HomeMy WebLinkAboutBuilding Permit #384 - 1459 Salem Street 11/17/2009 s —
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
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Date Issued: f
IMPORTANT Applicant must complete all items on this page
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PIt PERTY O1 /NER1 -
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His#oris D�stric# yes --no
w,MA`P�NO, T'ARCELp O1V1NG DJSTRICT
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, t�lachinetiop Villageres7�, o ate`
TYPE OF IMPROVEMENT PROPOSED USE
is Non-Residential
New Building One famil
Addition Two or more family Industrial
No. of units: Commercial
Repair, re lacement Assessory Bldg Others:
Demo i ion Other
Sept�e well � ' � � l=laedplain, etla ds �11a#ershed D stnct
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DESCR PTIO F WOTO BE PERFORMED:
Iden ' 'cation Please Type or Print Clearly) -
OWNER: Name: CW
( a I Phone:
Address: cJ 4 - 0? - ,,t
,-ON;-RACTOR Name : Phone .
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5 . ervisor s Ctnstruct�ora Licen s
_ � se ���d��• -Exp. Date.
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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, $ FEE: $
Ch 22
eck No.: � J Receipt No.: (�(91�,� �
NOTE: Persons contractin unregistered g wih g istere
d contractors do not have access to the guaranty fund
gnature'of,algentl , r rv.Sinature ofcoritractora
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
DATE REJECTED DATE APPROVED
PLANNING &''DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
i
tHEALTHReviewed 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: _
Located 384 Osgood Street
FIRE DE ►RTMENTT_effip,. Uipstersvr� side
ma
X'ocated at.14tlain Street
Fire De`partren#signaturldate _ t
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OMMEN 'S
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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 fine
NOTES and DATA— (For department use
E..
❑ Notified for pickup - Date
Doc:.Building Permit Revised 2008
j
i
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
❑ 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
o Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
o 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: Doc.Building Permit Revised 2008
Location
No. ? Date —��—�—�--
NpRTM TOWN OF NORTH ANDOVER
0 9
} ; : Certificate of Occupancy
Building/Frame Permit Fee $
saw
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # (01
L/
2.260 _
Building Inspector
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, l L4 02111
www.mass.gov/dia
Workers' Compensation.Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Busines anization/Individual): r X UA
Address:
City/State/Zip:_ Phone #: (M� (� '�- C j(,f (oe
Are you an employer? Check the appropriate bog: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 1 7• ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition
[No workers' comp. insurance 5. ❑ 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. 152, §1(4), and we have no 12.❑ Roof repairs
insurance required.] t employees. No workers'
comp.insurance required.]"'i13.[] Other
.-va_ checksbox� " �,""fill outhese, yyficatla` t --tion below showing their workers'compensation policy infornatian.
t Homeowner
s 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 sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins. Lic. Z Expiration Date:
P bo
Job Site Address: I U�9d" �� C. �� � P
Y 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 civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby c fq under the pains an nahies of perjury that the information provided above is true and correct
Si azure: J . t - Date:
l
Phone#: 103 (p
Official use only. Do not write in this area,to becompleted 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#:
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 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 or 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 completely,by checking the boxes that apply to your situation and,if
necessary;supply sub-contractor(s)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 be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign anddate 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.
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 permittlicense applications in any given year,need only 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 officially ally stamped or marked by the city or town may be provided to the
applicant asproof 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 bum leaves etc-)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
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 Washirtgton.Street
. Boston,MA 02111
Tel. # 617-7274900 ext 406 'or 1-877-I IASSAFE
Revised 5-26-05 Fax# 617-727-7749
w",",-rnass.gov/dia
hissaEctttbse s- Department of Public `Oct
X1Board of JK61t ow', lic�„Ef1ati€n-, mid tiiaaacl,"ds
.7 Constmetion Supervisor License
_ License: CS 70882
restricted to: 00
RICHARD J SMITH V.-
PO BOX 1769 µ, `t. .
SALEM, NH 03079
Expiration: 7!28/2011
-r r ': 19314'
Restficted to: 00
00- Unrestricted
1G-1 2 Family Homes
Failure to possess a current-edition of the.
Massachusetts State Building.Code
is cause for revocatioti of this license.
Refer to: W W W.Msss.Gov1DPS
t
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I
Board o iii1ding Regi lgions ain Stan ards
h.V, ,j One Ashburton Place - Room 1301
Boston, Massachusetts 02108
)-Tome Improvement Contractor Registration
Registration: ..106603
Type: Private Corporation
Expiration: 7/24/2010 Tr# 270264
AJ WOOD CONSTRUCTION, INC.
Richard Smith
PO SOX 1769
SALEM, NH 03079
Update Address and return card.Mark reason for change.
Address FRenewal R Employment Lost Card
_ Board of Buildmb Regulation's and Standards License or registration valid for individul use only
(j?� s•~, _K;' HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
'. Registration 106603 Board of Building Regulations and Standards
One Ashburton)Place Rm 1301
Expiration: 7/24/2010 Tr# 270264 Boston,Ma.02108
Type: .Private Corporation
AJ WOOD CONSTRUCTION,INC.
Richard Smith /
4 RUSTIC LANE
DERRY,NH 03038 Administrator Not valid withou ignature
I
Commonwealth of
Massachusetts
Division of Occupational safety
Laura M.Madin;Commissioner
Deleader-Contractor
RICHARD S.SMITH
Eff.Date 07/01/09
Exp.Date 07/10/102
00001721 '
NlemberofC.0.N.U.T.
BO
BOSTON-RENEW,
_
A(ZO-R-D. CERTIFICATE OF LIABILITY INSURANCE
P
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Mattheras? Ins _ -----
02/08/2009
_
' THIS C6RTIFOCA'GEIS ISSUED A8 A MaT7ER OF INFQRMATION
uranee Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
182 parker Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ALTER THE COVERAGE AFFORDED-BY.71,111 POLICIES BELOW.
Lawrence, " 01843
978-681-1112 INSURERSAFFORDINGCOVERAGE. NAICN
INSURED AJ Woo Construction, Inc INsuREeA Liberty N tual Ins
INSURER M
P.0.Box 1769 INeuaea
Salem, :NH 03079 INsuREatx
11-603-"23,5-7624 INSURER E:
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 13E ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIMAGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED By PAIDCLAIMS.
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FOUCYNUMS M U tJMRG
GENERALLIABILTIY EACH OCCURRENCE t
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WC231S353819029 02/23/09 02/23/10 .�F,LcmAccjO a100, 0.00.- _
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CERTIFICATE HOLDZR CANCELLATION
SHC=ANYOF TRE AROVEOE3CMMPOLLCUK CANCILLlDUFOIMINE E7IPMTM
DATE THEREW,THE I01112IN01199tNUUMB..ENDUVORTO MAIL LAYS WAfMN
NOTWETO TNECWFICAYBNOLOERNAILREDTO THE Lerr.BIRFALLUREm oo 9D aHALL
IMPOC ENO 015LIGATIGNOR L ANUTYOF ANYRIND UPONTHE NNBURER,ITb AGENTS OR
REPRIMENTATIYEIL
___-- AYTNORREdREMESENTATLIIE .
ACORDS(x+r /043) ' ®ACOROCORPORAnONIM
60 3E)Vd SNI SM3HIIVW SSOES89BL6IZ0=80 8002/6Z/Zt
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ACORODA,:--m ,CERTIFICATE OF LIABILITY E -
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PRODUCER (603)432-6414 rax: (603)432-3652 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Financial Yasurance Services 3nc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
PO Box 950 HOLDER. THIS.CERTIFICATE DOES NOT AMEND,_EXTEND OR
ALTER THE COVERAGE AFFORDED..BY__THE_POLICIES BELOYV..
Derry NH .03038 INSURERS AFFORDING COVERAGE
INsurtf� - - MAIC#
INSURERA:Peerless Insurance CO
A T Wood Ca tzuction Inc
INSURER B:
PO Box 3.169
INSURER C:
Sa1Esa INSURER D:
NK 03079 INSURER E;
COVERAGES
THE POLICIES OF,INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITNSTAN DING
ANY PERTAIN, HE I TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BYTHE POLICIES DESCRIBED HEREIN IS SUBJECTTOALL THE TERMS,EXCLUSIONS AND CONDITIONS OFSUCH
POLICIES.AGGREGATE:LIMITS SHOWN.MAy HAVE BEEN REDUCED BY PAID CLAIMS.
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1 p UCY EFFECME POLICY EXPIRATION
POLICY NUMBER LIf11T5
GENERAL LIABILITY
EACH OCCURRENCE $ 1 000. 000
X COMMERCIAL GENERAL LIABILITY
0.000
CLAIMS MADE ❑x OOCUR ENDI1aG 8/1.6/2009 8/16/2010 M p��v(My am $ _ 55 000
PERSONAL a ADV IN.URY ; 1,000,000
GENERAL AGGREGATE S 2 000 000
_. . PRo
GENtAGGREGATELIMITAPPLIESPER PRODUCTS-COMPIOPAGG a. .. 2 000 000
X POLICY LOC
AUTOMOBILE LIABILITY
ANY AUTO (Ee )COMMMED SINGLE WAIT $ 1,000,000
F+ ALL OWNED A ROS 3AB693505 7/8/2009 7/8/2010
X SCHE"AUTOS BODILY INJURY a
(Perpmm)
X HIREDAUTOS
X NO"VMIED AUTOS BODILY INJURY $
(Perecdclard)
PROPERTY DAMAGE
GBILITY
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AUTO ONLY-EA ACCIDENT S
ANY AUTO _
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------ AUTO ONLY: �AGG_It
EXCESS f UMBRELLA LIABILRY
EACH OCCURRENCE $
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DEDUCTIBLE
RETENTION $
WOR QRS COMPENSATION
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DESCRIPTION OF OPERATIONS I LOCATIONS f VEWCLS3 f EXCLUSIONS ADOW BY ENOORSWENrf SPECfAL PROVISIONS
CERTIFICATE HOLDER___ CANCELLATION
~ - - SMULDANYOFTHEABOVEDESCRIBEDPOI:IgESBECANceimgEFORETHEEXPIRAnor4
DATE THEREOF,THE MANG INSURER WILL ENDEAVOR TO MAIL 10 DAYS M TEN
NOTICETOTHE CERTIFICATE HOLDEtNAMED TOTHE Lwt BUTFAILWRE-m:00S0 SHALL
SA {`EL P I,r, IMPOSE NO OBLIGATION OR LIABILITY OF ANY)OND UPON THE INNRER,rM AGENTS OR
REPRESBdTAflVES.
AUTWFUED REPRESENTATIVE _
'Sam Fragala/DEBRA �z_.:.�•.:. _..�.-.-;,,,.,-_.t:.-„
._.-.. ..__. _
ACORD 25(2009/01) m
INS025(zoo1988-2009 ACORD CORPORATION. All rights resetved-
sm) The ACORD name and logo are registered marks of ACORD
i
Telephone: (603) 898-4468 CONTRACT Cell: (603)235-7624
Toll Free: (800) 458-4468 Fax: (603) 898-6942
A.J. WOOD CONSTRUCTION, INC.
P.O. Box 1769
Salem,New Hampshire 03079 V
Email: info@ajwoodconstruction.net
Website:www.ajwoodconstruction.net C
ROOFING•SIDING •VINYL REPLACEMENT WINDOWS•DECKS
Workmen's Compensation and Public Liability Carried on All Work
Date 12008/
I (we) the undersigned hereby accept our proposal to furnish Labor and Materials to perform the following work on premises
located at the following address:.
NO. t,q t Y {'1 ry' F �.. f`j l/l f ii t ��„1•n0 w .+ d 4.
-- 1 ��y t { .
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(Street) (City) (State) Zi code
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Owner'-s Name bq c, ",j 7..1A n ; Telephone Number:
Address
SPECIFICATIONS OF CONTRACT
�a
Instal43/8 pt. ibsulation l ar stal a ee',M ti or,e a vin m ust ap or coverall soffit, facia,_-wwindows and
doors w,idklco ' vammum m.'` perms and de is re r}� ee o r—Workmanship antd"pro'Vide a one(1)year
Labor Only
Only Warranty from date of completion.
T1-i )..i» ('� ,.Zi r .�yi
. L. 1. r j,S r - +
For the sum of�1
U
Additional work at ` f ;, ')
Deposit `7r '� Due with signed Contract
Owner agrees that the title or equity in this property is his and is security for this contract.
IN WITNESS WHEREOF the undersigned has(have)hereunto set his(their)hand(s)the day and year first above written.
Buyer(s)Acknowledge Receiving a Completed Legible Copy of This Contract.
This contract may be voided by the Owners giving written notice to the Contractor by ordinary mail within three full business
days following the date hereof.
(Legal owner of property t be'improved)
3 i '
B
L.S.
(Richard J. Smith,President) (Husband or wife of legal owner)
�t
A::
` yORTH
0VV`n Of Andover
SE -n
No.a8
W- 4
WPO
o y over, Mass.
COCMICMEWICK V
�� ADRATED PP� 5
`S BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
/..V........r..,...... .�....,...r....i o..I...
........................... .. ....................... BUILDING INSPECTORTHIS CERTIFIES THAT.......... . w ......... ............... .
Foundation
has permission to erect............... b ildin s on ........t.................•
Rough�. . ................
to be occupied as........... ......... ......... ............. .......®. ................................ Chimney
provided that the person accept g this permit shall in every re ct conform to the terms of the applica io 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 IN
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS
ELECTRICAL INSPECTOR
UNLESS CONSTRU S ARTS Rough
......... .... .. ............................................................................ Service
BUILDING INSPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Display in a Conspicuous Place on the Premises — Do Not Remove Rough l
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector.
Burner
Street No.
IL SEE REVERSE SIDE Smoke Det.