HomeMy WebLinkAboutMiscellaneous - Suit 67Location 7" / VW40 ec
No. .may'/ L- Date 71,-22111
Check # 22-5
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ 0
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
2451
T Building Inspector
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: ' OSZ/ — /-z
Date I
Date Received
I r IMPORTANT: Applicant must complete all items on this page I
_r,
Print /
MAP NO: � 41 PARCEL: 2,f ZONING DISTRICT:
Historic District yes no
Machine Shop Village yes no
100 year-old structure yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
0 New Building
0 One family
U Addition
0 Two or more family
0 Industrial
0 6Iteration
No. of units:
;6; --Commercial
'4Repair, replacement
0 Assessory Bldg
0 Others:
D Demolition
0 Other
well Iff'
spoic, �11'
1511am. W t,
e4b silc_
t
Type or Print Clearly)
OWNER: Name: / d
C,
Address: VS -1 AkxC1k)L)�C—V3
CONTRACTOR Name: o- 0 t F_z31V111 (I Y F/-4/,. Phone: 40 3 S"-ibJ_
Address: CA (t ZIL c) 30
Supervisor's-----Yxp. Date:
Construction Licens 2,S L
Home Improvement License:
Exp. Date:
ARCHITECT/ENGINEER Phon
Address:
Reg. No.
FEE SCHEDULE: BULDING PERMIT. MOO PER $1000-00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ _?_-) ft pt*o FEE: $_ 2,//. 40 0
Check No.: �c_V 7 Receipt No.: / —
NOTE: Persons contracting with unregistered contractors do not h;ar to the guaranty fund
,4e,le
_ Si nature_of co
. . ..... . ..... . . . ......
-
Signature
iof,'A - t/E,)
_,gen_.WR
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And/Or C.S.L. Licenses
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Pern
Addition or Decks
a Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permi-
New Construction (Single and Two Family)
❑ Building Permit Application
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg .Permi
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc: Doc.Building Permit Revised 2008mi
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
Tanning/Massage/Body Art ❑
Swimming Pools ❑
Well ❑
Tobacco Sales ❑
Food Packaging/Sales ❑
Private (septic tank, etc. ❑
Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE REJECTED
DATE APPROVED
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date- Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street
Fire Department signature/date
COMMENTS
Dimension
Number of Stories:_ Total square feet of floor area, based on Exterior dimensions._
Total land area, sq. ft.:_
ELECTRICAL: Movement of Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
MGL Chapter 166 Section 21A—F and G min.$1oo-s1000 fine
m
m
m
m
m
m
_2
.0
O
'C O
CD
n z CO)
CCD O 'O
Mr- 6
JW C
O
d _• CO)
O v
CD
CD o
CLQ
CD
CDCD CD
0o ao �
C CDCD
y
O CO2
CO �
CD
S
CO2O
-a z
CD
a a
O
71 CD
0
C
CD
C c o 0 2
O -
•yoQ N
06 C, � m = y
_=@ O ® C7
1CD H O d O m
Z =r -o N -4
CD
,rt Cl) o-�d = m
O -.40 CA
m N O. —1
N 0-,
m 2
CD i m -y m n
m o ..
WN
c� C� O O !2.n
W ;3. O CD
Er
C2cn
CD
CD
Cn cro
n mc.t
O d N
cn
�.s N CCD N
CD
cn
(� � N N _ �a
a�
m
m w N r
p p ao
CDi
N p
CD
CD CD C
cn
CD O .�
d m
= !J,
M
n
O
=s:
F
o
nE 'Ort•
o =
O _ ®
C* .
cf)
P�loGa
O
.Cf)
o
w
x
G)
`"
a
�
a�
c
�,
9
x
n
tri
Ix
z
a-
r
Ix
w
n
c
zITI
oda
x
:jO.
C
a.
�d
r
d
C/)
C
Irl
r
x
x
°
O0
z
c
N'S
WS
y
0
0
c
.4� ®® CERTIFICATE OF LIABILITY INSURANCE
DATE(MMIDD/YYY7)
3/30/2011
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER
Eaton & Berube Insurance Agency, Inc.
365 Nashua Street
Milford NH 03055
CONTACT
NAME: Gail Douglas
PHONE FAX
Alc No EXt : - - AIC,
IC No): 603 - 673 -
E-MAIL gdouglasCeatonberube.com
-
PRODUCER
CUSTOMER ID #: BEAFA
_ INSURER(S) AFFORDING COVERAGE NAIC #
CCP9266483
INSURED
INSURER A: Peerless Insurance Co
Beaudoin Family Enterprises, Inc.
c/o Claude Beaudoin
_
INSURER B
X COMMERCIAL GENERAL LIABILITY
X CLAIMS -MADE 1-1 OCCUR
16B Harry Brook Drive
INSURERC:
INSURER D:
Goffstown NH 03045
INSURER E:
DANUVGE
PREMISES EaEoccurrence$50,000
INSURER F:
PERSONAL &ADV INJURY $1,000,000
COVERAGES CERTIFICATE NUMBER: 1999551743 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY
PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO
WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT
TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFF
POLICY
YYY
LIMITS
A
GENERAL LIABILITY
Y
Y
CCP9266483
9/29/2010
9/29/2011
EACH OCCURRENCE $1,000,000
X COMMERCIAL GENERAL LIABILITY
X CLAIMS -MADE 1-1 OCCUR
DANUVGE
PREMISES EaEoccurrence$50,000
MED EXP (Any one person) $5,0 00
PERSONAL &ADV INJURY $1,000,000
GENERAL AGGREGATE $2,000,000
PRODUCTS - COMP/OP AGG $2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
X I POLICY PRO X LOC
$
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT $
(Ea accident)
ANY AUTO
BODILY INJURY (Per person) $
ALL OWNED AUTOS
BODILY INJURY (Per accident) $
SCHEDULED AUTOS
HIRED AUTOS
PROPERTY DAMAGE $
(Per accident)
$
NON -OWNED AUTOS
A
X
UMBRELLA LIAB
X_
OCCUR
CU9204816
9/29/2010
9/29/2011
EACH OCCURRENCE $3,000,000
AGGREGATE $3,000,000
EXCESS LIAB
CLAIMS -MADE
DEDUCTIBLE
$
X
RETENTION $10,000
$
p,
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / NLW
ANY PROPRIETOR/PARTNER/EXECUTIVEE.L.
OFFICER/MEMBER EXCLUDED? Y❑
N / A
WC9119806
9/29/2010
9/29/2011
X WCSTA'T- OTR -
EACH ACCIDENT $500,000
E.L. DISEASE - EA EMPLOYEE $500,000
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT $500,000
A
Leased Equipment
CCP9266483
9/29/2010
9/29/2011
$25,000.
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, N more space is required)
Workers Comp NH & MA Officer Excluded:Claude Beaudoin
l.tK I It -KA I t MULUtK LANL;t:LLA I ILIN
Whittier Place Condominium Trust
6 Whittier Place, Unit 10H
Boston MA 02114
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED
IN ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
h4 41fi'd
NlassWhu.setts - Department of' Public S;lf(.%t'%
; B ilt-d of Buil daig, A-e- fations tions and S t-ft'n (b i -d
"u - . - A.
-Construction Supervisor. License
License: GS 59666
Restricted Jo:._00
13LAUDE J. IEAUDOIN
16B HARRY BROOK DR
,.GOFFSTOWN, NH 03045
.77 Expirafidn:.3/25/201.2
(' rnunissiuter Tr#: .18886
,6eaudoin Family Ent. in,
16 B Harry Brook Dr.
Goffstown, NH 03045
Claude@Beaudoinfamily.com
Phone or Fax (603) 384-2076
DATE: 06-13-2011
THIS ESTIMATE HAS BEEN PREPARED FOR: Tallman Ete
WORK TO BE COMPLETED: 452 Andover st.
Permit 600.00
Demo and remove
Drape off
Sheetrock and finish
Repair ceiling
Cove base
Paint or repair wallpaper
Insurance and Material included in price unless otherwise noted above.
Total estimate for the work described above:$ 2780.00
500.00
100.00
800.00
200.00
100.00
480.00
We thank you for your interest in doing business with us. If I can be of any further
assistance to you please contact me.
Not valid aft 0 da Please sign, date, and return upon acceptance of this
estimate.
SIGNATURE DATE
Sincerely, Claude J. Beaudoin
CLAUDE J. BEAUDOIN
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
o Building Permit Application
o Workers Comp Affidavit
o Photo Copy of H.I.C. And/Or C.S.L. Licenses
o Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Pert
Addition or Decks
❑ Building Permit Application
o Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
o Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Mass check Energy Compliance Report (If Applicable)
o Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Perm
New Construction (Single and Two Family)
o Building Permit Application
o Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
o Mass check Energy Compliance Report
o Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg .Perm
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc: Doc.Building Permit Revised 2008mi
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: OS -Z/ 12
Date
IMPORTANT: Applicant must
_5"/ 4.n J 'A V) -f— V C1
Date Received .
Print /
MAP NO: � y PARCEL: ZONING DISTRICT:
all items on this
Historic District yes no
Machine Shop Village yes no
100 year-old structure yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
0 New Building
El One family
9
El Addition
0 Two or more family
0 Industrial
E1,8Iteration
No. of units:
;W�-Commercial
Nf
, -Repair, replacement
El Assessory Bldg
11 Others:
Demolition
0 Other
_E1
Floodplain ?
_ -MV-46-ish
ands -eWDisttict
1. QWjatb Water/Sewer
d
DESCRIPTION
OF WORK TORR PFRF0'R?%APT)-
�41 L) L&
12
OWNER: Name: / d
Address:
0 L)
Type or Print Clearly)
CONTRACTOR Name:&d,
0 (1 �4 Phone:
Address: L 6 &e-
V I
Supervisor's Construction
Home Improvement License:
ARCHITECTIENGINEE
�o..Exp. Date
Exp. Date:
Phon
Reg. No
40 3-13 P -
o 30'rs—
3-� � LL
FEE SCHEDULE. BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not h;
e 4to the guaranty fund
... .......
t
fte_n_t/(D.Wffer...' :o
idnAck o 49
N2 4650
TOWN OF NORTH ANDOVER
p PERMIT FOR PLUMBING
v n r
This certifies that ....1 . �.l 3 ! G�Z �' -C'....................
has permission to perform .....lft f-!.:.:............. .
,yy l ��/?�
plumbing in the buildings of .....!1./% Y �.... .
t ... .. , North Andover, Mass.
Fee .2l...... Lic. No..... % C1 '
/PLUMBING INSPECTOR
Check # f
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS 1_ ? >
Date
Building Location , °�
/44"'C– S Owners Name �, G (flu Vt Permit
_ Amount
Type of Occupancy Ly't' C4,�{�>✓
New Renovation Replacement Plans Submitted Yes No
(Print or type) <-7) r(`
Installing Company Name I t'f-6rWW-"'fie
Business
Check one: Certificate
Corp.
Partner.
Firm/Co.
Name of.Licensed Plumber 0 ✓ rP L ' 1
Insurance Coverage: Indicate the vmnreof in rance coverage by checking the appropriate box: ❑
Liability insurance policy 1__I Other type of indemnity M Bond
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under P it Issued for this application will be in
compliance with all pertinent provisions of the s chus State Plu g Cod Chapter 142 of the General Laws.
By:igna o ns um er
Type of lumbing Licens
Title �
City/Town License Numoer Master Journeyman ❑
APPROVED (OFFICE USE ONLY
•
i
.•
••
•
M
•
.N
of
y is a � � • ��5����������������������
(Print or type) <-7) r(`
Installing Company Name I t'f-6rWW-"'fie
Business
Check one: Certificate
Corp.
Partner.
Firm/Co.
Name of.Licensed Plumber 0 ✓ rP L ' 1
Insurance Coverage: Indicate the vmnreof in rance coverage by checking the appropriate box: ❑
Liability insurance policy 1__I Other type of indemnity M Bond
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under P it Issued for this application will be in
compliance with all pertinent provisions of the s chus State Plu g Cod Chapter 142 of the General Laws.
By:igna o ns um er
Type of lumbing Licens
Title �
City/Town License Numoer Master Journeyman ❑
APPROVED (OFFICE USE ONLY
N2 2663 Date .................
(-.. r�,v
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ........... u
.................. ..............................................................
has permission to perform ....... 1(............................... 6:- -17
wiring in the building of ...... ..............................
at ..... rth Andover s.
W/1' * * ....... 7 �--
,Fee..'/ ........ Lic. No:---�t ..... .......... ...... ....... e
ECTR AL SPECTOR
Check #
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
THE 09MM0NWF.4LTH0FMASS40WJSE77S Office Use only
DEPARTMEIVTOFPUBLICSAFM Permit No. Z6
BOARD OF MEPREYEWONMGM770A S 527CMR IZOO
%0,4"PLJCATIONFORPERWTOPEJZFORMELECMCAL
Occupancy &Fees Checked
WORK
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dat �� GC
Town of North Andover To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number)/V,,
Owner or Tenant /tip' 777-77-17-17,71
Owner's Address r ��>�%
Is this permit in conjunction with a building permit: Yes [ No M (Check Appropriate Box)
Purpose of Building
Utility Authorization No.
Existing Service Amps/ Volts Overhead D Underground No. of Meters
New Service Amps / Volts Overhead r-1 Underground No. of Meters
Niumber of Feeders and Ampacity
Location and Nature of Proposed Electrical Work
No. of Lighting Outlets
No. of Hot Tubs
No. of Transformers
Total
KVA
No. of Lighting Fixtures
Swimming Pool Above
Below
Generators
KVA
L'ground
El
ground
No. of Receptacle Outlets
/
No. of Oil Burners
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
t
Detection/Sounding Devices
Local Municipala
Connections
Other
N11of Dryers
(
Heating Devices KW
1'I of Water Heaters KW
No. of No. of
Signs
Bailasis
No. Hydro Massage Tubs
No. of Motors
Total HP
OTHER
hKam=cover g Resuartttotheregt�artaisoliviassachttsOtsGataalLaws
Ihawa=utLjabi*itnm=Pbb yni dmgCotvlele Co ctd.S ac "Au t YES ® NO E]
Ihawsuxn&dvMpoofof§ame1DtheOT=YES NO r-1 IfjcuhmetfWWYES,pieaseadc*thetyWofamr,, ebydwdd<gthe
NNc� Q' Bohn OTHER 0 (Plt espetdfy) V Q /
Expiration Dak
Es a Vahtecf�iecttical Walt $
WaklDSlatt %u/ k ;a, t gout, �G d d Fatal
Signed urXkrMRnaiaes ofperjt
FIRM NAME �G/rf��s; Idoer�seNa
OWNER'S INSURANCE WAIVER, Iamawar dAthe '
and Ifietmysignaluieunthis pamiappkEdmvmikcsthistet iuyien.
(Please check one) Owner a Agent
,5f
Btn�tessT�.NQ
s Alt. Tel Na
mamwomeapa-zsbsortWegrAatasm4mWbyNtmodmettsCRnaraiLmNs
Telephone No. PERMIT FEE (/U
N2 46:'3
Date. A ; .'. -,.
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that ...Fc. -!j . .... . f ���"'p "� ` /?' / ...........
n�................
has permission to perform
plumbing in the buildings of .�? .�.'!`�"' ..E`r{....... .
at..A/ 1... � G'. .. ?............. . North Andover, Mass.
Fee. .cI ?.... Lic. No .......... ........ ...�.— :7c..... .
.PLUMBING INSPECTOR
Check # //YG
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print) '
NORTH ANDOVER, MASSACHUSETTS
` / Date
d,� Building Location ��� I'lJC Owners Name ^ (( � ✓ 'i Permit # j
Amount
of
New M Renovation Replacement 1:1 Plans Submitted Yes [I' No
(Print or type) e-
Installing Company Name
of
D
Name of Licensed Plumber,. T V I I VLC, ( 9 ( L`\ I` C-ri
Insurance Coverap-e: Indicate the f ins ce coverage by checki
Liability insurance policyEr Other type of indemnity
Check one: Certificate
❑ Corp.
Partner.
Firm/Co.
the appropriate box:
❑ Bond ❑
Insurancq Waiver. I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
Asuran
Owner Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the M s us tate Plumb'ode an er 142 of the General Laws.
By: Igna o Ice um er .
Type of Plithbing License
Title 12-
City/Town License um er Master Journeyman ❑
APPROVED (OFFICE USE ONLY
c
MMMMMMMMMMMMMMMMMMMMMMMMM
MMMMMMMMMMMMMMMMMMMMMMMMM
MMMMMMMMMMMMMMMMMMMMMMMMM
mmmmmmmmmmmmmmmmmmmmmmmmmm
.,,: 4 V
MM
MMMMMMMMMMMMMMMMMMMMMM
� .:
�.
mmmmmmmmmmmmmmmmmmmmmmmmm
..•MMMMMMMMMMMMMMMMMMMMMMMMM
(Print or type) e-
Installing Company Name
of
D
Name of Licensed Plumber,. T V I I VLC, ( 9 ( L`\ I` C-ri
Insurance Coverap-e: Indicate the f ins ce coverage by checki
Liability insurance policyEr Other type of indemnity
Check one: Certificate
❑ Corp.
Partner.
Firm/Co.
the appropriate box:
❑ Bond ❑
Insurancq Waiver. I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
Asuran
Owner Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the M s us tate Plumb'ode an er 142 of the General Laws.
By: Igna o Ice um er .
Type of Plithbing License
Title 12-
City/Town License um er Master Journeyman ❑
APPROVED (OFFICE USE ONLY
Office Use Only Q `L
04e LIIIIIIITIIIIlUPFt�fi1 of ISfi�E S Permit No. a_
-^� Mepart neat of Vuhlic —Aufrtg Occupancy & Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 3M (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date
(X)� or Town of NORTH ANDOVER To the��/9
fWires:
The udersianed applies for a permit to perform the electrical work described below.
Location (Street 8
Owner or Tenant
0
Owner's Address �7 V� �G��y It '72�
Is this permit in conjunction with a building permit: YesZ No L_ (Check Appropriate Box)
Purocse of Building _ c� C -k7 Utility Authorization No.
Existing Service Amos _J Volts Overhead 11 Unagrnd r No. of Meters
New Service Amps _J Voits Overhead Uncgrno r No. of Meters
IJ
Number of Feeders and Ampacity
Location and Nature of Prcoosed Eectricai 11VcrK
Total
No. of Ugnting Outlets ' No. of Hct -_-ns Na. of 'ranstormers KVA
Abcve.— tn- r-
No. of Lighting Fixtures I Swim Pool grna. _ crnc. _ Generators KVA
t� i I No. of Emergency Lighting
No. of Recectac:e Cutlets No. of Oil Burners Battery Units
No. of Switch Outlets I No. of Gas Burners FIRE ALARMS No. of Zones
Total No. of Cetection and
No. of Ranges I No. of Air Core. tens init(atina Devices
'I Heat Total Total
No. of Sounding Devices
No. of Disoosals No.of Pur -.=s Tors KW
i vo. of Salt Contained
No. of Dishwashers SoaceiArea Heating K%^J Oetec::oniSounetng Devices
— Municioat-Other
No. of Dryers Heating Devices KW Local Connec::an
No. of No. of Low Vcttage
No. of Water Heaters KW I Signs Sa iasts Wirinc
No. Hydro Massage Tubs I No. of Motors Totai HP
OTHER:
INSURANCE CCVERAGE: Pursuant to the reeuirements o_f Massacnusecs ;eneral Laws _
I have a current Liabtiity Insurance Policy inctucing Ccmc:etec Ocerauons Coverage or its sucstantial equivalent. YES _ NO _
have submitted valid proof of same to the Office. YES _ NC _ it ycu nave checxee YES. -lease noicate the type of coverage cy
=UR
proonate Dox. -;,�v&2`//If
E - BONO = OTHER - (Please Sbec:fv)(ExDirauon Oate1
9 6
alue of E!ec:scat War 5 G ,
Worx :o Start Insoec::on Date Recuestec: Rough i tnai
Signed unser the Pen sties f p rlu
!J LIC. No.
FIRM NAME
Licensee Sig^attire
Bus. 7 No.
Address as Alt. .el. ?Jo.
OWNERS INSURANCE WAIVER: 1 am aware that the Licensee toes not have the insurance coverage or its substantial equivaient
A onto
quirea by Massachusetts General Laws. and that my signature on :r.is permit application waives this reouirement. Ow 9
(Please cnecx one)
:eieonone No. PERMIT FEE ' CCCYYY
(Signature at Owner or Agenti t �SoS j
�I
`'ter>-ti-w_.7-...'.+�-•.=�s'�.r-""-.-v....-y.v..�r -^., �..2 . -� � ._.-...-.,� ..- _. ..
is 2458 Date .....Q.
o�1ti„
M0RTM TOWN OF NORTH ANDOVER
A PERMIT FOR GP INSTALLATION
This certifies that ...t4r.A.��S ....!�v.........
has permission fonstallation ..Q (`f"t cr...,;'e...ti,
P
�^ ��
in the buildings of .. ��/jj.�i?�.1�'!Q!� .. � Sid G, ; , , _ , , , , ,
at5� �....!'!RvJ`?2,.51'• ,North Andover, Mass.
Fee. 2f�0.�............... .
A"'c1V11dd'
PECTOR
WHITE: Applicant CANARY. Building Dept. PINK: Treasurer GOLD: File
TOWN OF NORTH ANDOVER BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
Section for Official Use Onl - .,.
BUILDING PERMIT NUMBER: S DATE ISSUED:
SIGNATURE: zj A ((CA,
Bufldi5 Commissioner/ or of Buildings Date
1. l Property Address::
�� ' � ►1 � a J'�-1 3T'• %�Fiz��/>I �f%1/
1.2 Assessors Map
j� � Y
Map Number1l
and Parcel Number:
(;sem+ �-- �S
Parcel Number
C-- )
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Area Frontage ft
1.6 BUILDING SETBACKS (ft)
Front Yard
Side Yard
Rear Yard
Required Provide
RNuired
Provided
Required
Provided
1.7 Water Supply M.G.L.C.40. § 54)
Public ❑ Private ❑
1.5. Flood Zone Information:
Zone Outside Flood Zone ❑
1.8 Sewerage Disposal System:
Municipal On Site Disposal System ❑
2.1 Pwner of Record
Am I-rcvl iue ? Ir
ame ( rint) Abd ess for§ervice
%gj�iture Telephone
2.2 Authorized Agent
Name Priv: Address for Service:
Signature Telephone
3.1 Licensed ConstructionSupervisor
�
///
Not Applicable ❑
License Number
�'�
Address /
'q LA/1i vt e �i4 V'�.p Y' P 1 ✓►1 a. L
Li sed Construction Supervisor:
ignature Telephone
Expiration Date
3.2 Registered Home Improvement Contractor
Not Applicable ❑
Company Name,,
Registration Number
Address
Expiration Date
Signature Telephone
I, as Owner/Authorized
Agent
Hereby declare that the state ents and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury
v ct
Print me
S e of Owner/A t Date
Item
Estimated Cost (Dollars) to be =g - A x ' ft -w,
Completed b t applicant
P Y Perms PP
1. Building
(a) Building Permit Fee
Multiplier
2 Electrical
(�
(b) Estimated Total Cost of
Construction from (6)
3 Plumbing
Building Permit fee (a) x (b)
a� i
4 Mechanical (HVAC)
5 Fire Protection
6 Total (1+2+3+4+5)
Check Number
` ff. ¢.SY t 411
3.�iI 2r�`- X:, �xi Vry
t 11 �4 x d +£
�itl 1"si �y yt
f�.i..k'Y� p f
b1.fT
"14�F
€9..Y 2
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR THABERS iST 2ND 3RD
SPAN k
DEMENSIONS OF SILLS ,
DEMENSIONS OF POSTS
DMIENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
XWN�• <:`�,yy;: :.. z r
F R, ,
M
y.t ✓ i ,7- +� >,,F 'a`T$b '. .�` ^'1 ,�'+-�; t`�`"�. '3,-�+�3 tj,Y`x
1
...,. . •: i. S1 r -'}a1 �. e= alh i.." 4•'.- 4 k a•t @ t y 1W,4 J, k;Ca y� :cl. 1 Y 1 lY"y :A 4 >
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.
Sinned affidavit Attached Yea ..... _ No ....... ❑
5.1 Registered Architect:
Nam
Address
Signature
Telephone
A
Name:
Kesponsiote in unarge of Construction
Not Applicable ❑
Area of Responsibility
Registration Number
Expiration Date
Name:
Address:
Signature Total
Not applicable ❑
Registration Number
Expiration Date
Name:
Address
Signature Telephone
�
Area of Responsibility
Registration Number
Expiration Date
Name
Address
Signature Telephone
Area of Responsibility
Registration Number
Expiration Date
Name
Address
Signature Telephone
A
Name:
Kesponsiote in unarge of Construction
Not Applicable ❑
I
Independent Structural Engineering Structural Peer Review Required Yes ❑ No ❑
SECTION 10a Owner Authorization - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Owner of the subject property
Hereby authorize to act on
My behalf, in all matters relative two work authorized by this building permit application
Signature of Owner
Date
New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Addition ❑
Accessory Bldg. ❑ Demolition
❑ Other ❑ Specify
Brief Description of Proposed Work:
•z.
(M AAe A,622
USE GROUP Check as applicable)
CONSTRUCTION
TYPE
A Assembly ❑ A-1 ❑
IA
❑
A-2 ❑ A-3 ❑
A-4 11A-5
❑
IB
❑
B Business ❑
❑
2A
C Educational ❑
F Factory ❑ F-1 11F-2
❑
2B
2C
❑
H High Hazard ❑
❑
IInstitutional ❑ 1-1 ❑
1-2 ❑ I-3 ❑
3A
3B
❑
M Mercantile ❑
❑
❑
❑
4
R residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A
S Storage ❑ S-1 ❑
S-2 ❑
513
❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ Specify
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,
ADDITIONS AND OR CHANGE IN USE
Existing Use Group:
Proposed Use Group:
Existing Hazard Index 780 CMR 34:
Proposed Hazard Index 780 CMR 34:
BUILDING AREA
EXISTING if applicable)
PROPOSED
Number of Floors or Stories Include
Basement levels
Floor Area per Floor s
Total Area s
Total Hei t ft
Independent Structural Engineering Structural Peer Review Required Yes ❑ No ❑
SECTION 10a Owner Authorization - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Owner of the subject property
Hereby authorize to act on
My behalf, in all matters relative two work authorized by this building permit application
Signature of Owner
Date
New Construction ❑
Existing Building ❑
Repair(s)
❑
Alterations(sr11—
Addition 0
Accessory Bldg. 0
Demolition ❑
Other ❑
Specify
Brief Description of Proposed Work:
❑
❑
(ZIA 1%" A.A..) CCAJJ
C
❑
2A
2B
2C
BUILDING AREA
Number of Floors or Stories Include
Basement levels
Floor Area per Floor (sf)
Total Area (sf)
Total Height lftl
Structural
EXISTING (if
Structural Peer Review
Yes ❑ No 0
SECTION 10a Owner Authorization - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Hereby authorize
PROPOSED
Owner of the subject property
My behalf, in all matters relative two work authorized by this building permit application
Signature of Owner
Date
to act on
USE GROUP 7hck as applicable)
CONSTRUCTION TYPE
A Assembly
❑ A-1 0
A4 0
A-2
A-5
❑ A-3
❑
❑
IA
1 B
❑
❑
B Business
❑
2A
2B
2C
0
❑
0
C Educational ❑
F Factory ❑ F -I ❑ F-2 ❑
H High Hazard
❑
3A
3B
❑
❑
IInstitutional ❑ I-1 0 1-2 0 I-3 ❑
M Mercantile
❑
4
0
R residential
❑ R-1 ❑
R-2
❑ R-3
❑
5A
5B
❑
❑
S Storage ❑ S-1 ❑ S-2 ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND OR CHANGE IN USE
Existing Use Group:
Existing Hazard Index 780 CMR 34:
Proposed Use Group:
Proposed Hazard Index 780 CMR 34:
BUILDING AREA
Number of Floors or Stories Include
Basement levels
Floor Area per Floor (sf)
Total Area (sf)
Total Height lftl
Structural
EXISTING (if
Structural Peer Review
Yes ❑ No 0
SECTION 10a Owner Authorization - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Hereby authorize
PROPOSED
Owner of the subject property
My behalf, in all matters relative two work authorized by this building permit application
Signature of Owner
Date
to act on
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 Yea ..... No ....... ❑
SECTI41+1 5 - PROMlm , dI.1D" XM
Gt1�NSilC UC"J<i<Ol�t S R'ViCES FOB; BAGS UCTU S Wit"# TO
CONTBt11CTION C(3 OT PAT TCl► GSR 116 (+CONI MO1€►5,i1t18
5.1 Registered Architect:
Nam :
Address
Signature Telephone
3.21Re�s6eicd�'tef�sa� i�..n��t�s�; ,
Area of Responsibility
Registration Number
Expiration Date
Name:
Address:
Signature Total
Not applicable ❑
Registration Number
Expiration Date
Name:
Address
Signature Telephone
Area of Responsibility F
Registration Number
Expiration Date
Name
Address
Signature Telephone
Area of Responsibility
Registration Number
Expiration Date
Name
Address
Signature Telephone
, Not Applicable ❑
J a
Company Name:
Responsible in Charge of Construction
I, as Owner/Authorized
Agent
Hereby declare that the state ents and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of
perjuryr,
Print me
S e of Owner/A t Da e
y�
Item
Estimated Cost Dollars to be
Completed by permit applicant
1. Building
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction from (6)
3 Plumbing
Building Permit fee (a) x (b)
4 Mechanical (HVAC)
�-
5 Fire Protection
6 Total (1+2+3+4+5)
Check Number
G , .; � e ,x . a r ^ S ✓�fi.'.:� yr�t , .. ah Y � , .' 'pis 4-� 1.�'".. � r-' .� { 2 ��:, � a< ,� �,
tEc}
YkYk3 �1 (f _� ti yt# �YxE'Yuti£StSSr
s x •4C,�' �M2--"
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 1ST 2 ND 3RD
SPAN
DEMENSIONS OF SILLS 1
DEMENSIONS OF POSTS
DIN ENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CIENINEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
S 1
Y
��..
TOWN OF NORTH ANDOVER BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
Section for Official Use OnI Mum
BUILDING PERMIT NUMBER: 3— / /'f I DATE ISSUED:
SIGNATURE: IV
BuildiN Conunissioner/Ior Of Buildings Date
1.2 Assessors Map and Parcel Number:
1. 1 Property Address:
C-- L
Map Number Parcel Number
1.3 Zoning Information:
1.4 Property Dimensions:
ZonxmgDistrict Proposed Use
Lot Area Frontage (ft)
1.6 BUILDING SETBACKS (ft)
Front Yard Side Yard Rear Yard
ReqWred
Provide Required
Provided
Provided
_RWred
1.7 Water Supply M.GJ-.C.40. § 54) I.S. Flood Zoaclnform�afion: 1.8 Sewerage Disposal System:
Public 0 Private 0 zone — Outside Flood Zone 0 Municipal On Site Disposal System 0
2.1 Puner of Record
Am J.. vcv. 69 ,e �F Yt—, O.A-,je, J
i-10
k4ame 0 Ab&e�s for 'Service
$feature Telephone
2.2 Authorized Agent
Name Priv: Address for Service:
Signatuve Telephone
00 0. Z,
I ON
3.1 Licensed Construction Supervisor1-1
Not Applicable 0
beav
— (*+) S-715 t, L
License Number
Address
I eIL;Z 14et' 1 1 d,. L &q0;Gj,y
--LICAnsed Construction Supervisor:
7"L, S--
LyL a-
Expiration Date
%imiture Telephone
3.2 Registered Home Improvement Contractor
Not Applicable 0
Company Name_
Registration Number
Address
Expiration Date
Signature Telephone
Za— 0-0
044—
Z
0
I
0
M
X
Z
0
Z
M
90
0
-n
M
Z
G)
t
Town of North Andover p►ORTH
ot�ttgo ,6 ti
t, , o
Building Department o
27 Charles Street * _
North Andover, Massachusetts 01845
(978) 688-9545 Fax (978) 688-9542
�SSACb1Us��
DEBRIS DISPOSAL FORM
In accordance with the provisions of MGL c 40 s 54, and a condition of
Building permit # the debris resulting from the work shall be disposed
of in a properly licensed solid waste disposal facility as defined by MGL cl 1, s150a.
The debris will be disposed of in /at:
Facility locatiTignature
nt
Date
NOTE: A demolition permit from the Town of North Andover must be obtained for this
project through the Office of the Building Inspector.
A
✓fie (�oavrao,�eueaCC/ o��l/%aaaacivaea
k BOARD OF BUILDING REGULATIONS
y License: CONSTRUCTION SUPERVISOR
Number: CS 059666
Birthdate: 03/25/1952 w
Expires: 03/25/2002 Tr. no: 18267
Restricted To: 00'k P
CLAUDE J BEAUDOIN '
19 WESTMINSTER LN,
MERRIMACK, NH 03054 Administrator
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Please Print
Name:
Location:
City Phone
am a homeowner performing all work myself.
01 am a sole proprietor and have no one working in any capacity
I am an employer providing workers' compensation for my employees working on this job.
Company name:
Address
City- Phone #
Insurance Co. Policy.#
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00
and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do herby certify dei the pains and penalties of perjury that the information provided above is true and correct
Signature Date
Print name
aA�o cil Phone # 63- Y L
Official use only do not write in this area to be completed by city or town official'
OCheck if immediate response is required Building Dept
Contact person:_ Phone #.-
FORM WORKMAN'S COMPENSATION
n Building Dept
p Licensing Board
p Selectman's Office
E] Health Department
0 Other
E
Cl)
m
m
Cf)
0
m
w c C13 co c?=- m =
O —• to o CT y
a�m CA
Oo Cl)
co H m a C B,
c Z �-a H -I
= m �M y
C d m o CDH o
O ?m, o =
O� > opCAo
— d m o o ..
CO2 O Of y'cm)
10 O s��: :7
H _
�
CA z� r� a �Mm
CD O '0.
mmy
^omCD
it
fl.= ca lJ yam. Q
s
� � �_ � •
CL
'v O O r-► � H �
C7 a
c v
CD ,m H W
'� O 3E m y
Q = / N
VN
r�m O
CD C7 m
.. c)
CCD O CDQ O � � �
vo vo 3 " Z m o :�
c CD y: it►
a v CA m z
�•CCDD
Uj
CO) o C/)C7DH
.o to �, ! 1
CD Z
o m
n
O H o
CD
�m
5
K,
a
w°
wI
M
-x
w
T
P.:,
rte''
:v
po
�°
►d
1•�
z
n
po
�°
O
a7
y
(9
n
2)
W
H
0
9
0
c
Location
No. �'� Date
No T" TOWN OF NORTH ANDOVER
Certificate of Occupancy $
J
E<�' Building/Frame Permit Fee $
-1 CHUS
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # 3� 75
j V 1, Building Inspector