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Home My WebLink AboutBuilding Permit #356 - 137 HILLSIDE ROAD 11/24/2008 BUILDING PERMIToAORoTH qti. TOWN OF NORTH ANDOVER 3? toL APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received ��SSACHU`�E� . Date Issued: ."— IMPORTANT: Applicant must complete all items on this page LOCATION t, )d n PROPERTY- ,OWNER Pent Print MA "NO: PARCEL: ZONIN QI-S C-T •.Histofic Distract yes no - Mach rve Shop Village P Ayes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family •Industrial -- Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other Septic UVell1=loodplainNetlarids` :11/ teishbt!"District Water/Sewer i DESCRIPTION OF WORK TO BE PREFORMED: 3 Identification Please Type or Print Clearly) OWNER: Name: til,,;a- � I Phone r 1 24 ost Address: C(JNTRACTOR Nam Pb`ar� a w a A Address; -- ---''" Supervisor's Construction ticense: - i EE Date:, �_Horne,lm rovementi'License. P Exp :Date, ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $,,Y� FEE: $_ Check No.: _,, — Receipt NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund n5� atu re bf:A ent/O ` g 9. Signa#iae,oco�atlactorz Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tammng/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 COMMENTS HEALTH Reviewed on Signature .COMMENTS 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: A. Located 384 Osgood Street : IRE DEfl-PAR�'M N '.:-'TemAIDt�rn on si#e °yes:: no Locai '.,,at�124 1Nam.Streei � _ Fire cepa _ rtmentzlignaW ate x .. COMMENTS} t,�LL 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 21 A—F and G min.$10041000 fine NOTES and DATA— For department use U. Notified for pickup - Date Doe.Building Permit Revised 2008 C. i { 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 Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit o 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 ❑ 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 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 Doc:Building Permit Application Revised 2.2008 J Location/3 No. Date NORTq TOWN OF NORTH ANDOVER ? O s Certificate of Occupancy $ ��s'•^�';.�•wrBuilding/Frame Permit Fee mas , Foundation Permit Fee $ ;r Other Permit Fee $ `< TOTAL $ t Check # 21 Ti 0 Building Inspector tAORTIy Too Andover No.JS4 * - _ pi dower, Mass., a ° COCHICHEWICK y1. �ADRATE D �� BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT........... ........ .....�,..�........................... ..................... ...,........... .............................. Foundation Ahas permission to erect........ ............................... buildings on ...... .: :...... .... ...... ..I�. .�. Rough to be occupied as :......................5°�"�ll�!�Gr............. .�. . . Chimney provided that the pertan 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-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 a� PERMIT EXPIRES IN. 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRV TRough Service BUILDING INSPECTOR Final Occupancy Permit Required t0 Occupy Building GAS INSPECTOR 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 The Commonwealth of Massachusetts � Department o P ,f Industrial Accidents }L":G _•.� r ' Office Of Investigations i ii r , � t,. 600 Washington b Street Boston, MA 02111 t wwW.yn M-00VIdia Workers' Compensation Insurance.Affidavit: . Builders/Contractors/Eleet 'c"> a ns/Pium hersA lcant Information Please Print Legibly. Name (Business/Organization/Individual): Address: City/State/Zip: �� n r��r Phone#: w1 W 7CY Are you an employer?Check the appropriate box: l.❑ I an a employer with 4. ❑ I am a general contractor and I . F7. ype of project(required): employees(full and/or part-time).* have hired the sub-contractors . ❑ New construction 2.❑ I am a sole proprietor or partner- listed ori the attached sheet $ ❑ Remodeling. ship and have no employees These sub-contractors have working for me in any capacity. workers' comp. insurance. g' Demolition [No workers' comp. insurance 5. F7 We are a corporation and its 9• E] Building addition kfi required.] officers have exercised.their 10:❑ Electrical repairs or additions 3T I am a homeowner doing all work right of exemption per MGL HE Plumbing repairs or additions myself. [No workers' comp. c. 152, §1.(4);and we have no insurance required.] t employees. [No.workers' 12❑ Roof repairs comp, insurance required_) 1.3•0 Other *Any applicant.that checks box#I.must alsorill out the section below showing their workers'compensation policy information. t Homeowners who submit.fhis affidavit ittdicatine L'iej are uuili�a:'c=.�tr;k ar,LI�;en hire outside coniriu lore iuusi submit a new affidavit inai�iinb soca. Contractoes that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. I am an employer that is providing workers'compensation insurance or a to ees. Below is the oli andjob site information. f n mP Y p cy I Insurance Company Name: .j. 5 Policy#or Self-.ins. Lic.#: Expiration Date: Job Site Address:_ City/State/Zip:__h j OV6 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 a STOP WORK ORDER and a fine of hp to $250.00 a day against the violator. Be advised that a Investicopy of this statement may be forwarded to the Office of gations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Siartature: Phone#: .p (p fonly. Dn not write in this area, tobecompleted by city or town officiaL 1ci n: Permit/License# Issuingority(circle one). I. Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector son: 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 ofhire, 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 o r 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 compl-etely,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 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 anyquestions reLrEt-rding the-lava,or if you are required to obtain a workers' compensation policy,please call the Department at the nmrnber.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 permitflicense number which will be used as a reference number. In addition,an applicant at must submit multiple c that p e perm�t/h erre applications in ani green year,needonly 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 co of the affidavit that has been officials sta A copy y rnp„d 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 burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance g y e for your cooperation and should you have an questions, P Y Y9 , 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 Investigatloas 600 Washington Street Boston, MA G2111 Tel. # 617-727-4900 ex-t 406 or 1-977-MASSAFE Revised 5-26-05 Fax#617-727-7749 ww v.mass.o ov/dia poRrp TOWN OF NORTH ANDOVER o `"•� '',"°0 OFFICE OF BUILDING DEPARTMENT ` 1600 Osgood Street Building 20, Suite 2-36 North Andover'Massachusetts 01845 1sswcNuse� Gerald A Brown _ Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION Please p&t DATE: JOB LOCATION:-/ ,)I S Number Street Address Map/Loot HOMEOWNERjj- P�P�—��S�- Lt-O�� Name Home Phone Work Phone PRESENT MAILING ADDRESS _,, City Town State Zip Code The current exemption for"homeowners"was extended to include owner -occupied dwellings to two units or less and to allow such homeowners toe an' n individual for ' gage hire who does not possess a license,provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned"homeowner"assumes responsibility for compliances with the State Building Code and other Applicable codes,by-laws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requiremenu. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 10.2005 Form Homeowmrs Exemption ROARD OF \PPE.U.S 00 9541 CONSERVA'rjoN F,gR-9530 I IE.ILTH 08-95.10 PLANINING 688-9535 Date....v ... i - NORTH 3 °f, °:•""° TOWN OF NORTH ANDOVER PERMIT FOR WIRING 'lit+O+•np SSACMUs� Thiscertifies that .................................................... ................................ has permission to perform ...., . .......... .. .........t� ......`7. wiring in the building of.��b.�....,/... G at.... ,,5.7....h4jlk/a'��................................... orth Andover,Mass. t Fee35.............. Lic.No..%. fA................. "iECTO �� ... ELECTRICAL INSPECTOIC//"� 7758 Commonwealth of Massachusetts ' Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [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 W INK OR TYPE ALL XFORNMATION) Date: r 2— Z 6 — 0 '1 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) 13 7 Owner or Tenant h.` c Telephone No. t. Owner's Address L.2-9 4? IS Is this e p rmit in conjunction with a building permit? Yes ® No E] (Check Appropriate Box) Purpose of Building A e5- _ A Utility Authorization No. •7 Existing Service toy Amps 12-0rd o /2.40 Volts Overhead ® Und l g ❑ No.of Meters �VW`5�- E New Service 2 QIV Amps 2 p / /c)Volts Overhead® Undgrd /❑ No,of Meters F.2q115f Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 01 2 Vr,C Completion o the ollowin table may be waived b the Ins ector of Wires. No.of Recessed Luminaires �o ENo. EHot usp.(Paddle)Fans o.of Total Transformers KVA No.of Luminaire Outlets bs Generators low- KVA No.of Luminaires Z. Swimming Pool Above ❑ In- o,o Emergency ig g nd. d. ❑ Batteg Units No.of Receptacle Outlets No.of Oil Burners FIRE Dete_c=ionan�� No.of Switches No. of Gas Burners o.of b Initiating Devices -" No.of Ranges Total g No.of Air Cond. Tons No,of Alerting Devices No.of Waste Disposerseat PSP _ umber Tons KW No. n of a -Contained Totals: . ..........._......._.. Detection/AlertiDevices No.of Dishwashers Space/Area Heating KW Local❑ Municipal Connection Other No.of Dryers Heating Appliances , Security Systems:* No.of water No.of No.of Devices or Equivalent He KW No.of Heaters s Ballasts . Data Wiring: Si No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring; OTHER: No.of Devices or Equivalent Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: D d'� (When required by municipal policy.) Work to Start: 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 ® BOND ❑ OTHER ❑ (Specify:) I certify,under the pains andenalties o p ) p ofperjury,that the information on this application is true and complete. FIRM NAME: S � L ,A LIC.NO.: 42_7 -4,2_ Licensee: ��,A_ Signature -� (If applicable, enter-exempt"in the license number line.) LIC.NO.: g,�s t2 Address: Bus.Tel.No.; !yo 26 � 7 *Per M.G.L c. 147,s.57-61,securitywork requires Department of Public Safety"S"License: Alt.L cl.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.&j 3 Z�3 S i. �� ♦ �1 r 1 J /L � // �' — r(P �'- � Td � �� :� ;� ,, .,. The Commonwealth of Massachusetts [WrDepartment of Industrial Accidents � �- Office of Investigations . 600 Washington Street Boston, MA 02111 www.mass gov/dia . .Workers' Compensation Insurance Affidavit: Builders/Contractors/Eiectricians/Plumbers Applicant-Information Please Print LeQi b! Name (Business/orgenization/Individual): Address: City/State/Zip: Phone#: . Are you an employer?Check the appropriate box: i.❑ l am a Employer with 4, ❑ 1 am a general contractor and I Type of prefect(required): employees(full and/or part-time),* have hired the sub-contractors 6• ❑Now construction 2.❑ I am.aaole proprietor or partner- listed on the attached sheet._ 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demoiition working for me.in any capacity, workers' comp.insurance. , insurance 5. 9• El Building addition [No workers'comp. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11-El Plumbing repairs or additions myself,[No•workers'comp. c. 1.52, §1(4),'and we have no 12.E] Roof repairs insurance required.] employees. [No workers' comp. insurance required..] 1.3:❑Other 'Any applicant that checks bort#1 must also fill out the section below showing their workers'•eomoensation policy information, t Homeownen who submit thisaffidadit indicating they are doing all wotk and then hire outside contractors must submit a new affidavit indicating such. $Contactors that check this box mustattached an additional sheetshowing•the name of the sub-contractors and their worker;'com p.policy infotmadon I ant an employer that is protuduig_workers'compensation insurance for nw entpinyees: Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lie,#: Expiration Date: Job Site Address: City/State/Zip: 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 civilenalties in the form orm of a STOP WORK ORDER of up to$250.00 a day against the.violator. Be advised that a copy of this statement may be forwarded to the Off f d a fine Office Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true'and correct Signature, Date: Phone#: EaAuth only. Do not write in this area,to be completed by city or town official �. n: Permit/License# i� hority(circle one):Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Pinmbing Inspector son: Phone#: i 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 thaii three apartments and who resides therein,or the occupant of the c dwelling house d mai o air work on such d I n dwelling house of another who employs persons to o maintenance,construction r rep g g 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 orpermit toors pete a business or to construct buildings in the commonwealth for any . . .. no produced acceptable evidence.of compliance with the insurance coverage required." applicant who has t p p p � R Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its•politicw 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 cavy 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. x 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 penniMicense applications in any given year,need only submit one affidavit indicating�cuarent f 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 officiaily 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 flog license or permit to bum leaves etc.)said person is NOT required to-complete this affidavit ations would like to thank you in advance fnr our coo 'ration and should you have an questions, The Office of lnvesttg, y y pe y y q , 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 1-8.77-MASSAFE Fax#617-727-7744 Revised 5-26-05 www.mass.gov/dia `A DaW< . . . . . . NORYN TOWN F N04TH ANDOVER E PERM, IT fOR PLUMBING - ,SSACHO o'^ �` This certifies that . . . . . . ... . . . . . . . . . . . . . . . . . . has permission to perform^��'. . " .!..... .. . . . . . . . plumbing in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . at.f --�' ��r. :. ,i. . . ., North Andover, Mass. Fee+1.d Lic. . f PLUMBING I J PECTOR Check # 7552 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Date )0 4 , lo BuildingLocation OwnersName pw P Permit# &Z a Amount _ ' �5 co Type of Occupancy �cot*�•Q AC� New Renovation Replacement Plans Submitted Yes 1:1No FIXTURES w cc � O D U w O -- W W E., U O a U zO W 04W z A Z O A E, x a w w x w Z a� w o U of O Z. ra cn A a A H �W SLDME 1ST FI10�2 20 HtOM J M)"DOOR 4IH MOM 5IH HDM r` GIH FIi M 71H FIlOOR SIH FLOOR Ft (Print or type) f` _ Check one: Certificate Installing Company Name j h5 (� p lv_(A�I f'\, +4&-" Corp. Address r �� GIBS d. � r 6 (cam El Partner. Business Telephone to 7-x•75 Firm/Co. Name of Licensed Plumber: n� (/'' 1�1Y1�1Cs71.0 Insurance Coveraee: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ 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 infor*ins, Il tted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing woperformed under Permit Issued for this application will be in compliance with all pertinent provisions of the Plumbing Code and Chapter 142 of the General Laws. By' e um er ing License Title City/Town iL c� um er Master ❑ Journeyman APPROVED to�tcE USE ONLY