p9 .r O O N Em Qo CLC., 1► C'm� m ac yCR o �c a 'v O VL ICD M Z � o R 000 a of � CD S COD CLI; ,.m to t m m w W o C r .� H .y ' Z re AA C Z W E v .o as ca O a CM m� C3 CD �1 COD A 0� y O C �._�CLO > �� Z O co Do O c■ L CD z h O — I C C CD cm O ca ca O O ■ ca CC CD Z O� O O � O CC ® a cmQ CA c ev v � ■v d O ca Z � C CD CL v y � c c— ■� C Cos LLI 0 UI LLI U) Ix W cz LLIW N Location—/ No. o�6ro Date TOWN OF NORTH ANDOVER F w ' Certificate of Occupancy $ Building/Frame Permit Fee $ QCMUS Foundation Permit Fee $ 1 Other Permit Fee TOTAL Check # t" P W// 17662 )_ to -2 // Bu ding -Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT Ai'PLICATION TO CONSTRUCT REPAIR, RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING s� s t7777m BUIL DING PERMIT NUMBER. DATE ISSUED. O ic SIGNATURE: )� 7-6� --I Building Commissioner/lETectoi of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Ai1,)&I.,�234ee 1 l /G', L n% Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Reqt1ired Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood lune Information: Public ❑ Private 0 Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHM/AUTHORIZED AGENT " 51:CMC; District: Yes �t� M "2.1 Owner of Record Name (PnV Address for Service U Signature Telephone �:d 2.2 Owner of Record: Name Print Address for Service: z M Signature Telephone }0 SECTION 3 - CONSTRUCTION SERVICES R" 3.1 Licensed Construction Supervisor: Not ApplicableLC7 Licensed Construction Supervisor: 0 License Number Wn Address Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number r Address z Expiration Date G) Si nature 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 s0 applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: vIkI u7 'o V4.0v /J./ .LAG I CRCTInN 6 - F.CT1MATFTI Pn?VQTDTT9—r4/lAT nnc•rc Item Estimated Cost (Dollar) to be Completed by permit applicant—, OlF#FICIAL'USE ONLY 1. Buildinga () 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 ,"` acv ,j o-� 00 Check Number •--• �• ----• • . » .� .......ate .z....i�+av�e� a ivi� a v ur. 1. v1�1tLL' 1 EL W t1C.19 OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property an +�/— Hereby authoriz �I/�,GL j /1??a 0� � �nQ to act on y beh, ; z CLM H CO3 W H oc W H f - c O � O H C v V MC �O A m C :Z O O Ea c 0 0 m O o. 0 h C ii� ..;cm C oQ 0 O C z C O` O O d CL O Ota O d Z CO �.+ c UI.,.0a " JD CD C o�t� .. a .. m E Z NJ G* C co m 0) m 0 cm C .0 N m Z O z O g 0 M N O O E O L cr. v v Z � O y Q C CO CM I C� C Q .� y O .co) f m m CD L- CD O� �3 C O O Q O L m O d CQ c � c ev C Z tsO O Q. U y O � C t0 CO) Cl u o a w w w a U � A w w°' w a°' w c,° 79 w a w r. t. aq z cn o cn z CLM H CO3 W H oc W H f - c O � O H C v V MC �O A m C :Z O O Ea c 0 0 m O o. 0 h C ii� ..;cm C oQ 0 O C z C O` O O d CL O Ota O d Z CO �.+ c UI.,.0a " JD CD C o�t� .. a .. m E Z NJ G* C co m 0) m 0 cm C .0 N m Z O z O g 0 M N O O E O L cr. v v Z � O y Q C CO CM I C� C Q .� y O .co) f m m CD L- CD O� �3 C O O Q O L m O d CQ c � c ev C Z tsO O Q. U y O � C t0 CO) Cl u TOWN OF NORTH ANDOVER AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application MGL c. 142 A requires that the "reconstruction, alteration, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units...or to structures which are adjacent to such residence or building" be done by registered contractors, with certain exception, along with other requirements. Type of Work:-%aw-lyiIr64w &10-10o2 Est. Cost OO Address of Work ��r/Il�rn S�rP Owner Name: J Date of Permit Application: ate' I hereby certify that: Registration is not required for the following reason(s): For office Use Only Work excluded by law Pemit No. Job under $1,000 Date Building not owner -occupied Owner pulling own permit Other (specify) Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FIND LINER MGL c. 142A. Signed under penalties of perjury: I hereby apply for a permit as the agent of the owner: Date OR: Notwithstanding the above noti 4V /� D to Contractor Name Registration No. Date.. �/:-. "). �. -. �. '- TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . (.'. 4 - . . . //)/( ............... has permission to perform ... ..... D.(,k .................... plumbing in the buildings of ... PA1.0. q � ................ at ... (?. ....... North Andover, Mass. Fee. . Lic. No..p .. ....... .... .......... PLUMBING INSPIECTOR Check # 5217 MASSACHUSETTS UNIFORM APPLICATION FO PERMIT TO DO PLUMBING �-\ !Print or Type) NORTH ANDOVER, . Mass. ()aten�-- 5,217 J Building Location - 0/' s'7 Permit * •XMI! 11004 de; owners Pop G/ Uw ,- ..Name,-. (_ New ❑ Renovation ❑ Replacement p-- Plans Submitted: Yes ❑ No. ❑ FIXTURES P- Check one: installing Company NameLL/�.t� �/� cod, �._.�1'� f� Carp. Address 9/ aitz&'L� ❑ Partnership Al - zl&,c U1- — C, Firm/Co. ou=:...ss Telephone Cr 5u 3 Name of Licensed Plumber 7—,,/7 Certificate ' -y/ 51C iNSUF[AiiCE COVERAGE: peck o►�e I have a current liability Insurance policy or Re substantial equhraterd. Yes 9 No 0 If you have checked M, please indicate Ihe�bjpe coverage by checking the appropriate box A liability Insurance pollcy 9- . 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 o(the Masa. General Laws. and that my signature on thla permit application waives this requirement. Check one: a care of Mnef of Owmer s en 11- Owner ❑ Agent ❑ (hereby certify that al of the detalls and Information 1 have sub Mad for en ira0 In it�knowled�e and that all plumbIng work and InstaNatlons performed under thei\pie2m.►611yWInen provislons of the Massachusetts State Pkanblrp Code and Chapter 1 By Title Ctty/Town Al"UM) (OFFICE USE ONLY) bctKAJA to the best of my in Kana with all License:qg `16 3 O / Typed license: Master [j-' Journeyman ❑ si M r� sW • » a s N J M < st < h s O d M` log .� M r M r = �. aL a s M M •66 0 IL x 3 < u y$- a I i a I- i o$ WX s ` v 0Us me le 1 i or o j s e6 M d a o s s e`ri i e=i sua—aaMT• MAeRMaNT 16TFLOOR INOFLOOR $110 FLOOR 4TH FLOOR sTH FLOOR STH FLOOR. ^ ITH FLOOR aTHPL00R - Check one: installing Company NameLL/�.t� �/� cod, �._.�1'� f� Carp. Address 9/ aitz&'L� ❑ Partnership Al - zl&,c U1- — C, Firm/Co. ou=:...ss Telephone Cr 5u 3 Name of Licensed Plumber 7—,,/7 Certificate ' -y/ 51C iNSUF[AiiCE COVERAGE: peck o►�e I have a current liability Insurance policy or Re substantial equhraterd. Yes 9 No 0 If you have checked M, please indicate Ihe�bjpe coverage by checking the appropriate box A liability Insurance pollcy 9- . 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 o(the Masa. General Laws. and that my signature on thla permit application waives this requirement. Check one: a care of Mnef of Owmer s en 11- Owner ❑ Agent ❑ (hereby certify that al of the detalls and Information 1 have sub Mad for en ira0 In it�knowled�e and that all plumbIng work and InstaNatlons performed under thei\pie2m.►611yWInen provislons of the Massachusetts State Pkanblrp Code and Chapter 1 By Title Ctty/Town Al"UM) (OFFICE USE ONLY) bctKAJA to the best of my in Kana with all License:qg `16 3 O / Typed license: Master [j-' Journeyman ❑ 14 - ?7 2-- Date..................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ..................... ............. has permission for gas installation ...................... fimhe buildings of ................ ......................... . . . . . . . . . . . at North Andover, Mass. Fee:: . Lic. No ........ '4 ........... GAS IN90ECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) G ri /i Ajea)p ell- MA Date 3 /y 20OxX Receipt# Permit# Building Location 9b ���>/.� sT Ownet'sName Map: Lot: Zone: Type ofOccupancy..�-T., G New Renovation ❑ Replacement Plans Submitted: Yes ❑ No ❑ EncTTiDNT PPnPQNF X, nTT. TNr Installing Company Name_ Address 131 WATER Estimate Value of Work: Business Telephone ST DANVERS MA 01923 800-322-6628 Checkone: Certificate /"' Corporation ❑ Partnership ❑ Firm / Co. Name of Ucensed Plumber orGas Fitter 4!v / e— INSURANCE COVERAGE: I have a current liab"ty insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 3No ❑ 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 an this permit application waives this requirement. Checkone: 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 knowledae and that all plumbing work and installations performed underthe 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. By Type of License: ;z��� Plumber Signature of Licensed Plumber or Gas Fitter Tide Gas -fitter Master City /Town �Joumeyman APPROVED (OFFICE USE ONLY) License Number Revised OW171CO ��ME ■moi■ouu■■ ME ME ME �ME SOMME ME OEMMMooMM■Mmo ONSME ME SEEM MEMEMEMMEMENE mum■ ou■■n��■■ ■�■n■�■■■■■ nom u�io o�iiiii ��v�o�i■■gym■�■� EncTTiDNT PPnPQNF X, nTT. TNr Installing Company Name_ Address 131 WATER Estimate Value of Work: Business Telephone ST DANVERS MA 01923 800-322-6628 Checkone: Certificate /"' Corporation ❑ Partnership ❑ Firm / Co. Name of Ucensed Plumber orGas Fitter 4!v / e— INSURANCE COVERAGE: I have a current liab"ty insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 3No ❑ 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 an this permit application waives this requirement. Checkone: 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 knowledae and that all plumbing work and installations performed underthe 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. By Type of License: ;z��� Plumber Signature of Licensed Plumber or Gas Fitter Tide Gas -fitter Master City /Town �Joumeyman APPROVED (OFFICE USE ONLY) License Number Revised OW171CO r . u Z O r U W a N Z_ U) cn LU C7 O a y W T U r LU Y N W W LL 0 N n W r z Q d W W IL 35r u Date ....,//� ... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........ �.... �........... .......................... .........:................ has permission to perform........................................................../................... wiringin the building of .......................................................................... bat / '�r 1 ! '' �l ..... , North Andov ( a's Fee..Jf .5.. t..J... Lic. No.�. ..............:.........lh�...... ............ ELECTRICAL INSPECTOR Check # (� ✓ THECO,ILNfOA E4LTHOFALIMC f]USrEM D0?4RT MW0FPUBIK&4FE7Y BOARDOFFIRE'PRE71 MONREGUTATIONN52704R]2,00 Office Use �only � r Permit No. 'S Occupancy & Fees Checked hr -PLICA TTONFUR T'LK1 .j TO 1'EKFO1UVJ ELEC1RICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE IvtASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Town of The undersigned applies for a permit to perform the electrical work described below Location (Street & Number) Owner or Tenant r /may r/vv w+ To the Inspector of Wires: PARCEL O"mer'S Address Is this permit in conjunction with a building permit: YesNo (Check Appropriate Box) Purpose of Building Existing Service —, New Service Amps / Volts O>reP]'iead r=J-underground Overhead Underground Number of Feeders and Ampacity r Location and Nature of Proposed Electrical Work Utility Authorization No. No. of Meters No. of Meters No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA ground ground No. of Receptacle Outlets No. of Oil Bumers No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipal a Other No. of Dryers Hcating Devices KW Connections No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OT ER - 1 ." . • •Y. 1. ` - tl . 1 - :. il: : 1. • ♦`:• I, rz Rkit : N. .• nr:• . i• • •• • • .• 1 • •ilr 5. � • 1 • s • :• :• •`t► • xc- � uw: i - •• • •• :..�• • • :• � � 1 •i.n• b'r `u :1::• •. 'SNI •1 Al :• or. 1 `: ; 11 • • •: 1=1sce �atxx_f _��_77V Zs9mn _ Li=wm � 3 BuinmTd7 —2/ ey Td.Na OWNER S WSUR/INCE WAIVER; I amawkmethat tht:Ltomsc&*N m th wthemard=ov mig�crz sulMrt,tl e4zmibias mgmudi y,Nb%advgc m C==dLa"s and diarm-stg muconrbcspeurmapphca6mwarmsthisr4maTntl (Please check one) Owner Agent a Telephone No. PERMIT FEE $ Igmature o %veer or Agent L$cation No. Date % 112- N0RTh TOWN OF NORTH ANDOVER 9 + � • + Certificate of Occupancy $ cNBuilding /Frame /Frame Permit Fee $ s�usE Foundation Permit Fee $ Other Permit Fee $ dV TOTAL $ Check # 'i 5 3 Building Inspe� or SIGNATURE: it SECTION 4 -WORKERS COMPENSATION (NL G.L C.152 § 25c(6) =� Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will res in the denial of the issuance of the build' permit. Signed affidavit Attached Yes ...... No. .-...o ' SECTION 5 Descri ..tion of Proposed Work check an a livable New Construction 0 Existing Building ❑ Repair(s) ❑ Alterations(s) .8- Addition 0 Accessory Bldg. ❑ Demolition . ❑ Other ❑ Specify Brief Description of Proposed Work: cek,� SECTION 6 -ESTIMATED CONSTRUCTION' COSTS Item Estimated Cost (Dollar) to be Completed by permito cant I . Building(a) Building Permit Fee C)y cc , -LU Multi tier 2 EletWedll (b) Estunated.Total Cost of - .. Constntc�'ot1 3:Plumbing .Building Permitfee-.(aj x (b) 4 ,Mechanical(HVAC)7-77. 5 Fire Protection 6 ..._.Total ,.f+2+3+4+5 ..:.....1.C*)nC._,Ch jVumber. SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WREN OWNERS AGENT 11 OR CONTRACTOR APPLIES FOR BUHDING PERMIT I, Uas Owner/Authorized Agent of subject property ( n ,. Hereb uthorize -q to act on My ali relative to work authorized by this building permit applicat- Vct (�. Si er Date SECTION 7b OWNER/A AGENT DECLARATION I, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are tree and accurate, to the best of my knowledge: and belief = oc L Print N e t2 C a Signature o r/ Date i NO. OF STORIES SIZE , BASEMENT OR SLAB SIZE OF FLOOR TIRABERS ] 2 3 RD SPAN DIMENSIONS OF SILLS DEMENSIONS OF POSTS DEVIENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS 7 SIZE OF FOOTING X MATERIAL OF CHDANEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE )I Z Ok 43 W s: � c o O o a o U o � x 0 w p dC w cum O C 'O °o w v cn O cc � G o w o w v �c U x a o o; x w x o w u G w CD It o w' G w w r. rA 6 cn Q O cn I m _N Z zoo C2 N C 0 cc cm C m O CD C �C N O Z 0 Z Q 25 T a7 O O O � L O V Z °D 0. O y � C I cm C) O •— CACD 0 ._ y CD O 'E m m cm CD L MO Off. CL C a ca C Cc v ca .0 Z ts CD V h c C C■_ ■ C cc CLH 0 U) U) w w LLJW U) c o o i o � wv a'o dC cum O C ;t O ++ yr O cc N Ea co ;r _ ts CD It 0 ,0 O O y r r cm MILE N r9 o m3 m '= c N O Eca CD O dV i N O m O r � •: c y Q CL V N O Cx Z cc C� O O. H O y m C = m m:3 � O �pH W C pw-Z LL � •tN mr Cr O •� dt C r Q 'D V cm H d m� O� a N _ � =00"a v O m I m _N Z zoo C2 N C 0 cc cm C m O CD C �C N O Z 0 Z Q 25 T a7 O O O � L O V Z °D 0. O y � C I cm C) O •— CACD 0 ._ y CD O 'E m m cm CD L MO Off. CL C a ca C Cc v ca .0 Z ts CD V h c C C■_ ■ C cc CLH 0 U) U) w w LLJW U) North Andover Building Department Tel: 978-688-9545 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 a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: kL-ut;auun of racniry) Si nature of Permit Applicant Daae NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector Please Print F -IU am a homeowner performing all myself. 01 am a sole proprietor and have no one working in any capacity am an employer providing workers' • Cornony name: Address City: Phone #: working on this job. Insurance Co. Policv # 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, a the sins a e perju that the information, provided above is true and correct Signature v Date < Print name�i�'�C�� ��� Phone #<R-7 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 Contact person: Phone #: E] Selectman's Office ❑ Health Department ❑ Outer FORM WORKMAN'S COMPENSATION