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Miscellaneous - 98 MARBLEHEAD STREET 4/30/2018
06 `�1C1Ws� CERTIFICATE -OF USE & OCCUPANCY TOWN NORTH ANDOVER Building Permit Number 233 Date: Feb 13 2008 THIS CERTIFIES THAT THE BUILDING LOCATED ON 98-100-104 Marblehead Street MAY BE. OCCUPIED AS Multiunit Dwelling ZBA Approved 2007 IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Joanne Stewart 98-100-104 Marblehead Street North Andover MA 01845 Building inspector, I I- m (A m x m 4 m x cn m m t= ra" Cl) CD MZ CA CD C) '0 06 CA C* CD CD CL C7 CD CD 0 CD W w S CO) CD CL CO2 CD == I co CD rT, A Aw Cf) C/) to 0 8 n, 0 cl) z o ca cr COD O 0 o 0 CD 0 COO CCDL CO) CD 01 ) 0 xr� U.5 mom CD dl M 0 =r CD m -1 Cf) C/) to 0 8 n, 0 =r z o ca cr COD O 0 o 0 CD 0 COO CCDL CO) CD 01 ) 0 2L rD' 2L CL mom CD dl M 0 =r CD m -1 0 ;; CD = .0 0 CCD2 co Pq 0 o 0 MC * 0 CD CC.'J) S- =r EL CL co 0 CD4C CD y -4, CD co 0 CL CC.D CD 0 0 CA C. CL ccl CL CA U T *."r'. \, cc VJ Go M 0 CD ON ;w co CD C.) -6, Cl) 0 C.D C) C=,,r CD NA CD ti CLa: n c C2 cc,) CA 2 c CD CD Cf) C/) to 0 8 n, 0 0 C, z o o 0 pr CD z Cl PTJ M Pq 0 o �- '.., v - _7 W F cn V ►Oyy-u O cn O —• ca CD Q CA MC CD CO3 CD S m®n m C N C7 a C7 T CD c Z =r -C CA -� o � NO a ca — T CD s CD y m O m CA p N Wim: m 2 > > D o :� m O O C07 O y C2 W O_'CD C a ' a a col C �, cc =r =r; c a >� m O HWE ca H a O? -7 C r CO .� �CD m ,.�.� N CO) H Ni O `1D O CDCD ^� CD o es IN: CD co CD mo,J� o o :� Z o ,o CL C, 2o C, �. H 0 �I 0 5 z "+ �� =; z �? 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Rebar as required 1� Anchor bolts or straps Damproofing Foundation drain - pipelstonelfabric filter/cover and outlet connection. FRAME: Fifeblock - over girts/plates between floor joist- , Penetrations for plumbing,. heat, elec, etc. Walls at stair stringers. Windbrace corners and center' bearing� partitions. Size ridge to provide full bearing at rafter cuts. Hip and Valley rafters - watch bearing at walls. Ridge & Hip - Provide proper connections. Cathedral roof rafters provide proper connections and use "Hurricane Clips" tie to plate. Stair stringers - watch cuts and heal support. Joist hangers - fully nailed w/ hanger. nails. L Sill plates 2-2X6 (1 PT) w/iill seal. _'Girts - solid brick or steel plate,bearing,-at foundations 1/2" air space at sides in foundation pockets. Lateral bracing afe6ds. Certified calculations. required for Beams/LVL's Trusses. :Solid bearing support for Headers/Beams etc. Check headroom clearances -' stairways, under beams Attic Access. (min. 22x30 wd headroom above). Crawl space access. (min. 18x24). Bath exhaust fans to have.,m6tal duct to exterior (not in soffit). Firecode S/R wood frame of "0" clearance fireplaces & stoves Window Schedule or Every Habitable Room Must Have: Natural light equal to 8% of floor area. '/z of required glazing shall be openable. Bedrooms required min. 20x24 egress window or door. Vent attic spaces - "proper vent", soffit and required ridge vents. Firecode under stairs if used for storage FIREPLACES: Separate permit required. Inspections at Footing - Smoke Chamber - Finish Smooth parging, clean joints, 8" solid @ combust. DECKS: Lag to house, provide flashing. Rails min. 36 " high, Baluster max space 5" on center. Over 8' above grade, use 6x6 posts w/lateral bracing. Lag all posts and rails. Pier footingsdawn 48 t6nc.'pad at stair base. FINISH: Handrails returned to-wall/newall post. Guardr6ils required alongside open cellar stairs. Exterior,grading complete. Certificate or occupancy required prior to occupying structure. Temporary Stairs required for inspection. Re-inspbdion fee - $30.00 (Be Ready). Certificate of occupancy required prior to occupying structure. NOPTq .ifAt.. '►.+n ,fit+ �C11� CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 233 Date: Feb 13, 2008 THIS CERTIFIES THAT THE BUILDING LOCATED ON 98-100-104 Marblehead Street MAY BE OCCUPIED AS Multiunit Dwelling ZBA Approved 2007 IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Joanne Stewart 98-100-104 Marblehead Street North Andover MA 01845 Buildinginspector' m m m x m v m _= d CO) Cl) Cl CD O Z CO) CLO �� C CZ a CO) 0 v CD CD Cl CL cr CD CCD O CCD C O Vag — CD = 0 y co CD I C7 CO) O CD 'O Z O CD O CD C oo ?o o d C2 C y O Q y = dO o " y CO2 m n HC! nO m R H o �CA y BAD Co, N ?m m = OcoO ••► n o z5 C2 C O o C9Cc a { l CD S Er coo CL Cn c CD rn C/)m Cc�-0 ' b = CD CA �. > > CA: e-* y n Q cn o a ►� n o ...k _ CD c w cop) N CD O CD Co „n„ CD 0 U' O H 3 Y c D �o..0't CE CDS ►fi ; C ' : . ti(YQ cn \. n OO °�" z ►� � nN ;C 44p-,oma0` n o tz y q 0� d OC) l ft APPLICATION FOR CERTIFICATE OF OCCUPANCYIINSPECTION Building—Permit # .3 ADDRESS/LOCATION OF PROPERTY: /vo , Map Parcel Lot Number SUBDIVISION DATE REQUESTED FILED/READY FOR INSPECTION CLOSING DATE ON PROPERTY: FIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED ALL WORK AND SIGN -OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A RE- INSPECTION FEE OF TWENTY DOLLARS $20.00) WILL BE CHARGED IF THE STRUCTI IRF DOES NOT MEET ALL APPLICA13LE CODES. Permit Issued to: &44wE .S✓ ,Oavv f" Address SIGNED ROUTING CONSERVATION L44�0� PLANNING O DPW - WATER METER SEWER/WATER CONNECTION NOTE DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO _v/SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST DPW Signature File: Application for OC form revised Jan 2007 Jeffrey Jo Cook Architects, Inc. 4 Jackson Street • P.O. Box 7101 • Lowell, MA 01852-0101 - Tel. (978) 937-1871 . Fax (978) 452-2723 February 13, 2008 Gerald Brown Building Inspector North Andover Building Department 1091 Turnpike Street North Andover, Massachusetts 01845 RE: 98-100 Marblehead Street: Renovation & Addition Proiect (#070201) 98-100 Marblehead Street; North Andover, Massachusetts 01845 Affidavit of Compliance and Completion Dear Inspector Brown, In conformance with the Massachusetts State Building Code, 780 CMR - 6th Edition, I have inspected the work and find the work to be in compliance to the applicable Sections of the Massachusetts State Building Code 780 CMR e Edition, MA Architectural Access Board Regulations 521 CMR, ADA, other applicable Codes & Regulations having jurisdiction on this work with all the applicable local, state, and federal codes, requirements, and laws. The original signed off Building Permit Number is No. 233. As such, as the Architect of Record for the project I request Occupancy of the work and the pertinent "Occupancy Permits" and/or "Final Sign -Off s" be issued by your office. If you require any further information relative to this matter, please call me. Cc. JJCA Files Frank Stewart 0701occaoe.DoC CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 233 Date: Feb 13, 2008 THIS CERTIFIES THAT THE BUILDING LOCATED ON 98-100-104 Marblehead Street MAY BE OCCUPIED AS _ Multiunit Dwelling ZBA Approved 2007 IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Joanne Stewart 98-100-104 Marblehead Street North Andover MA 01845 Building Inspector �v m m m m CO) m CA Epm H CO CA Cl) CD n Z y O CL y O go v CD CD O CLc CD CCD .O CCD w a C CD yCD� CL O CO) CD I � v CO) O � Z CD n .ny O CD O CCD =r 0�'` " O C• VJ O Q H CL CD no m z m..c cj 0 oa,Im ti :a CD -4 0 o N m O 7 .CDCA om CD .00 ^O co a�► O Z C• O h oo aom� M C C -0 s Mm Cn c C ? nCD + ` 00 10 l'^f y O =.: d 07 CQ ►� aw CD m CA m CD 00 N; d _ �.TA CG. 4 tik cn o ... o tTj CD ItV o x ti 0 m ' m T N rn C042 t � O z - µa; n,p OQ p, } M- Q w ,?4C c6E v� °o z o �'IN to c x O rl " x z F� f ►�y ��►/�ry � 4.. ►��yy �,a ,� 1 1 r �.z� J v CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 233 Date: Feb 13 2008 THIS CERTIFIES THAT THE BUILDING LOCATED ON 98-100-104 Marblehead Street MAY BE OCCUPIED AS Multiunit Dwelline ZBA Approved 2007 IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Joanne Stewart 98-100-104 Marblehead Street North Andover MA 01845 Building Inspector CA m m m m C4 m CA m d H CD n. Z y d C O H � o � o v CD O O.cr � CD CD CD C CD V, CD CL O CO) CO CDD F as H O \Y 0 CD O CD AA cn Cn n O cn C a 25 CA Cl) m m CO) 2 Cn Cn Cx7 0 -Gi G -moi 7d oc n J /rjC: ?, t G 4 �. C17 r � 7 O 1 C H C cr to z ►r1 CA a� 0®m ti+ w dE3 _ m n dC) d Zy 4: 'tea `I � f• = a o V �\'l ,. Bp ("•1 -4 o m� o \ � O: � •C. H . � V R m O 25 CA Cl) m m CO) 2 Cn Cn Cx7 0 -Gi G -moi 7d oc n J /rjC: ?, t G 4 �. C17 r � 7 O 1 C H C cr to z ►r1 a� 0®m ( to w dE3 _ m n dC) d Zy 4: 'tea M = a o ."555' �\'l ,. Bp ("•1 -4 o m� o \ � 1•� H . � V OO m O s s ca m co o CD Z W cl Q ; � 0 D M C s• N M t s..,�c: CD �=r: OC CD CD '�'':.s. p oCL col cr CL Iff Cc• W a �r N m :P"- �. CO �t C cD CA y o� mCD gr a tr O '.•, CD ;_ .C2 CD ►•� } e� VN CD a IOU '..� s C O W y„z� a ' 25 CA Cl) m m CO) 2 Cn Cn Cx7 0 -Gi G -moi 7d oc n J /rjC: ?, t G 4 �. 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Bp ("•1 yyO� \ � 1•� y •"" Gy'' q yyyyy � V \•° VAI < a -v u 0 r' V z O ti w W H 0 9 0 c CD Zoning Bylaw Review Form Town Of North Andover Building Department 1600 Osgood Street, Building 20, Suite 2-36 North Andover, MA. 01845 Phone 978-688-9545 Fax 978-688-9542 Street: 98-100 Marblehead Street Ma /Lot: 9/25 / Applicant: Frank Stewart Request: Convert existing 2 -family dwelling to a 5 -family dwelling Date: 3-12-07 Please be advised that after review of your Application and Plans that your Application is DENIED for the following Zoning Bylaw reasons: Zenina District: R-4 Remedy for the above is checked below Item # Special Permits Planning Board Item # Item Notes Setback Variance Item Notes A Lot Area Common Driveway Special Permit F Frontage Variance for Sign 1 Lot area Insufficient Independent Elderly Housing Special Permit 1 Frontage Insufficient Earth Removal Special Permit ZBA 2 Lot Area Preexisting Planned Residential Special Permit B-4 2 Frontage Complies X 3 Lot Area Complies X 3 Preexisting frontage 4 Insufficient Information 4 Insufficient Information B Use 5 No access over Frontage 1 Allowed G Contiguous Building Area 2 Not Allowed 1 I Insufficient Area 3 Use Preexisting 2 Complies 4 Special Permit Required X 3 Preexisting CBA 5 Insufficient Information 4 Insufficient Information C Setback H Building Height 1 All setbacks comply 1 1 Height Exceeds Maximum 2 Front Insufficient X existing 2 Complies X 3 Left Side Insufficient X existing 3 Preexisting Height 4 Right Side Insufficient 4 Insufficient Information 5 Rear Insufficient X I Building Coverage 6 Preexisting setback(s) X 1 Coverage exceeds maximum 7 Insufficient Information 2 Coverage Complies D Watershed 3 Coverage Preexisting 1 Not in Watershed X 4 Insufficient Information 2 In Watershed j Sign 3 Lot prior to 10/24/94 1 Sign not allowed 4 Zone to be Determined 2 Sign Complies 5 Insufficient Information 3 Insufficient Information E Historic District K Parking 1 In District review required 1 More Parking Required 2 Not in district X 2 Parking Complies X 3 Insufficient Information Remedy for the above is checked below Item # Special Permits Planning Board Item # Variance B-4 Site Plan Review Special Permit C4-5 Setback Variance Access other than Frontage Special Permit Parking Variance Frontage Exception Lot Special Permit Lot Area Variance Common Driveway Special Permit Height Variance Congregate Housing Special Permit Variance for Sign Continuing Care Retirement Special Permit Special Permits Zoning Board Independent Elderly Housing Special Permit Special Permit Non -Conforming Use ZBA Large Estate Condo Special Permit Earth Removal Special Permit ZBA Planned Development District Special Permit Special Permit Use not Listed but Similar Planned Residential Special Permit B-4 Special Permit for Extra Units R-6 Density Special Permit Special Permit Pre-existing, Non - Conforming Watershed Special Permit Supply Additional Information The above review and attached explanation of such is based on the plans and information submitted. No definitive review and or advice shall be based on verbal explanations by the applicant nor shall such verbal explanations by the applicant serve to provide definitive answers to the above reasons for DENIAL. Any inaccuracies, misleading information, or other subsequent changes to the information submitted by the applicant shall be grounds for this review to be voided at the discretion of the Building Department. The attached document titled 'Plan Review Narrative" shall be attached hereto and incorporated herein by reference. The building department will retain all plans and documentation for the above file. You must file a new building permit application form and begin the permitting process. Building Department Official Signature Application Received Application Denied Denial Sent: If Faxed Phone Number/Date: Plan Review Narrative The following narrative is provided to further explain the reasons for denial for the building permit for the property indicated on the reverse side: B-4 A Special Permit from the Zoning Board of Appeals is required for the conversion of an existing structure to a 5 dwelling unit structure per 4.122.14.0 of the Zoning Bylaw "The conversion of an existing dwelling to accommodate not more than five (5) residential units, by special permit from the Zoning Board of Appeals in accordance with Sections 10.3 and 4.122.14.1) of this Bylaw." B-4 A Special Permit from 9.2 of the Zoning Bylaw is required for the change, extension, or enlargement of a pre-existing, non -conforming structure is required from the Zoning Board of Appeals in order to construct the proposed addition. C-5 Dimensional Variance for the rear setback on the proposed addition will be required from the Zoning Board of Appeals per 7.3 & Table 2 of the Zoning Bylaw. B-4 A Site Plan Special Permit is required from the Planning Board for any "Any construction which results in the addition of more than two thousand (2,000) square feet of gross floor area to an existing structure; or results in the requirement of five (5) or more new or additional parking spaces..." per 8.3.2.ii. Referred To: Fire Health Police X Zoning Board of Appeals Conservation Department of Public Works X Planning Historical Commission Other BUILDING DEPT ZoningBylawDenia12000 1 1 A Date ....g n m:� G... � TOWN OF NORTH ANDOVER �^`-�► p PERMIT FOR WIRING This certifies that .............. r�!'.... ......................... has permission to perform�L�� �/�%� .C.!!E�� wiring in the building of ............ . ��� ....................................................... at 9.. g /�.. 1....5!:. , North Andover, Mass. Fee .... .......... Lic. No. f.......27.3-19.1.49. ............... � QQQ •qp ELECTRICAL INSPECTORI Check # _l_✓ O— 7673 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 74E 7 j Occupancy and Fee Checked Cis [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: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) 99-106 4 Owner or Tenant Owner's Address //5 Telephone No. 97 f ko y o yh;3 Is this permit in conjunction with a building permit? Yes 0' No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service '100 Amps 17-a /7 -yo Volts Overhead ❑ Undgrd Eg*' No. of Meters S New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed ; No. of Recessed Luminaires No. of Luminaire Outlets j No. of Luminaires Z No. of Receptacle Outlets % ctrical Work: Wax nIfw�.,.-f _A , Completion of the No. of Ceil: Susp. (Paddle) Fans No. of Hot Tubs Swimming Pool Above ❑ In- - rnd Sri No. of Oil Burners of Switches 72— No. of Gas Burners L/ vin table ma be waived by the Inspector of Wires. Total Transformers KVA Generators KVA No. ot Emergency Lighting ❑ Batte Units FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total — Tons /O No. of Alerting Devices No. of Waste Disposers Heat Pump umber Tons..... KW o. of Self -Contained / Totals: """' Detection/Alertin Devices o� / No. of Dishwashers �/ Space/Area Heating KW Local Municipal ❑ Connection ❑Other No. of Dryers �� Heating Appliances, Security Systems:* No. of Water No. of Devices or E uivalent No. of No. of Heaters KW Signs Ballasts Data Wiring: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent 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: 9 2 6 - p 1 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 V BOND ❑ OTHER ❑ (Specify:) I certify, under thepains andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee: �, Signature,, , , _ �{� LIC. NO.: /( 2 3 (If applicable, enter "exem t " in the license number line.) 3 Address: %,5 21 �, Bus. Tel. No.: L 1 o Alt. Tel. No.: k/ ,r *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, Zi Ov %al /0- 0,-e>7 P14� i A The Commonwealth of Massachusetts 1 Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 t www mass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aplicant Information Please Print Legibly Name (Business/Organization!Individual):_��t,o.,,�kr-vt . Address: % /c• o ..l�.o /gyp City/State/Zip: _21 . "-611A ©r"e-y ' Phone #:. q7 M'Yv t18 3 Are you art employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 2. �employees (full and/or part-time).* I am.a.sole or have hired the sub -contractors listed proprietor partner- on the attached sheet. ship and have no employees These sub -contractors have working for me .in any capacity, [No workers' comp, insurance workers' comp. insurance. 5. ❑ We are a corporation and its required ] 3. ❑ I air a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No -workers' comp. c, 1.52, § 1(4),' and we have no insurance required.] t employees. [No workers' Yd.., --I.- comp. insurance required.] Type of project (required). 6. VNew construction 1. Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.[] Plumbing repairs or additions 12.❑ Roof repairs I3.❑ Other t - -x n I must ME) nu out the section below showing their worked' 46nipensation policy information. Homeowner¢ who submit this affidavit indicating they are doing all work and then him outside contractors must submit a new affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing the now of the sub-conttactons.and their workers' corit p. policy infomiation ant an employer that is Providing: workers' compensation ins information. urance for my employees: Below is the policy and job site Insurance Company Name:_ rete- Policy # or Self -ins. Lie. #q: / C C. ie H z ? ' Expiration Date: (D — O Job Site Address: 6 f 0 O ° City/State/Zip:_ %f • Qin,�Br -e, c) �- 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 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. 1 do hereby cert-& under the Pains a!nd penaa es of perjury that the information provided above is true and eorrea Sienatwe: �'wa-railer '^ems Hare - cl ,7 Official use only. Do not write in this area, to he completed by city or town off ciaL City or Town: _ Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person Phone #: t _ �• ::i GU '?7 U: AK J. -41;: -41I:C_,UNA =t'Jvi V74 d _=a -,a -•l0 s a..:= _._ ACRD. CERTIFICATE OF LIABILITY' INSURANCE i D�e/`�v2o�,'' i RODLICIRR ITHIS CERTIFICATE IS ISSUED AS A. MAT! ER OF INFORMATION MacDonald & Pangione Insurance Agenov, Inc. ONLY AND CONFERS 140 RIGHTS UPON THE CERTIFICATE HO0ER. THIS CERTIF!CATE DOES NOT AMEND, EXTEND. OR P. 0. Box 426 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 104 Main Stmt Nortr Andover. t,4 A 01845 I INSURERS AFFORDING COVERAGE � NAIC it — ';NSURW Frank Stewart d/b!a Stewart Electrical Cc—'��F��= PREFERREO MUTU 4L INSURANCE } 15 Biuerdge RoadsF== THE HART::'ORQ GROUP ! Ne Andover, MA 0134;zONE BEACON iNSURAPJCE i COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEC TO THE IN;S-JREO NARKED ABOVE FOR THE POLICY PERICD INDICATED. NOTIWITHSTANDING ANY REQUIREMENT, TERRA OR CONDITION OF ANY CONTRA -7 CR OTHER D00WENT WITH RESPECT -0 WHICH THIS CEP.TIFiCATE MAY BE iSSUEC OR MAY PERTAIN, THE INSU."IANCE AFFORDED BY 7HE nL'C'ES DESCRIBED HEREIN !S SJBJECT TO ALL THE TERMS. EXCLUSIONS .ArID CONOITiONS OF SUCH POI! CIES. AGGRE°3ATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY ?=SID C a.IMS. `NORNERS COMPENSATION AND R C R , D6100 -f-007 D C0 2 TCrR'r ,2 I B !3� fJE H�343 '9/'00& S ,�T; H. EMPLOYERS' LIABILITY o,c __ EAC. A-CC!",S JT s 5VJ i 41d'✓AOPF!=TCk�.DPF.rc,c �kc,. J'. r1E _.—_.-.__—._—.—.--�- �U,� i j ! r:CERrtgEASE'EP,=;K�LUDED' =i DISEASE - EA EMPLOYEE I3 500 one I b,- ulder 0?;ER.P-1l,i F;SO�cw, EL DISEASE-P=,jry!ijrr i4 500.000 i I DESCRIPTION OF OPERATIONS) LOCATIONS J VEIACLES I EXCL USi.ONS ADJED EY ENDORSEMENT J S?ECIAL PROb7S10PJS Job Site: Rercvations 106 & 107 Marblehead St.. No Ancover MIA 0.1845" � i i I I I i CERTIFICATE HOLDER CANCELLATION l 3HOLLD ANY OF THE ABOVE DESCRIBED POL iC'ES BE CANCELLED BEFORE THE EXPIRATION I i Town Of Ncrtn Andover DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL IC DAYS WRr TEN NC710E TO THE CERTIF!CA7E HOLDER NAMED TO TH"c LEFT, BUT ZAILURE TO DO SO SHALL 1380 agood St !!AROSE N'0 CEL13ATIOIJ OR UA51L ' OF AN- KIND UPION THE INSURER, iTS AGF_NTS OR North Andover. MA 01845 REPRESE11TATIVEs. _ AUTHCRIZZEO REPRESWrAT',VE --' Attu. Building Dept I ACORD 25 (21)0'1/08) T CACORD CORPORATION 192P I GUERALL!A810-9 , 10,„ D ]r 8nc is 2;; ,'406 12/02i2007_ 1,000,0001 ^PLMEF.CIAL GEWEF.FL i II�X LiAEILIT; iC ' I 1 Iice, 0-,? ncr5,xm' 4 oV P,IU v $ _ OG' i .—.j i -_I•JERi, GPE AT= I a nOrC 3.000.000 f !' J,_ �JtySJ!(:. 4:: i_ I ! 4 .moi. Ol7�n.'.000' f-� I Ar.: IC""L'l i A OINOBILE LIABILITY T— F vc �,- G ^^,^_- C� ,0 'D /1`;'. �. 1 �s, 1� ,� nn l: 12006 _,• 3r,':Es- rr!.E Jmtr i— q 1 .! a.LL OWNED r.IUTOG SCHEOLL_DALTOS I -t parse^ { 1,000,00o j X I HIRED 4IJ'--"-, -----'---1 --------� :PC-o-Cidcmi, � 5 1,000,00 I i ,� 00,000 j ! I I GARAGE LIABILITY -� I .,U-0 PA ACCIDEN- ! 4 I Ar•rvAUTO ! __ Co! F-cj 0114C7 ' I �CESSUMBRELLA LIARILITY —� IvGCUF. CLhR�SlvtiriE I I -- .4�=.;;REi;ATE ; --- I I PE -EN -I -N S I -- -- ------- `NORNERS COMPENSATION AND R C R , D6100 -f-007 D C0 2 TCrR'r ,2 I B !3� fJE H�343 '9/'00& S ,�T; H. EMPLOYERS' LIABILITY o,c __ EAC. A-CC!",S JT s 5VJ i 41d'✓AOPF!=TCk�.DPF.rc,c �kc,. J'. r1E _.—_.-.__—._—.—.--�- �U,� i j ! r:CERrtgEASE'EP,=;K�LUDED' =i DISEASE - EA EMPLOYEE I3 500 one I b,- ulder 0?;ER.P-1l,i F;SO�cw, EL DISEASE-P=,jry!ijrr i4 500.000 i I DESCRIPTION OF OPERATIONS) LOCATIONS J VEIACLES I EXCL USi.ONS ADJED EY ENDORSEMENT J S?ECIAL PROb7S10PJS Job Site: Rercvations 106 & 107 Marblehead St.. No Ancover MIA 0.1845" � i i I I I i CERTIFICATE HOLDER CANCELLATION l 3HOLLD ANY OF THE ABOVE DESCRIBED POL iC'ES BE CANCELLED BEFORE THE EXPIRATION I i Town Of Ncrtn Andover DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL IC DAYS WRr TEN NC710E TO THE CERTIF!CA7E HOLDER NAMED TO TH"c LEFT, BUT ZAILURE TO DO SO SHALL 1380 agood St !!AROSE N'0 CEL13ATIOIJ OR UA51L ' OF AN- KIND UPION THE INSURER, iTS AGF_NTS OR North Andover. MA 01845 REPRESE11TATIVEs. _ AUTHCRIZZEO REPRESWrAT',VE --' Attu. Building Dept I ACORD 25 (21)0'1/08) T CACORD CORPORATION 192P V 0 Jeffrey J. Cook Architects, Inc. 4 Jackson Street • P.O. Box 7101 - Lowell, MA 01852-0101 • Tel. (978) 937-1871 • Fax (978) 452-2723 ARCHITECT'S FIELD REPORT #1---- November 06, 2007 RE: 98-100 Marblehead Street: Residential Renovation & Addition 0070201) 98-100 Marblehead Street; North Andover, Massachusetts 01845 OWNER: Frank E. Stewart, Permit # 233 CONTRACTOR:, General Contract: Frank E. Stewart. WEATHER: Cloudy with heavy rain. TEMPERATURE RANGE: 52 degrees Fahrenheit WORK IN PROGRESS: 1. None. PRESENT AT SITE: 1. Architect, JJCA Office Manager, and Owner. OBSERVATIONS: 1. Demolition of interior and exterior complete. 2. Exterior and interior rough framing complete. 3. Rough HVAC @,75% complete. "4. Rough Electrical @1501d complete. 5. Rough Plumbing @ 75% complete. 6. Rough HVAC @ 75% complete. 7. Rough Sprinkler @ 75% complete. 8. Rough Fire Alarm system @ 75% complete. ITEMS TO VERIFY: 1. Estimated date of substantial completion. INFO/ACTION REQUIRED: 1. Architect suggests installing new code compliant additional rails on top of existing at both stairwells in the construction phase. ATTACHMENTS: 1. Stamped Affidavit of Rough Framing Completion. Frank E. Stewart 070201 \0701 REP 1 -own, Building Inspector; 1600 Osgood Street dover, Massachusetts 01845 "Cook Architects, Inc. I `1W P� 1 Jeffrey Jo C ook Architects, Inco 4 Jackson Street - P.O. Box 7101 - Lowell, MA 01852-0101 Tel. (978) 937-1871 - Fax (978) 452-2723 ARCHITECT'S AFFIDAVIT OF ROUGH FRAMING COMPLETION November 06, 2007 RE: 98-100 Marblehead Street: Residential Renovation & Addition 0070201) 98-100 Marblehead Street; North Andover, Massachusetts 01845 I herein certify that the work as stated in the Field Report #1 is in conformance with the Massachusetts State Building Code, 780 CMR - 6th Edition, I have inspected the work and find the work to be in compliance to the applicable Sections of the Massachusetts State Building Code 780 CMR 6t` Edition, MA Architectural Access Board Regulations 521 CMR, ADA, other applicable Codes & Regulations having jurisdiction on this work with all the applicable local, state, and federal codes, requirements, and laws. INSPECTOR: Gerald Brown, Building Inspector; 1600 Osgood Street North Andover, Massachusetts 01845 Jeffrey J. Cook Architects, Inc. cc. JJCA Files Frank E. Stewart N=! 06 07 02:31p Jeff Cook 0784522723 p.1 Jeffrey J.. Cook Architects, Inca 4 Jackson Street - RO. Box 7101 • Lowell, NIA 01852-0101 • 'Tel. (978) 937-1871 - Fax (978) 452-2723 ARCHITECT°S FIELD REPORT #1 ---- November 06, 2007 RE: 918-100 Marblehead Street: Residential Renovation do Addition €4070201.1 919-100 Marblehead Street: North Andover, Massachusetts 01845 OWNER- Frani; E. Stewart. Permit 4 233 CONTRACTOR: General Contract: Frank E. Stewart. WEATHER: Cloiudv with heal,v rain. TEMPI CRATURE RANGE: 52 degrees Fahrenheit WORK IN PROGRESS: 1. Drone. PRESET' T AT SITE: 1. Architect, JJCA Office. Manager, and Owner, OBSERVATIONS: 1. Demolition of interior and exterior complete. 2_ Exterior and interior rough framing complete. 3. Rough HVAC L, 75% complete. 4. Rough Electrical 4,,75% complete. 5. Rough Plumbing `c 75% complete. h. Rough HVAC @ 75% complete_ 7. Rough Sprinkler L 75°/'a complete. 8. Rough Fire Alarm system 75% complete. ITEMS TO 'YTRIFY: 1. Estimated date of substantia! completion. INFO/ACTION REQUIRED: 1. Architect suggests installing new c:ode'cornpliant additional rails on top of existing at both stairwells in .he construction prase. 070201't0731 REP 1 Stamped Affidavit of Rough Framing Completion. -rald Brovm, Building Inspector; 1091 Turnpike Street arth Andover, Nlassachusetts 01845 Jeffrey J. Coon: Architects, Inc. OG 07 02:31p Jeff Cook 97®4522723 Jeffrey Js Cook Architects, Inc. at.lacktoo Street - P.O. Box 7101 • Lowell, MA 01852-0101 • Tel. (978) 937-1871 • Fax (978) 452-2723 ARCHITECT'S AFF'II3AVIT OF ROUGH FRAMING COMPLETION November 06, 204 7 RE: 93-100 Marblehead Street: Residential Renovation & Addition#Ob 70201,, 9R-100 Marblehead Street, North Andover, Massachusetts 01545 p.2 I herein certify that the work as stated in the Field Report #1 is in conformance with the Massachusetts State Building Code; 780 C -!AR - 6th Edition, I have inspected the work and find the work. to be in compliance to the applicable Sections of the Massachusetts State Building Code 780 CMR 6`t' Edition, MA Architectural Access Board. Regulations 521 CMH ,ADA, other applicable Codes & Regulations having jurisdiction on this work with all the applicable local, state. and federal codes, requirements, and laws. INSFI C:TOR: Gerald Brown, Building'Inspector; 1091 'Turnpike Street North Andover, Massachusetts 01845 Franc E. Stewart 0RTH (,**" _1 0 " ti oG 0 6 0 0 P) Date......?- ..7-7-o.7 .............. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies thit ........... .............................. has permission to perform .......... �'aa";7 -WP/e'F .................................................................... W� 7 . . ................ wiring in the building of ....... / ...... AVI . ...... 5.7 at ... /..!n ..... /Po .... ....... . .............. .... ...... 1 ...,North Andover, Mass. -7 Lic. No./ 1-91.3 .. � ............. ... .... LCTRICAL INSPECTOR Check 'V Date .'�. ORT" 1.1e TOWN OF NORTH ANDOVER 0 V. Miwaak' PERMIT F4R,JP,,LUMBING t-101 S This certifies that .... P., ./4 ....... ............... has permission to perform .... p 4.44;................... plumbing in the buildings of ................ at ... (::�/ �-7/.Oo ... Av.,i,05W. 4 A,. Ir. A. North Andover, Mass. ?P Fee Lic. Nol. . ..... Lut �UMBNG INSPECTOR 7 Check # 7510 tt■ MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO B® PLUMBING (I1iar rtr TES) —20-29�2_ Permit_.. -- Building Location9,f —lt fo P1 jp_,S Owner's Name�/�9�/, � lit ✓_�f2_�_ Owner Tel# 9%f - 190 V- QS/ -63 Type of Occupancy New ❑ Renovation A Replacement ❑ Plan Submitted: Yes k No ❑ FIXTURES Installing Company Name J }� C �) + l t`i "L � ;+y(} 3. RTt G , Check one: Certificate Address 1 Z Cr tic La 2 d Sx t1r-1-U uX "- MA ❑ Corporation ❑ Partnership Business Telephone # q - (tj -'S`) ' ❑ Firm/Co. Name of Licensed Plumber S -r Ile r.1 C_&(Lg INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL Ch. 141 Yes x No ❑ If you have checked rtes. please indicate the type ,overage by checking the appropriate box. A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ OXVNER'S INSURANCE \VAIVER: 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 Checkout: Owner 13 Agent 13Signature of owner or Owarr s Agent I herrhv certifv that all of the details and informalion I have submitted tar entered) in above anoGeation are true and accurate to the beat of my knowlede e and tint all phrmbing work and installations performed under the p for this appliu ation will be in compliance with all pertinent provisions of City -'Town APPROVED (OFFICE USE ONLY) I Chapter 142 of the VwA laws. Sign of Licensed Plumber Type of Liceffie: Master ❑ Journeyman Of U. Number of 7 Q 7 I • lin. • Y 1 • .. _.1.. ■e■■ori■■■■■■■■■■■®®■■■■■■® Installing Company Name J }� C �) + l t`i "L � ;+y(} 3. RTt G , Check one: Certificate Address 1 Z Cr tic La 2 d Sx t1r-1-U uX "- MA ❑ Corporation ❑ Partnership Business Telephone # q - (tj -'S`) ' ❑ Firm/Co. Name of Licensed Plumber S -r Ile r.1 C_&(Lg INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL Ch. 141 Yes x No ❑ If you have checked rtes. please indicate the type ,overage by checking the appropriate box. A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ OXVNER'S INSURANCE \VAIVER: 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 Checkout: Owner 13 Agent 13Signature of owner or Owarr s Agent I herrhv certifv that all of the details and informalion I have submitted tar entered) in above anoGeation are true and accurate to the beat of my knowlede e and tint all phrmbing work and installations performed under the p for this appliu ation will be in compliance with all pertinent provisions of City -'Town APPROVED (OFFICE USE ONLY) I Chapter 142 of the VwA laws. Sign of Licensed Plumber Type of Liceffie: Master ❑ Journeyman Of U. Number of 7 Q 7 d _ ` Date . `/7. G�!� .7..... . 3�0� . a o` TOWN OF NORTH i ANDOVER O F • PERMIT FOR GAS INSTALLAT ;i u �. �9SS�Ic MUSE�4 This certifies that .. '�/.:-'... l.................... . has permission for gas installation ....� in the buildings of / .................... at `. �,� ..! f'.'�.. /!�+'f f!/'.� �- h t. Ai::� North Andover, Mass. Fee./0-0 .. 7Lic. No. . AS INSPECTOR Check # 6 % 6155 �-N MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FITTING (Type or print) Date 9 - .24' , o 7 NORTH ANDOVER, MASSACHUSETTS Building Locations % lea Permit # 61,)-1 Amount $ Owner's Name 5:S—�12 7 - New Renovation ® Replacement Plans Submitted (Print or type) Che k one: Certificate Installing Company Name Sic l/E/✓ Corp. Address __/Z �ruGo/lr� T 0 Partner. Business lelephone f6 0 Firm/Co. Name of Licensed Plumber or Gas Fitter a=v-/e2 INSURANCE COVERAGE Check one: 1 have a current liability Insurance policy or it's substantial equivalent. Yes 13 NoO If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy P Other type of indemnity D 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. Signature of Owner or Owner's Agent Check one:Owner 13 Agent 13 1 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 installatio# p rformed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts to Gas Code and Chapter 142 of the General Laws. Title City/Town (APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter M Plumber a %d 73 ® Gas Fitter License Number 13 Master ® Journeyman CA 0 ocn w x v v w x z n a a > d m d x a W w A 44 N x Z: w d F (A m z C w x o Z Z a SU B -BA SEM ENT > a H o BASEM ENT 1ST. FLOOR Z 2ND. FLOOR / 3RD. FLOOR / 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8TH. FLOOR (Print or type) Che k one: Certificate Installing Company Name Sic l/E/✓ Corp. Address __/Z �ruGo/lr� T 0 Partner. Business lelephone f6 0 Firm/Co. Name of Licensed Plumber or Gas Fitter a=v-/e2 INSURANCE COVERAGE Check one: 1 have a current liability Insurance policy or it's substantial equivalent. Yes 13 NoO If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy P Other type of indemnity D 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. Signature of Owner or Owner's Agent Check one:Owner 13 Agent 13 1 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 installatio# p rformed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts to Gas Code and Chapter 142 of the General Laws. Title City/Town (APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter M Plumber a %d 73 ® Gas Fitter License Number 13 Master ® Journeyman r Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 7�0 BOARD OF FIRE PREVENTION REGULATIONS [Revc 1/07] upancy and Fee Checked 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: - Z. -7 — o "7 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gtv n ce of his or her intention to perform the electrical wor described below. Location (Street & Number) �U o Owner or Tenant Owner's Address 1171- Is 171. Telephone No. Is this permit in conjunction with a building permit? Yes � No ❑ (Check Appropriate Box) Purpose of Building "J-,Q.E`t, ` �-(- t.-,.�� Utility Authorization No. a 7 3 5 Existing Service ZOO Amps 177.6 / Z.Yy Volts Overhead Undgrd ❑ —3 No. of Meters 2 - New New Service Vim'® Amps !z, / Z -Y6 Volts Overhead ❑ Undgrd L2 No. of Meters Number of Feeders and Ampacity o. o Units ig g _ Location and Nature of Proposed Electrical Work: No. of Receptacle Outlets No. of OR Burners FM ALARMS No. of Zones No. of Switches No. of Gas Burners httacn additional detail y desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: 3 e2ci o (When required by municipal policy.) Work to Start: $-' 2-9S -® `1 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 cove a is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE B OND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee: _t— Signature LIC. NO.: 4/4 Z 3 (Ifapplicable, enter "exempt " in the license nu ber line) Bus. Tel. No. - Address: 11 2z� Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, s unty work requires Department of Public Safety "S" License: Lie. 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: $ �.« vow w"" tante may oe waived o the Inspector o Wires. No. of Recessed Luminaires No. of Ceil:sp. (PSuaddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ o. o Units ig g rnd. rnd. Batte Units No. of Receptacle Outlets No. of OR Burners FM ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Number I -Tons KW....... No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local El E] other Connection Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Water No.KW No. of of No. of Devices or Equivalent Data Wiring: al Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: httacn additional detail y desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: 3 e2ci o (When required by municipal policy.) Work to Start: $-' 2-9S -® `1 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 cove a is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE B OND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee: _t— Signature LIC. NO.: 4/4 Z 3 (Ifapplicable, enter "exempt " in the license nu ber line) Bus. Tel. No. - Address: 11 2z� Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, s unty work requires Department of Public Safety "S" License: Lie. 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: $ T a� ,Ynk G c9 t a -r ice' J 0 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations i' 600 Washington Street it Boston, MA 02111 j www nsass gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Al Plicant Information Please Print Legibiv Narrie (Business/Organization/individual): Address: City/State/Zip: Phone #:. 9 Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I a employer with 4. F1 am a general contractor and I 6. ❑New construction employees {full and/or part-time).* 2. I aim asole proprietor or partner- have hired the sub -contractors listed on the attached sheet. t �• ❑Remodeling ship and have no employees These sub -contractors have 8. [] Demolition working for me in any capacity. [No workers' comp, insurance workers' comp. insurance. 5• ❑ We are a corporation and its 9, Q Building addition required.] officers have exercised their 10. F1 Electrical repairs or additions 3. ❑ I air a homeowner doing all work right of exemption per MGL 11.Q Plumbing repairs or additions myself. [No workers' comp. c. 1.52, § 1(4), and we have no 12.[] Roof repairs insurance required.] t employees. [No workers' f 3.❑ Other comp. insurance required_] - nny appucam tnat cnecKs box V l must also fill out the section below showing their workers' compensation policy information. t Homeowner; who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Scont actors that check this box must attached an additional sheet showing the name of the subcontractors and their workers' comp. policy information. I am an employer that is providing workerscompensation insurance for my employees. Below is the policy and job site information. / Insurance Company Name: Policy # or Self -ins. Lie. #: G OR % b $'�, �/S Expiration Date: /2 ` 2 77 Job Site Address: �t ! Oc City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expirationdate). te). 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 the pains andAenalties of perjury that the information provided above is true and correct. Phone #: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #• Information and 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 including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. 'However the owner.of a dwelling house having not more than 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 'coverage 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 to your situation and, if necessary, supply sub -contractors) 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 Department 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, not;the 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 license number on the appropriate 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 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. 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 Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-977-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia 3.•' .2007 9PANG I:-, I j7- Mac=:.,a=d ie :, c Aar- c �A' _::�_. --- LID! 001 ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MtNDD(YIYY} 08/01/2007 r PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION MacDonald & Pangione Insurance Agency, lrc. I ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE j P. BOX d78 j HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND. OR 0. { ALTER THE COVERAGE AFFORDED BY THE POLICIES SELOW. 104 Main Street - JOrtl Andove, , NIA 011845 INSURERS AFFORDING COVERAGE NAIL it j "S Frank Stewart d/b/a Steevar- Electrical Co F k_ PREFERRED MILITURL INSURANCE 115 Blueridge Road 's.eE THE HARTPURD GROUP No Andover, MA 01845 1sueEG ClVF RFA.(1-)N iPJSU cAIJCF -- I IhJSU�E� U: !fly>JF.S= c. 1 THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEC TO THE INSLIRED .NA+b1ED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR C'ONDIT'ION OF ANY CO!+ITRA.CT CR OTHER DOCUIVENT WTH RESPECT 70 WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSiONS AND CONDITIONS OF SUCH ?OUCIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY RAID CLA.IMIS. INSR iADD'L �— — rF U -Y EFFECTIVE POL!-Y EXnIRAT�.^.N LTR NN_ SRS 01 TIDE OF INSURANCE ; POLICY NUMBEF DATE i�AM,'DDM9 DA iWFAtDDNV1 LIMIT'S A cErIERA�LABILrY CPP 0i 10 58 45 76 1._102'2006 12/02/200 RR E i $ 1,00C,000 M'4ERCIAL ENESFLJSE_Tr' i 1 r .l.i I I CLAN: -S r AGEL r`_1 ` � ..i I D Etr A On? D 5 ;. ¢ S. 5.'000 j j r--1 3.0001.0 0 rEVL L.GGfiEGAi E LIMIT r,F-FL ES FER: i �— I rr,'iJDU._T=...,•C�r4yp!(r.�. di,G j C 3,00n..00c, G` ALIT AOBILELIABILITY L-0 1F05c4:O n0n8 tP.?'aa�E:; �IniCLE LIMr I 'JL11 i;70)D04111/22008 A N y A1.1 -C; j ice aaident$ ALL OWNED AUTOS I ! I I r— 'KI D ALTOS E c ; M,WR iPe' P rs.^n: g 1, 000, 000 HIRED AI,1-GS ; j i' I i Xyf BOPP_'! YJ.IL'F'i cdyniNOf-JN=DpUs: ,0� _100 !--� j 1 i PROPERTY ^PIJ AGE I rpe-zti:idanti $ I 200,000 ! j !D!•JLr GARAGE LIABILITY , n- DEN r _ EA AC:Ig Aov AUTO ! T EXCESSIUMBRELLAIIABILITY ! -_--_—_-----~ a^^-_.Jp:=1.iC �� �1 �� vCCUF. CLARr!8MOE I --�I j AGGREGATE i i I :iEDU,.TiBLE i i $ i —: RE-EN'ICy $ 1 q B I `X� ORKERSCOMPENSA71ONAND - I 08 VVEC Ri•-10343 36/09{200/ 06,109/2008 : Tuk'SLi 1TS 1 ICER I EN1P:0/ERS'LIABILITY E=EAC.u_C=JCSW _ CCT--_�$ .)�1 -- .-.— ✓�'J �3iJ OFFICER WEfifEER EXCLUDED? ED? . E L DGEASE - EA. E61P!C•YEE S 5000001 ! Cescribaund�r " E_:A_. FK7„tJ'CPiE D?bn! 1 ” I I � �,� v EL TEASE -POLICY M(T I g i 500400 I OTHER i i �— I I I ..�••-�..� ..v.. yr yr �r,�„v,�u. ����.n , •,. v YIJyCi..iC+iL!VIJVRJCHiCIVIIJYCi.IhLL YKI�VIJIUN� ,Job Situ Rerevations 106 & 107 Marblehead St.. No Andover. MA 011845 - HOLDER Town of Nortn Andover 1080 Cegood St North Andover, MA 0!845 At n; Building DeDt I CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION I DATE THEREOF, THE ISSUING INSURER WL:- ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER. NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL j IMPOSE NO OBLIGATION OR UAB)LIT" OF AN" KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REP!lE9E247A7IVE �T7``0��'A--COORD CORPORATION 1998 i, 1ISACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTIHC-/� (Print or Type) - f NORTH ANDOVER ,Mass. Date Iuildin Location LI 9 9% MAA L le ff C A 8 � 7r Permit #/ 3,2- -Owners Names ` A Sii f/ • :j New "7 Renovation �] Replacement Plans Submitted 0 FIXTUP=c (Print or Type) / Check one: Certificate Installing Company Name Corp. AddressV U 0® /V G d M ed Partner. L, X1Ret1rCC M14S S Firm/Co. Business Telephone: a7 7 3� Name of Licensed Plumber or Gas Fitter Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy ly� Other type of indemnity Q Bond Ej s - Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. Signature of owner/agent of property Owner U Agent M 1 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 InstaUations performed undcr' Permit izsLed fox this application will -be -In compliance with all patineat otovisions of the Msstachusetts State Cas Code and (hinter 141 of the Genual Laws, By Title City/Town: APPROVED (OFFICE USE ONLY) t ` TYPE LICENSE: Plumber Gasfitter Signature of Licensed Master Plumber or Gasfitter Journeyman ,/C%J License Number MEESE No No MAIMIMEMIMMIMME lip (Print or Type) / Check one: Certificate Installing Company Name Corp. AddressV U 0® /V G d M ed Partner. L, X1Ret1rCC M14S S Firm/Co. Business Telephone: a7 7 3� Name of Licensed Plumber or Gas Fitter Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy ly� Other type of indemnity Q Bond Ej s - Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. Signature of owner/agent of property Owner U Agent M 1 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 InstaUations performed undcr' Permit izsLed fox this application will -be -In compliance with all patineat otovisions of the Msstachusetts State Cas Code and (hinter 141 of the Genual Laws, By Title City/Town: APPROVED (OFFICE USE ONLY) t ` TYPE LICENSE: Plumber Gasfitter Signature of Licensed Master Plumber or Gasfitter Journeyman ,/C%J License Number Date..................... +1 4 NORTH TOWN OF NORTH ANDOVER ,, 10 1�yO A PERMIT FOR GAS INSTALLATION. A�A ^: 3,p SACNUSESS This certifies that.Z. ............. ................ .......... has permission for gas installation ............................ in the buildings of .......................................... at ................................... . North Andover, Mass. Fee. I ...... Lic. No........... .......................... GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File Location No. / Date � f °"7" TOWN OF NORTH ANDOVER p Certificate of Occupancy $ y Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ Z S v-0 Sewer Connection Fee $ Water Connection Feed $ TOTAL $ JA1! 16 1992 ` b6ilding Tnspector %ndov-sr Collect, Div. Public Works r I :1 NV"id LO1d S3aV1d321 SIHl 'a3SOdW12i3df1S '013 'S39V21 -V9 'S3H0HOd H11M 'S°JNIa'11f19 d0 SNOISN3WIa 1aVX3 aNV S3N11 101 WONA 37NV1S1a aNV 1O'1dOSNOISN3W1a laVX3 MOHSisnW NO1133S SIHI .w I Z t ADN Vdf1OJ0 I I ab0D38 JNIa11n9 ONIIV3H ON" I i J161J313 P"L 1•W.8 110 SWOON d0 'ON L SVO S631V3H 11Nn O.1.H 1NVIOV6 ONINO110NOJ 8IV _ s631jV6 OOOM NOdVA b0 b.1.M IOH SIOJ 8 'sW8 13315 WV31S _ 'S10J 4 'SW8 d9swI1 'N6nj 61V IOH 03JMOd 3JVN6nj SS313dld 1sIOf 0006 ONIlV3H it ( ONIWVMd 9 OOVO 3111 b0014 3111 _ 33dn1X1j Nd300W `JNIjOOM 1106 _ 83MOHS 11V1S 13AVdO 8 "I _ ONiewnld ON 31V1S _ ANIS N3HJ11)1 S30NIHS DOOM 1,601VAV1 S310NIHS IIVHdSV 13SOIJ 631VM 03HS 1Vlj kl3Tb8WVO I'XI3 LI 'W6 131101 06VSNVW 'XIA Cl H1V8 dIH 319VO 'JNigwnld Ol dOOM 5 LNoN 3 600d I I dOld3daS ONIMIM 3WV6j NO 3NO1S kdNOSVW NO 3NO1S 'A18 630NIJ bO ':)NO:) _I 6001] 8 'S61S JII1V 3WV6d NO AJ168 kdNOSVW NO AJIN —� £ t 8 3111 'HdSV NOWwOJ 3WV6j NO OJJni A6NOSVW NO OJJn1s ONIOIS '163A ONIOIS SOIS39SV 0 rAGdVH ONIOIS 11VHdSV HldV3 S310NIHS DOOM 313yJNOJ ONidlS060 S(JdVOgdVID SMOOId 6 SllVM v N 3HJ11A Nd300W S3JVId 3dll V3dV JI11V NIA V36V .1.W.8 NIA `� W008 0V3H 1.W 8 ON % `b %i llnj V3674 1N3W3SVH £ £ L E3136JNOJ NIINn IIVM 1,60 d31SV1d S63Id 0.M06VH 3NO1s 60 AJI68 3NId 'A.18 1138DNOD HSINId MOIM MI $ NOIIVONnOd Z NOi-Lon .LSN0a SINMAVdV _- s3Jljj0 ,111WV7 I1lnW _- S3160!S kIIWVA 31ONIS Z t ADN Vdf1OJ0 I I ab0D38 JNIa11n9 PER -MIT NO. D I.3 APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 MAP 140. LOT NO. I 2 RECORD OF OWNERSHIP IDATE BOOK :PAGE ZONE SUB DIV. LOT NO. LOCATION ,� r e ` �.� PURPOSE OF BUILDING/ o ^�L�/ /r✓/"/�-� it J /,IJ OWNER'S NAME OWNER'S ADDRESS k4 fit NO. OF STORIES SIZE BASEMENT OR SLAB -u ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME sr. 0 SPAN --- DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES - SIDES REAR GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE 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 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METEPS 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 IZED AGENT FEE �5�= PERMIT RA ti /6 19 OWNER Z - TEL. Et. CONTR. LIC. 3 PROPERTY INFORMATION LAND COST ^^ EST. BLDG. COST .S006). O IJ 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 v 5 0 rA 0 0 A ro Z rc 0 � -1 cp � a W f CD p 00 (D CD m r« 3 ° O A A 0 0 o 3 -a A C Z % 3 W CD 1 A (AD c_ N r► o �l < 0 A \ S m m f _ ! _ m m co 0 0 7 § M � \ & FD 22 r 0 z�z G ) ! - j 500 0 y � \ \ 2 °\ A § % ; 5 Z / I m au Fri$5 °k \ 2 / Eo %m Zf3 }2 CC! m 2 e / DZe !@ » � > 2 i. § ■ gonz m 3 m m f _ \ § |q 'G\ 0 / � \ & r 0 § G ) _,� / 500 � au Fri$5 °k \ 2 / Eo %m Zf3 }2 CC! m 2 e / DZe !@ » � > 2 i. § ■ gonz m 3 r � 2 i � \ § c 0 / � & r 0 § / ) _,� m � \ \ § k \/ z ak\ % 0 5 Z m / m / / 0 m @ in X �n _ r \ to _ 7 § \ $ \ z- \ 2= � AM m 0 ,11 r m � ,� /( § 0 r 0 § / ) m � = 9 ( _ j\ m m 0 j § m k -< > 0 C: x 0 _ c § \ K k ® z- 2= m m 0 \ \cn n \ ) m r Z O rmA) v aQ 'Q n 0 0 A O � o � - (D we e M A � � a. -v � 3 .� _. Wt y O ii t A CL cr L C z T� ^N RE i.n O A � � N U1 w?1 m T Cl)m ?1 m ?1 0 m 3 c 0 B. m 0 3 0 0 0 :3a0o m m °-' (0 "a °-' 3 C M m m c � c v 0� CI) ,� .. W c Z y T O A Z 0 0 * T n m m z 9 Location l6`t4W&61-164P S� No. n -} ? Date �RTIy TOWN OF NORTH ANDOVER p Certificate of Occupancy $ • -,Building/Frame Permit Fee $ Foundation Permit Fee Ower Permit Fee Vwer Connection Fee Water Connection Fee, G TOTAL ��d�� v15031 Building Inspector Div. Public Works 'NV -Id 101d S30V"id3EI SIHl 'a3SodWIM3dnS '013 'S3ovu -V0 'S3H:)UOd H11M 'SE)N1a-lln9 d0 SNOISN3W1a 10`9X3 aNV S3NM 101 W021d 3ONV1S1a aNV 101 JOSNO1SN3W10 10VX3 MOHS1SnW N01103S SIHl zI I AONvdn000 L Gb0D3V JNiciin9 VNIIV3H ON :I81:313 _ I P+6 PAZ 110 SWO07A i0 'ON L SVo S531V3H 11Nfl - -- 0.1.H 1NVIOVM ONINO1110N00 MIV MOdVA 50 5.1.M IOH _ SM31iV21 OOOM 'slOD 4 'SW9 13315 WV31s 'NMn9 51V 15H 03:503 3:VNMn9 SS313dId 11 -S10D'8'SW9M39WI1 1SIOF OOOM ONIMH II I ONIWVHi 9 OOVO 3111 50013 3111 _ S35n1X13 NM300W ON13005 1105 _ _ 53MOHS 11VIS ON19Wnld ON 13AVdO 8 MVI 31VIS _ JINIS N3H:11X S30NIHS DOOM AMOIVAVI S310NIHS 11VHdSV 13S01: 531VM O3HS 1V19 13M9WVO ('X13 Z) 'WM 131101 OSVSNVW — 'X13 E) H1V9 dIH 319VO Wownld OI ioon 9 3 �I MOOd 50153dns 'JNIMIM 3WV59NO 3NO1S AMNQVW NO 3NO1S 'X19 MlOND 50 ':NO: _I 50019 a S51S:111V 3WV59 NO X:159 ASNOSVW NO X:159 —� E F—� —3WVn _ONIOIS 9 NO omnis A5lOsvW 10 o::nls 3111 'HdSV ON101S 'MA NOYlWO: ONIOIS SOIS39SV IIVHdSV S310NIHS OOOM HldV3 3135:NO: 1o9dOl: S05V SMOOI9 6 II SI1VM IF N3H:11X N5300W W005 OV3H S3:Vld 3513 1, W.9 ON VRV :Illy 'Nid %t 1/1 %i V3MV .1.W.9 '113 lln9 V3MV 1N3W3SV9 E E L I 9 NIANn 11VM AK M31SVld S53Id O.MOMVH 3NO1S MO X:IM9 3NId 'X.19 3135:NO: 3135:NO: HSINIi VOI1131NI 8 NOUVONnoi Z N0110n2i1SN00 S1N3W15VdV 63:13,10 kllWV9 I11171W _— 53150!S AlIWV9 310NIS zI I AONvdn000 L Gb0D3V JNiciin9 PER311T NO. (QS / APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE i MAP +40.I LOT NO. 2 RECORD OF OWNERSHIP ;DATE BO;PAGE fZONE SUB DIV. LOT NO. a r' — LOCATION/ft „1 ,7"-j••7 ,IY PURPOSE OF BUILDINd OWNER'S NAME NO. OF STORIES SIZE OWNER'S ADDRESS 66CA BASEMENT OR SLAB ARCHITECT'S NAME C'4 SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME SPAN DISTANCE TO NEAR YST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET " POSTS DISTANCE FROM LOT LINES - SIDES REAR " GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY INSTRUCTIONS c1 l SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METEPS 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 6 (3 L1, 9/ 2 - IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE SIGN tt:JgjZrA. 17TWORIZED AGENT uwNER TLL. # 3 4 `f FEE .209 OL -o CUiiIR. TEL. # q GUNK LIC, # PERMIT GR TED /?�� Q9 J' 2-- 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY J BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN orca. � vn , :Cb \ q \ � 2 CO) CO) f ƒ ; o 2 00 : 0 .—/� o W a , . {/ rn ��� / P�� �/ / �O � � . -At Co) Fri •r a�n � � � $f0 _-4� � -6®� �� 0 /� 4% o� r" CO2 A� ���. -: 4%.-v ru a 4c . J 0 , r \ / a. /. . b Q �rno M7ƒm _ -90 lob . � Z m m 2 / 2 m m o a/ J. 0 0 Z 2 0 2 nƒ / . ƒ n ^ CO2 n m _ » 't. 0X � / F rn jib/ r Z ., col ICj) . $ CD m "77 . � _ % Orm Poo O C ucr M 0 O O I y cr N = A A � A n c 3 � G. O 00 O � EWA w a rte! Q V1 � QJ -1 m 11 fA m T m T n m 3 m O , m 0 o O O A/ C W c T d C y r- 3 3 =r C W In N v m Z v � v o !R 19 rn Z Z Z T M CA 'Q ._ O N o !6