Loading...
HomeMy WebLinkAboutACFrOgAQ2Nwsrm3GwK1s8yJ4MXs0NClDxbaLrXv...7tyfBzVFLVuuxvIGWz34V2sduboXGoxUVgF9g= Claim # Advantage Claim Services Adjuster Assigned: Glenn Guarente 522 Chickering Road #B North Andover, MA 01845 Form of Notice of Casualty Loss to Building ' Under Mass. Gen. Laws, Ch. 139, Sec. 3B To: Building Commissioner dol Board of Health or Inspector of Buildings Board of Selectmen Town Hall Town Hall North Andover, MA 01845 North Andover, MA Re: Insured: Karen Mulcahy Property ai:?dress: 57 Third St. North Andover, MA 01845 Policy #: 1690181 Loss of: 2015/03/15 File or Claim No. AD 1717 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1, 000.00 or cause Mass.—Gen._Laws, Chapte.r_143,_Section_6 to be applicable. If any. notice under Mass—_Gen_Laws,_Ch._139_Sec. 3B is appropriate please F direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Glenn Guarente Title: Adjuster On this date, i causPd copies of this notice to be sent to the persons named at the addresses indicated above by first class mail. 03-16-15 Signature and date !. Location No. Date TOWN OF NORTH ANDOVER Certificate of occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL Check # Building Inspector TOWN OF NORTH ANDOVER BUILDING EPA T ENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING .. �., Iti � BBUILDING PERMIT NU€1�IBER: 0� DATE ISSUED. C)3 SIGNATURE: Building Commissioner/In r r of Buildings Date SECTION 1-SITE INFORMATION 1.l Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use _ Lot Area(sf) Fronts e ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Prate Re red Provided Re aired Provided 13 Water S 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: gpplyM.GL.C.4(1. 54) Public t"� Private © Zone Outside Fluod Zone ° Municipal Ou Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owncr of Record {� tar p-v� � --- 1 , S -- Name(Print) Address for Service W Signature Telephone" 2.2 Owner of Record: Name Print Address for Service: Signature Tel hone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable Licensed Construction Supervisor: License Number Mn Address Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable Company Name t� Registration Number Address >® Expiration Date Signature Tele hone SECTION 4 e ORXERS COMPENSATION(NLG.L.. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......[I No.....:. SiCTI N 5-Description of Proposed Work check ail a hcahle New Construction ❑ Existing Building ❑ Repair(s) (K Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition Other ❑ Specify Brief Description of Proposed Work: rr'� Cq SECTION 6 m ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be 3 dCI U ONLY Completed by IDearnit applicant ant 1. Building4(44 (a) Building Perrin Fee �j�t3pt3 Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Pen-nit fee(a) x (b) 4 Mechanical HVAC) 5 Fire Protection 6 Total (1+2+3+4+5) t j t�J-� Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONT€tACTOIpiAPPLIES FOR BUILDING PERMIT t.-1 C CLI as Owner/Authorized Agent of subject property llerebv authorize to act on My behal- in all matte relative to work auth rized by this building permit application. Siguat&e of Owner Date SECTION 7b OWNER/AUTHORIZED.AGENT DECLARATION I, as Owner/Authorized Agent of subject property Herebv declare that the statements and information on the foregoing application are tube and accurate,to the best of my knowledge and belief Print Name Signature of Owner/Agent Date NO.OF STORIES SIZE. BASEMENT OR SLA13 SIZE.OF FLOOR TIMBERS Is ;�Nrj3R SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS I LFIGI IT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL,OF CI MNEY IS BUILDING ON SOLID OR FII.1ED LAND IS BiALMNCT CONNECTED TO NATURAL GAS LINE NORTH To' wn of ,.:w . .�, No. 3 _ O C�-OC M LICA NE EWIC o 1- dower, Mass., K A0RA'UD PAp���� S' BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System I) �� � Ay BUILDING INSPECTOR THISCERTIFIES THAT.......L............. .................................... ................................................................ Foundation has permission to orect... 1. � ..... b Tidings on �� w • .f Rough ............................ ....... ......................... to he occupied as roe 0 .....�b C. ^^ p O r ti chimney r..............................................}... ....................1........................................................I.—........ provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final . this office, and to the provisions of the Codes and By- ws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. jO IV Sd PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTI N S T ELECTRICAL INSPECTOR A Rough zService BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises -- Do Not Remove Find No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE smoke Der. i Noah Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM !n accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is-that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. The debris will be disposed of in: Zi . ( cation of Facility) Signature of Permit plicant /" /q 0 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT PHONE 15 LOCATION: Assessor's Map Number PARCEL SUBDIVISION }} — LOT(S �f STREET ST. NUMBER ********************** ************OFFICIAL USE ONLY*****#**************** ***** **** RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS a' TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE-REJECTED COMMENTS PUBLIC WORKS- SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm