Loading...
HomeMy WebLinkAboutBuilding Permit #264-13 - 110 MARBLEHEAD STREET 10/4/2012 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 6 qrP� Date Received Date Issued: /04 z IMPORTANT:Applicant must com Tete all items on this age I j LOCATION 1 /2, M mI(c head Shts_t- ` /y Print PROPERTY OWNER C:61Y0l C0 r-C Unit# Print MAP NO: _PARCEL: d 6.%6 ZONING DISTRICT: Historic District yes no It Machine Shop Village yes no 100 year-old structure yes no r PE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial Repair, replacement ❑Asses sory Bldg ❑ Others: ❑ Demolition ❑ Other --L� 7- ®�We'�tl'ands a�rshedlDisfnct r Sewe"r� - DESCRIPTION OF WORK TO BE PERFORMED: j (Identification Please Type or Print Clearly) OWNER: Name:_ Phone 97 Address: ar( b �'+rr,-t no(� r� 0 ver /� 0 ! � `f I - ` CONTRACTOR Name: ` Phone: 6 3 1 " 4 Address: ( � ,,� s+ —�— v i l� IIS Supervisor's Construction License: C�31 Exp. Date: -1,0 Home Improvement License: I d y S(0 9 Exp. Date: -1 1 ), ARCHITECT/ENGINEER Phone: Address: Reg. No. . FEE SCHEDULE:BULDING PERMIT.$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. c Total Project Cost: $_ (� °`' FEE: $ � / � �,� Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund - CGiinafii�a'nf;r nnfr�rinr 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 o Photo Copy of H.I.C..And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permi Addition or Decks ❑ Building Permit Application tf Certified Surveyed Plot Plan o 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 Permit 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 o 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 o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg .Permit 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 I Doc: Doc.Building Permit Revised 2008mi i I Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ J TYPE OF SEWERAGE DISPOSAL I 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 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature f COMMENTS 1 HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes { Planning Board Decision: Comments i Conservation Decision: Comments i 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 I COMMENTS ILS 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. 100- 1000 i $ $ fine NOTES and DATA— For department use 1 �l ❑ Notified for pickup - Date Doc:.Building Permit Revised 2011 June/mi 0 A Location No. y— Date t • ' ° TOWN OF NORTH ANDOVER ® Certificate of Occupancy $ ,? Building/Frame Permit Fee $ O`) Foundation Permit Fee $ Other Permit Fee $ TOTAL $ :i r: Check# 7 7 25783 B ilding Inspector :i NORTH Town of 2 . t E 1� Andover p - ,' 0 No. — # T v t��. h ver, Mass, Za /�- coc 1C.1—Cu y1' S V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ' G�E.rc BUILDING INSPECTOR /� Foundation has permission to erect ......... buildings on . 1. �t.�':�� / �7S. ................. ................. ...... ......... Rough to be occupied as .............S .l. ..................................................... ............... Chimney provided that the person accepting this permit shall in every:respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. - PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN. 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough Service ......... ..... . .................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE DAVID CASTRICONE, PROS CASTRICONE ROOFING&SIDING INC. ROOFING,SIDING&REMODELING REPLACEMENT WINDOWS HOME IMPROVEMENT CONTRACTOR REGISTRATION NUMBER 104569 9J 12gg•SUTTON STREET,SF3t`f?B'LZ6,NO.ANDOVER,MA 01845 In North Andover 978-683-3420 In Basford 978-887-6147 In HaverhUl 978-374-7314 Uwe the owner(s)of the premises mentioned below,hereby contract with and authorize you as contractor,to furnish all necessary materials,labor and workmanship,to install,construct and place the improvements according to the following specifications,terms and conditions,on premises below described: l ... • ........., Telephone Owner's Name......... v€c.1aeV #.. ....,.)..$........3f..PU..�....—.........�.'...�.j. ...... . city......., ................State- ........... Job Address............. .1.. .........t� � .........hh Specifications: ......................................................................................................................J.........,.. ........................................... v,..trip exist' g shi les. ply new drip edge to all edges. �pp)y 6 feet ice and water shield membrane to bottom ed es of house. 3 feet ice and water shield membrane in valleys and bottom edges of any unheated areas of house. ...............................................•.•••••.•..•...,,,,,,,, ..................................................................................ntt.....................G�......rG..J. Apply felt ppper underlayment. ✓install ridge vent to ..�:}!. '1.....rr.. ,G ear warrant n I / �.�r�jC shingles with..�G Y y Reroof using ��ei� z�,. r< r�rr ••••• r�al dis sal of all debris. C terflash chimney. Ne vRnt pipe flashing. : " fm ........I........ Area(s)to be worked on: //......}S�t.(RtL •„i.•..G0 .. ............••• . . . .....................................................pND ...........................:......... ...... .....................:....................................................................................................... .......................................... ........ ..... .... ........... ... .... ... . .. .....................................................................I........................, Root board......replacement. ... . ..i.f.necessar.. y@ $ D/sheet or 4/foot ....................... .................................................................................................................................... Two Year Workmanship. Warranty(Not Transferable) Manufacture. . r Warranty as specified by manufacturer The contractor agrees to perform the work and furnish the materials specified above for the SUM of$...4 .p` Payable..........fit 1 ..........on.......5:�1&............. d Payable...........................on.................................. vtsalance payable on completion of job Owner or Owners are not responsible for Property Damage or Liability while job is in operation. my►a)or Contractor is not responsible for any damage to the interior of property,including pre-existing conditions(i.e.water stains,crumblinposed n�fastderr exattic posed n curer living conditions resulting from application of materials specified above(i.e.objects coming loose of nom w�trac ;crumbling dmumpstcr placedeb contractor is for his use only.Upon spaces).Items in attic may need to be covered by homeowner.fW materials are propertytcd completion of above work,all undersignedagreetat its execute an declare the entire ctor,t air joce or o much accordanceint note in then remains Paid,i bone obligation and 03 s bi rs to do o contractor y p •n addition to the amount due and unpaid.that contractor. Upon refusal me fees and expenses,e agreed that,if permitted by law,contractor shall be paid by the owners)all reasonable lien costs,attorney that this contract may be assigned by shall be incurred in enforcing the terms and conditions of the contract their rsY Isucces ors in or estates of the parties.Th unon herewith.it is further dersigned warrant(s)that he is(they are) contractor,and also that the obligations hereof shall bind and appynames( Themlies or the owners(s)of the above mentioned premises and that legal title thereto stands�fcollateralrrerehereto,(their) ir)s the contract dependent uponnorlsubjectguw�any conditions tool warranties,except such as may be herein incorporated,if any,her any agree herein stated.My subsequent agreement in reference hereto shall be binding only if in writing end signed by all parties.ubCOniraCtOr relating t0 8 registration and an inquiries about a contractor Home Improvement Contractors shall be registered Y 4 coin 1301 Boston,MA 02108 All should p , should be directed to:D�{ector,Home Improvement Contractor Registration, One Ashburton Place, R Tel:617-727-8598 Any and all necessary construction-related permits shall be obtained by the Contractor. Any Owner who secur his own consttucdon- related permit or deals with unregistered contractors is excluded from the Guaranty Fund provisions of MGL c.142A. ... Completion date......:.................................................. Approximate starting date of work............ .... gned that e foregoing Receipt of a copy of this contact is hereby acknowledged,and it is further acknowledged or agrelementlnof herein tcontained shall be understood and that no p provisions have been read and the contents thereof Linde herein. P parties are contained her - of said binding upon the parties and that all of the agreements and understandings p DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Owner has three business days to cancel this contract and incur no penalty (see notice of cancellation). IN WITNESS WHEREOF,the parties have hereunto signed their names this..................day of............................20........... Accepted: dll�l.•••..1-,. .............. Owner Signe Signed ............................................... Owner ................................................................... David Castricone,President The Commonwealth of Massachusetts Department of Industrial Accidents A? Office of Investigations d 600 Washington Street Boston, MM 02111 ,.•�•y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information CPlease Print Leizibly Name (Business/Orgarvzation/Individual): CAST 81 CME Address: 3 T rb N STRFF—T 3A City/State/Zip: hl6 An b oy a MA d MS Phone #: 9q VW W Are you an employer? Check the appropriate box: Type of project (required): 1.® I am a employer with 7 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. $ Remodeling ship and have no employees These sub-contractors have 8. ElDemolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] officershave exercised their 3.El I am a homeowner doing all work right of exemption per MGL 11.❑ lumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12. Roof repairs insurance required.] t employees. [No workers' 13.0 Other comp. insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information: Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such Contractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information. 'am an employer that is providing workers'compensation insurance for my employees. Below is the.policy andjob site reformation. nsurance Company Name: A(Z TIS Q ?olicy#or Self-ins. Lic. #: W C O a 31117.13 Expiration Date: �L• 013 lob Site Address: ( � mCQJ �J GLCG T City/State/Zip: R) rW61t.., w- U/M kttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a =ine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a SWOP WORK ORDER and a fine )f up to $250.00 a day against the violator.--Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA-for insurance coveragq.venfication. do hereby certify u�`ndeerr the pains and penalties of perjury that the information provided abov�et is true and correct Signature: �J C Date: 'hone#: !i u � � Oficial 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): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: Boj :trltu>ctf - Ucltarfntcnt ul l'ultli� lafcll guard of guiltlin_ FZc_ul:lhun�� ,iu11 titanllartl Construction Supervisor Specialty License License: CS SL 99358 Restricted to: RF,VVS DAVID CASTRICONE 31 COURT STREET >rt NORTH ANDOVER, MA 01845 Exp ration 12/16/2013 Trr: 7924 SCA 1 is 20M-05/11 " —'\ Office of Consumer Affairs& Busidess Regulation _ OME IMPROVEMENT CONTRACTOR egistration: 104569 Type: xpiration: 7/14/2014 Private Corporation DAVIASTRICONE ROOFING, SIDING& David Castricone 231 R SUTTON ST SUITE 3A NORTH ANDOVER, MA 01845 Undersecretary DATE(MM/DD/YYYY) AC"R& CERTIFICATE OF LIABILITY INSURANCE 9/24/2012 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(les)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 NAME: Select Eastern Insurance Group LLC-Main PHO NN E 08 651 7 00 FAAicVC. No: 65 8 89 233 West Central Street E-MAIL Natick MA 01760 ADDRESS: I c e c om INSURERS AFFORDING COVERAGE NAIC* INSURER A: INSURED 31969 INSURER B: David Castricone Roofing&Siding Inc INSURER C: 231 Rear Sutton Street, Unit 3A INSURER D: North Andover MA 01845 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 1538501247 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 A POLICY EFF POLICY EXP LTR TYPE OF INSURANCE N POLICY NUMBER MM/DDIYYYY (MO LIMITS GENERAL LIABILITY EACHOCCURRENCE $ D7WCOMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS-MADE 0 OCCUR MED EXP(Anyone person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO LOC $ JFCT AUTOMOBILE LIABILITY Ea aoCiderrt ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIREDAUTOS AUTOS Peramklenl $ UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE � AGGREGATE $ DED I I RETENTION$ $ A WORKERS COMP ENSATION W0003989723 /23/2012 /23/2013 X I WC STATTORYLtMU- OTH- AND EMPLOYERS'LIABILITY Y/N ER ANY PROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT $100,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $100,000 It Cres,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS;LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,11 more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN David Castricone Roofing&Siding Inc ACCORDANCE WITH THE POLICY PROVISIONS. 231 Rear Sutton Street, Unit 3A North Andover MA 01845 AUTHORIZED REPRESENTATIVE ®1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD AC40R"® CERTIFICATE OF LIABILITY INSURANCE F DATE(MM/DDIYY 9/11/20122 PRODUCER 978 273 6368 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Willows Insurance Agcy ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 51 Cochichewick Drive ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. North Andover MA 01845 INSURERS AFFORDING COVERAGE ' NAIC# INSURED INSURER A:WESTERN WORLD INSURANCE CO DAVID CASTRICONE ROOFING & SIDING INC & ; INSURER B: CASTRICONE ROOFING & SIDING INC INSURER C: 231 Sutton St #3A - -- ------ _._ INSURER D. NORTH ANDOVER MA 01845 ...- COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. - --- LTRINSRDI PO LICYEFFECTIVE POLICY EXPIRATION -LTR N RDI PE RAN POLICY NUMBER DATE MWDD DATE MMIDD LIMITS GENERAL LIABILITY j 11—� EACH OCCURRENCE $ 1000000 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED -- — PREMISES_Ea occurrence ,$__-_... __ .50000 A CLAIMS MADE �}�OCCUR rPP1332888 19/6/2012 9/6/2013 MED EXP(Any one person) 1000 1 ' ---- ----- --- ---— I i �-PERSONAL&ADV INJURY $ _ 1000000 -- -- --- — -. I i GENERAL AGGREGATE $ 2000000_ GENT AGGREGATE LIMIT APPLIES PER:j --- PRODUCTS-COMP/OPAGG $ 2000000 POLICYj PRO- LOC i ----_..-------------i---------._._._----------- 'AUTOMOBILE LIABILITY i- COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS i BODILY INJURY L. $ — SCHEDULED AUTOS I (Per person) � I HIRED AUTOS --- - ----------- I i NON-OWNED AUTOS (Peri accidentBODILY )RY $ PROPERTY DAMAGE $ j (Per accident) GARAGE LIABILITY I I AUTO ONLY-EA ACCIDENT $ - A ANY AUTO ----- - - I. 'OTHER THAN E!�ACC'_$ AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY r--I ( EACH OCCURRENCE i$ ------- -----._._T-...-- __._... OCCUR CLAIMS MADE AGGREGATE i --, $ DEDUCTIBLE 7 j---.--..---- $ -- .. _$ I RETENTION $ WORKERS COMPENSATION WC STATU- I OTH- AND EMPLOYERS'LIABILITY Y 1 N TORY ANY PROPRIETORMARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? F-11 E.L.EACH ACCIDENT (Mandatory in NH) $'------ -- If yes,describe under E.L.DISEASE-EA EMPLOYE $ j SPECIAL PROVISIONS below I OTHER E.L.DISEASE-POLICY LIMIT $ L ; � I I j i I ' I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Castricone Roofing & Siding DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN Unit 3A NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL 231 R Sutton Street IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR North Andover, MA 01845 REPRESENTATIVES. 17 AUTHORIZED REPRES ATI t ACORD 25(2009101) ©'1988-2009 ACORD CORPORATION. All rights reserved. INS025(200901).01 The ACORD name and logo are registered marks of ACORD Town of North Andover N�kr 0�4TlNO Building Department o 27 Charles Street North Andover, Massachusetts 01845 4 i (978) 688-9545 Fax (978) 688-9542 ° 0R�reo 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 sliall be disposed of in a properly licensed solid waste disposal facilityas defined b MGL GL cl l s150a. Y The debris//will be disposed of in/at- { Z4 ems, Facility location Signature of Applicant C2 o�l Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector,