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North Andover Board of Assessors
awN
roperty Record Card
Parcel ID :210/045.F-0009-0000.0 FY:2013 Community: North Andover
ttion: 99 ADAMS AVENUE
ier Name: KASPRZAK, GREGOIRE
ier Address: 99 ADAMS AVENUE
City: NORTH ANDOVER State: MA Zip: 01845
;hborhood: 5 - 5 Land Area: 0.31 acres
Code: 101-SNGL-FAM-RES Total Finished Area: 1387 sqft
ASSESSMENTS CURRENT YEAR PREVIOUS YEAR
Total Value: 294,100 285,100
Building Value: 126,300 112,600
Land Value: 167,800 172,500
Market Land Value: 167,800
Chapter Land Value:
http://esc-ma.us/PROPAPP/display.do?linkld-2252990&town=NandoverPubAcc 3/19/2013
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Location �l� f�1�3/HS i4✓�
No. Date 7
,40*, TOWN OF NORTH ANDOVER
0 • , Op
" Certificate of Occupancy $
Building/Frame Permit Fee $
4CMU5
j
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ �� W
Check #
SGY �Q � � �y� �✓ ft�U /��
17435
Building Inspector
7 -
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER: DATE ISSUED:
.00
SIGNATURE: .7—
Building Commissionerll for of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map and Parcel Number:
h Pere
Map Number Parcel Number
1.3 Zoning Information:
1.4 Property Dimensions:
Zoning District Proposed Use
Lot Area Frontage It
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Required Provide Required Provided
Rapired Provided
1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information:
1.8 Sewerage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone ❑
Municipal 0 On Site Disposal System 0
SECTION 2- PROPERTY OWNERSEIP/AUTHORMEDAGENT
MistOric District Yes No
2.1 Owner of Record
n
44,
Nam P Address for Service :
Signatur Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Tele hone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable ❑
Licensed Construction Supervisor
License Number
t
Addresrs
4
Expiration Date
Signature Telephone
3.2 Registered Home Improvement Contractor
Not Applicable El
/� R
J131,4b
I`? / I?
Company Name
�� �� H� ��•�� ��, ��� �f® � � , RAO
Registration Number
�� ` .
Ad �'► �.:J /V'
Expiration ate
i
Signature Tele one
00
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Proposal Submitted To:
Address /y
Phone #
Pae # � `� of Ipa
/
es
V
Z) C0W 57?�Crowq /,f• 13 -O1 .
Aae, '0/U � �4 � aa�
141,4
Job Name Job #
c' f�i4s Z14 /f
XUAJob Location
Date Date of Plans
Po
Fax # Architect
i
We propos hereby to furnish material a r complete v accorda e with the above specifications for the sum of:
O 4//
Dollars I
with payme o be ade as follows:
Any alteration or deviation from above specifications involving extra costs will be Respectfully
executed only upon written order, and will become an extra charge over -and submitted
above the estimate. All agreements contingent upon strikes, accidents, or delays
beyond our control. Note — this proposal may be withdrawn by us if not accepted within days.
I
acceptance of 3propo
The above prices, specifications and conditions are satisfactory and are Signature
hereby accepted. You are authorized to do the work as specified.
Payments will be made as outlined abov .
Date of Acceptance Signature
NC3819 MADE INJSA ....
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Name �/Please Print
Name / v1
rrlt%i A AvPjr %Ozl? . Ai /4,. Phone # `"/ �7 rJ z a �7
av I am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
F7I am an employer providing workers' compensation for my employees working on this job.
Company name:
Address
City Phone #:
Insurance Co Policv #
Comoany name:
Address
City Phone #:
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..penattiesintheform ofa.STOP WORK_ORDER..and a.fine of_(.$100.D0)aAay 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 hereby certify under tpe pains and penalties of perjury that the information provided above is true and ccrTect.
Signature P7�/�'Jl��/t Date d 6 U
Print name 111010,4,41RLPhone #
Official use only do not write in this area to be completed by city or town official'
City or Town Permit/Licensing
Building Dept
❑Check if immediate response is required I] Licensing Board
❑ Selectman's Office
Contact person: Phone #: F-1 Health Department
❑ Other
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 O h fb 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:
four 7;4- ) ,
3�
(Location of Facility) �1► ,
Signature of Permit Applicant
X16
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
\ Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
a Registration: 131950
Expiration: 10/1-3/2004
Type: Individual
NORMAN L. BLAD . -
NORMAN BLAD
40 FERNVIEW AVE #10
N. ANDOVER, MA 01845 Administrator
I
NORFOLK AND DEDHAM MUTUAL FIRE INSURANCE COMPANY
SMALL CONTRACTORS POT,Try
Business Description
[CARPENTRY
POLICY DEDUCTIBLE
BUSINESS PERSONAL PROPERTY Limit
T O T A L P R E M I U M P E R B U I L D I N G
NO
$250
$10,000 Included
$1,566.00
EXCEPT FOR FIRE LEGAL LIABILITY, EACH PAID CLAIM FOR THE THE FOLLOWING COVERAGES REDUCES THE AMOUNT OF
INSURANCE WE PROVIDE DURING THE APPLICABLE ANNUAL PERIOD. PLEASE REFER TO PARAGRAPH D.4 OF THE BUSINESS
LIABILITY COVERAGE FORM.
LIABILITY AND MEDICAL EXPENSES $300,000 Included
MEDICAL EXPENSES $5,000 Included
TENANT FIRE LEGAL LIABILITY $50,000 Included
BP 00 06 01-97
Included
BP 00 02
12-99
Included
CM 00 01 07-90
Included
BP 00 09
01-97
Included
BP 01 08 03-98
Included
BP 04 19
06-89
Included
BP 04 96 10-01
Included
CTF-91
07-00 $5,000
PER OCC Included
INS -99 07-00 $5,000 PER DCC
Included
NDCL-2
11-02
Included
, OT THE; POLIGY PROV�SlONS ;REQi#I$E THAT: A $ aoo
GOJUNTERSIGNED BY ;AUTHORIZED i El'RESEiVT
MINIMUM PREMiUr. CHARC lUQF3MALLY :APPLIES I1 YQ11
iGAIV
Cil <PRtOa TQ 1t'1#1A114iU tJATE ;INE SHALL
R`CAIPt A7 l t �1S t
$3D,Q REGARDLESS OF TERM
.
BOP -2
..... .
(REV.01194)
Type
Of Payment:
DIRECT B 11SLJ
PAY
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