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HomeMy WebLinkAboutBuilding Permit #278 - 200 FRENCH FARM ROAD 10/17/2008 BUILDING PERMIT of NORT01 q ttLeo b � TOWN OF NORTH ANDOVER ►0.32 APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received .o'�"'�y �SSACHU`-+�� Date Issued: 6 �0 IMPORTANT: Applicant must complete all items on this page ry 12 stn AI �'P.ALOi1GV7STC � #orislnc# moo: 6afflne flp` l lade' des:. Sao TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more.family Industrial Alteration No. of units: Commercial epair eplacement Assessory Bldg Others: emolition Other IIerSewic, DESCRIPTION OF WORK TO BE PREFORMED: 01.1 �,>dt—y t. L>) !.. ISI d Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: -, COW.RK game# r ��� age ' ,. p�er��sC�nruc#ae 1crs1 a 1 ;d ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING P RMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST 8 SE)D ON�0 PER S.F. 9 Total Project Cost: $ 00 FEE: $ Check No.: p�00 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund agr�afiur 'AgeOval ,9 ego actor - a Location( C)p No. Date R NORTH TOWN OF NORTH ANDOVER f 9 Certificate of Occupancy $ - t� Building/Frame Permit Fee $ Foundation Permit Fee $ ar Other Permit Fee $ TOTAL $ Check # G f 2 ,, 6 1 Building Inspector A 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 ti Packa in /Sales g M��`"',"~,_• Private(septic tank,etc. Permanent Dumpster on Site _y 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 , I 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 ilk =�r�?A��i i 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 ❑ Notified for pickup - Date I Doc.Building Permit Revised 2008 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 A-pplicatiofl - - - - - -- - -- - - ❑ 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 ❑ 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 Dor.INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 I NORTH Town of tAndover , 0 IR ' No. ~ _ -__ �=: o dover, Mass., /40 COCHICMEWICK y1. ADRATED PPS\ '`C7 BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System THIS CERTIFIES THAT rw BUILDING INSPECTOR 1.1L am'....... d.V..1.. ......................::........................................................................ Foundation has permission to erect........................................ buildings on . � Z,�......:. .........:....:. Rough f Chimney to be occupied as......... ...... ................. .. , .. .. ........................................... provided that the person acce in this permit hall in ode res ect conform to the terms of the application on file in P P g P rY P PP 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 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION- r �S�_ Rough .:................................................................................... Service ...........................' BUILDING INSPECTOR ,1 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 a Street No. SEE REVERSE SIDE j Smoke Det. v �1a��aChu�clt� - �ll)alin)�nt')'f �i;li1'.i �iil�i� � if 811ildinz Re-ulamfins and Standards Construction Supervisor License License: CS 72449 Restricted to: 00 . CARL G GRENIER 53 STILES RD STE B102 SALEM, NH 03079 p;ration:: 4/11/2010 i <;„;,;,,;•,,, ; - .: 3156 Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. if found return to: Registration.: 136029 Board of Building Regulations and Standards Ezt.Pn -16/3/2010 Tr# 273532 One Ashburton Place Rm 1301 ,,Type.,_13A Boston,Ma.02108 CARL GRENIER;: CARL GRENIER 53 STILES RD SUITE B102 . //✓ / a� SALEM,NH 03079 Administrator of valid wi hout signature N1 Y-e YY Cc) • `� \ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street i` Boston, MA 02111 i" www.n:ass.gov/dia • Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly 57 Name (Business/Organization/Individual): ; Address: Jr' S f le's l t7d V City/State/Zip: ��/rte Xl . 030 Phone#: l 03 �2� -gfJOQ Are you an employer?Check the appropriate box: Type of project(required): L❑ I a ,,a employer with 4. ❑ I am a general contractor and 1 .6, ❑ New construction ployees(full and/or part-time).* have hired the sub-contractors 2 I am a sole proprietor or partner- listed on the attached sheet. $ 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 area 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 1 1.❑ Plumbing repairs or additions myself. [No workers' comp. c. 1.52, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' comp. insurance required.] 13.0 Other +Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who subniii.this aflidavii indicating they arc doillg all work and then hire outside eontraciors 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. 1 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. Lie.#: �— �-- Expiration Date: Job Site Address: c21�t–„Zaae-l- Yet. �o.f, 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- ear imprisonment as well as civilenalti p es 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. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Si�riature: 'Date: Phone#: 72a- Official use only. Do not write inn 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#: 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-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 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. 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 copy of the affidavit that has been officially 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 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 for your cooperation and should you have anyq uestions, 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 0211.1 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 5-26=05. VAM.Mass.gov/dia d V--eA fi Date:10/82008 04:55 PM Sender's Fax ID:603-890-0315 Page 1 of 1 • OP ID NN DATE(MWDDWW) ACORD. CERTIFICATE OF LIABILITY INSURANCE GCCON-1 10/08/08 PRODUCER THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Santo Insurance - Salem HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 224 Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELO Salem NH 03079 Phone: 603-890-6439 Fax:603-890-0315 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Nationwide Companies INSURER B: G C Contracting, DBA INSURER C. Carl Grenier 52 Stiles Road Ste 101 INSURER D: Salem NH 03079 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 RESPECTTO 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. IN51K L)U POLICY EFFECTIVE MyLTR NSR TYPE OF INSURANCE POLICY NUMBER DATE(MM/DDIYY) DATE(MM/DD/YY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $1,000,000 A COMMERCIAL GENERAL LIABILITY SlAC1116323001 10/18/07 10/18/08 PREMISES(Ea occurence) $100,000 CLAIMS MADE X❑OCCUR MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $1,000,000 POLICY 7 PE4 LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR ❑CLAIMS RADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND TORY LIMITS I I ER EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE EL.EACH ACCIDENT $ . OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS RE: Mike Souza 200 French Farm Rd North Andover MA CERTIFICATE HOLDER CANCELLATION TOWNNAN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Town of North Andover 400 Osgood St REPRESENTATIVES. North Andover MA 01845 AUTHORIZED REPRESENTATIVE James A Santo ACORD 25(2001/08) ©ACORD CORPORATION 1988 AC RD. CERTIFICATE OF LIABILITY INSURANCE OP 10 DATE(MM/DDNYYV) GCCON-A 10/08/08 PRODUCE4 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE T. A. Sullivan Ina, Agcy, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 344 S. Union St. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Lawrence, MA 01843 Phones: 978-683-4700 INSURERS AFFORDING COVERAGE NAIC# nusuREO INSURER A: Mass.Workera C01X_I,p.Assigned INSURER B: G.C. ContractingRER C: Carl Grenier INSURER _ 52 Stiles Rd Suite 101 INSURER D; Salem NH 03079 - -..... ._.� INSURER E. COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO TME INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REgUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RFSPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN I$SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR INSR0 TYPE OF INSURANCE POLICY NUMBER DATE M /OD/YY DATE(MRtUprm LIMITS GENERAL UABILITY EACH OCCURRENCE $ COMMERCIAL,GENERAL LIABILITY PREMISES(Era gccurpnce),„ $ CLAIMS MADE n OCCUR MEO EXP(Anyone person) S _ PERSONAL&ADV INJURY GENERAL AGGREGATE $ GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGC S POLICY PSC LOC - AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S ANY AUTO (Ea eccldenl) ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) WIRED AUTOS --._._..�._...... - BODILY INJURY $ NON-OWNED AUTOS (Per aecfdent) ._._._. PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-FA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY; AGG EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ 1 OCCUR E CLAIMS MADE AGGRFGATE $ $ DEDUCTIBLE RETENTION $ � WORKERS COMPENSATION AND TORY LIATU MITS ER A EMPLOYERS'LIABIUTY WC 8265004 12/22/07 12/22/08 E.L.EACH ACCIDENT $500000 ANY PROPRIETOR/PARTNEWEXECUTIVE OFFICER/MEMBER EXCLUDED? EL.DISEASE-EA EMPLOYEE $500000 If Yveee,deecrlbe Under stSECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $5000 00 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS 1 VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS RE MIKE SOUZA 200 FRENCH FARM ROAD NORTH ANDOVER, MA 01945 CERTIFICATE HOLDER CANCELLATION rrowom SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WPMEN 'OWN OF NORTH ANDOVER NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.RUT FAILURE TO DO SO SMALL BRIAN LEITHE IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR NORTH ANDOVER MA 01845 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2001106) G ACORD CORPORATION 1999 -N° 2210 Date......��/..`��..... ;C f �aOR7M 1 l� ° ,�`'°;• "° TOWN OF NORTH ANDOVER °L am lift, p PERMIT FOR WIRING 4L ;,SSACNUSE� This certifies that .......:1.� .S..c.........E-.t x A.`..�.................................... has permission to perform ......... .................................... wiring in the building of..... ......(� ................................................................ ...... . .....................North Andover,Mas's.-/ ............ .5/7. , ., .-` Fee....,..d:v�..... Lic.No�.... . �................. ..�............. .... ....... ELECTRICAL INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer �– rm� 1 Office Use Only � (� of 4t (bmmuntutato of fflaggar4ustfts Permit No. i9e;yaL'finent of Public —AafPtlj Occupancy A Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 3/90 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 1 `:00 (PLEASE PRINT IN INK OR TYPE ALJ, INFORMATION) Date / 6� City or Town of d IS-7 (j �, To the Insp ctor 4f Wires: The udersigned applies for a permit to perform the electriical work describe-below. Location (Street & Number) Owner or Tenant Owner's Address Is this permit in conjunction with a buildingermit: Yes No ❑ (Check Appropriate Box) Purpose of Building �1 V1 ,BYYI f Utility Authorization No. Existing Service Amps —J Volts U Overhead ❑ Undgrnd ❑ No. of Meters New Service Amps _J Volts Overhead ❑ Undgrnd ❑ No. of Meters A Number of Feeders and Ampacity l���"+"���, Location and Nature of Proposed Electrical Work vo ed fc���kn 1-'h I No. of Lighting Outlets No. of Hot Tubs ( No. of Transformers Total KVA / —No. of Lighting Fixtures ( Swimming Pool Above In- grnd. ❑ grnd. ❑ Generators KVA No. of Emergency Lighting j No. of Receptacle Outlets I No. of Oil Burners I Battery Units FY No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges I No. of Air Cond. Total No. of Detection and tons Initiating Devices No. of Disposals No.of Heat Total Total Pumps Tons KW No. of Sounding Devices No. of Self Contained 0 of Dishwashers Space/Area Heating KW Detection/Sounding Devices t Municipal ❑ of Dryers Heating Devices KW Local ❑Other ,�. Connection No. of No.of Low Voltage No. of Water Heaters KW Signs Ballasts Wiring r, / No. Hydro Massage Tubs No. of Motors Total HP I` I! �(, 4PA /C OTHER: { F� fw e /10 G1IecUl-r SU[ ' � INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES X NO V I have submitted valid proof of same to the Office. YES K NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box. T/i�/��L��� -S INSURANCE X BOND ❑ OTHER ❑ (Please Specify) (Expiration Date) Estimated Value of El ctrical Work$ Work to Start 3 1 ZJ Inspection Date Requested: Rough Final Signed under the nalties of perjury: --��-- FIRM NAME 74 G if C� ���C LIC. NO. 6 3� Licensee S. /�%�• V�/�.4 J2 Signature LIC. NO. AS-93 3 Address ��/e/G�<`/�/V6 ✓C.i� /L'/9, 4.1,7VL-2. /f�0 alt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as re- quired by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) Telephone No. PERMIT FEE $ A40,,) ) (Signature of Owner or Agent) I x-6565 Date N2 465 ,ORT TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING �► '-Z �,SSACNU5� This certifies that . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission to perform . . . .p L'..: . . . . . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . . . .5. .. . . . .7. . . . . . . . . . . . . . . . . . . . at . . . v o. .F �`.' ` North Andover, Mass. Fee. . . . : Lic. No.. . . . . . . .' . . . . . . . . . . . . . �tPLUMBING INSPECTOR Check # L 6' ,, -) WHITE: Applicant CANARY: Building Dept. PINK:Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING L°v (Print or Type) Mass. Date Permit # ^b Building Location a R-12�C-Z-t 6owner's Name `/� �l L�7�} v z✓�1 fie( ,) _ NCO✓�� Type of Occupancy.2iS1 D EQ Ti A t✓_ New ❑ Renovation ❑ Replacement UrPlans Submitt Yes ❑ No ❑ FIXTURES = y y = Y Q - !� y y y O Z y W Y J y } U < y •• W W y CC CC Zy < ¢ ¢ _ ~ z O Z y 4 J y W y 1-- W y F- U ¢ Y < y W 2 a v i.. U ¢ m df y ¢ } Q F H Z ¢ a o < ;: < 3 Z O O ¢ Q W ¢ > Q W - o < of Z .¢ ¢ U. W = < S 3 O 2 = Y d ¢ F- < Y G W tL LL C Y W SUB—BSMT. BASEMENT 1ST FLOOR a 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR 11TH FLOOR Installing Company Name Q- ,-'j,a,(rm t4T A e Q Check one: Certificate Address ��(` Co A C 4 mf4 k) /-&) ❑ Corporation /Y) E%N i 'F_ Al-- YO A U t , / C3 Partnership Business Telephone_ ��^ Z-i9 7 d L-Firm/Co. Name of Licensed Plumber ,f 3 F,P 7- h� ,5-A,MmA re-4er"•% INSURANCE COVERAGE: I have a current f bility insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked yes, please /indicate the type coverage by checking the appropriate box A liability insurance policy ld" Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's agent 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 ormed under the permit issu for this application will be in compliance with all pertinent provisions of the Massachusetts State Plum ' g e and apter of the oral Laws. BY '�.•L Title Ore ot Licensed Plumber City/Town Type of License: Master j j/ Joumeymab ❑ APPFlONED OFFICE USE ONL License Number33 5 BELOW FOR OFFICE USE ONLY FINAL INSPECTIONS SKETCHES 1 PROGRESS INSPECTIONS FEE NO. APPLICATION FOR PERMIT TO DO PLUMBING NAME A TYPE OF BUILDING LOCATION OF BUILDING PLUMBER PERMIT GRANTED DATE 19 PLUMBING INSPECTOR