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HomeMy WebLinkAboutBuilding Permit #Exception - 50 WOODLEA ROAD 9/6/2016t%oRT11, 0* BUILDING PERMIT C TOWN OF NORTH ANDOVER 0 APPLICATION FOR PLAN EXAMINATION —0 [-1 PerrnitNo#:_ D �e Re eived ACHU Date Issu I PORTANT: Applicant MIfst ompl all iteyns on this page LOCATION 00 kM00dJF0,_ Kc --4 P int PROPERTY OWNER �u_re yes rict y n _Z 100 Year Structure yes no PARCEL: ZO��NG DI VRI T:' "a Historic District no MAP 10 C V y 11 Machine Shop Village y no TYPE OF IMPROVEMENT 1 7 -- � US PROPOSE US _�pRs�ide��tial Non- Residential El New Building kONfamil�� 0 Addition El Two r more family El Industrial N-Kiferation N:\Of its: 0 0 Commercial 0 Repair, replacement ED] A ses o Bldg El Others: 0 Demolition 11 Other Pg1g, DFlood0l NW,-etraribs; 4, 1 '7- I -d P Is, F.1 0' J 4� 4, OWNER:\ Name: LAS',-,�_ Address- --;CA Contractor N e: L.,b f E m a i Addres\sl- Please Type or Print Clearly 0— Phone: Phone: cf 7,Y - L�S-J -� Sur')�-,Wisor\'�,Construction License: . . Exp. Date: Exp. Date - Home Imkovernent License: ARCH ITECT/ENGI NEER Phone: Reg. No. Address: 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: $ o2V(,) (A Check No.: Receipt No.:_�36 NOTE: Persons contracting ith unregistered contractors do not have access to the guarantyfund 4 32' 8" ---------------- to 0 Ei. Ln (D 0 (D n 3 :3 ::F m -0 LD. LO Ca. to 0 =r Cl co C� OL 0 n It 4' 0"-� Cn co Lol 3 4 1 1* 2' 4!'� 0 i i -h M) -D; i n -h OD a CL t I I :C) CD n (D �. lo-,:) :3 X C.L Ili 0 10 4 9 4�'� 00 LD. rD (D c f � G. D F"P 0 cq Lf) > 426 0 44t CL co Di fa o 0 n Z3 Ln (D OL 4 9 4�'� 00 LD. rD (D c f � G. D F"P 0 cq -0 M r) ;� 2-, 6 E o 33 - (D 0) 0- n (D (D CL Lf) rD (D (D o n �E E < (D rD r (D D > 7 o r5D n 0 0 0 (D 0 .5 0 I'D - (D 70 n Z3 Ln (D CL n =:3 0. m a', Q 73 - cr ILI. -1 rt rDL 0 (D 0 -0 M r) ;� 2-, 6 E o 33 - (D 0) 0- n (D (D CL Lf) rD (D (D o n �E E < (D rD r (D D R I 32'9' Ul Ln m -V m N3 Ul -1. 26' 8" 0. m Ln (D :E (D 77 Town of North Andover of tAORTN Building Department 27 Charles Street 0 0 North Andover, Massachusetts 0 1845 (978)688 -9545 Fax (978) 688-9542 Irk] ADDRESS LOT NUMBER____X_____S UBDIVISION_.. j00 c/ - DATE REQUEST FILED 611'14o") DATE READy FOR INSpECTION FIVE (5) DAY' i N TICE PRIOR TO CLOSYNC- n Arr ire pEQKU1RED ALL WORK AND SIGN-OFF'S MUST BE COMPLETED WITHIN THIS TIME FRAME. A RE -INSPECTION FEE OF TWENTY-FIVE ($25.) DOLLARS WILL BE CHARGED IF THE STRUCTURE DOES NOT MEET ALL APPLICABLE CODES. SIGNATURE OFFICIA SE ROUT CONSERVATION DATE PLANNING rl- DATE D.P.W. — W R METE' 6>1<:::� DATE _.LV -5T4 D.P.W. MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO TTJE INSPECT�ON REQUEST DATE. SIG A AUTHORIZATION t IF ca"t S CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number . 6-3 Date c�2 -c� THIS CERTIFIES THAT THE BUILDING LOCATED ON-Ac±914L� 0 RCI MAYBEOCCUPIEDAS --S11V(eXe 501k eoOee— IN ACCORDANCE WITH THE PROVISIONS OF TtfE MASSACHJUSETTS STATE BUILDING CODE AND SUCH OTHERREGULATIONS, AS MAY "PLY. CERTMCATE ISSUED TO -14,-)�7 wood De6), fo��z �)q- Ke A)�l ��30blG Building Inspector -1. ri W co MINN, m LLI CQ \ 2) UW x u cc 0 < 0 0 U) �2 C2 'S u x x ca .4 tko 7g r. 0 06 M cc 'D m LLI M -W cf) Z o 4.4 U) CD 9 E co CL CO2 CD CM Q co CO) C13 .ff C13 CO CD 0 CD L- 1. J= CL. co cm CD Q Cc C2 M: , CMIR Cc Q CL o CD CO3 2c CL C.3 CO2 cc cc 'a *6 rl "I 0 06 M cc 'D :*a Mm CD IA C.2 4D CL r 32 0 t cm cm M-0 GO MO E C42 cm -Ma ID cm 32 co C2 C2 .5 Ne 0 cm CL =3: 0 CO3 Lu =0 -0 za a fA 'i a C�J, CUD cm LU G) L- 4D CL C.3 CM CO3 Cq = C) 0 CL a M -W cf) Z o 4.4 U) CD 9 E co CL CO2 CD CM Q co CO) C13 .ff C13 CO CD 0 CD L- 1. J= CL. co cm CD Q Cc C2 M: , CMIR Cc Q CL o CD CO3 2c CL C.3 CO2 cc cc 'a *6 rl "I Feb 08 02 08:21p Angela Mandalinci FROM JON MAREN CB HUNNEMAN FAX NO. : 978-794-1429 --------------- &-I ILI- IT -FF-B. 617-492-4885 p.4 Feb. 08 2002 01'55PM P2 11�U. �41,i r-*': ADDENDUM Install Flooring After Closing S ELLER agrees to allow- BUYER to provide tilcir own carpet for the house at Lot 7, 50 s, Woodlea Rd., N. Andover, MA."to beinstaUcd after the clos7fiv. BUYER agree to adhere to Ashwood's schedbl& as arra.nged with the Site Manager. BUYEK.agmes to-hoUSELL ER. harmless for any loss or darnage of tWS carpet jastalled by the BUYER. BUYER fin-ther agrees that should any damage occur by any means to ca I ep na -je BUYER'S sole Tespovib tytor airtheda, ge,jf1)UYF.R said carpeting tilat it is jr Pli d at so chooses. SELLER andBUYER agrec thAt-cal-peting AuP c nd in&t ed by BUYER is not included in any warranty by the SELLER and maintenance, wcar and tear, and repair are the ssole responsibility of the BUYER. BUYER also agrees to accePt 6-10 subfloor preparation and surfuce as installed by SELLER SELLER (Ashwood Companies) Authorized Representative -7 LettereJAddendlnstallFlnoring j Date Date Date W ,iLoat Ae5p /1-91 No. ate. /0 40RT#q. TOWN Hk�NDOVER OF NORT + r> 0 Certificate of Occupanc) BLfilding/Frame Permit Fee $ Foundation Permit Fee $ AD 0 X- Q?AC Gth w- Permit -Fee /'26,3 -'-Sewer Connection Fee $ I—C-422. 02-2 Water Connection Fee gz $ � i TOTAL BullUing 1, pect �IR/oq/4420-7- 1"312.00 PAID r.% 4= biv. Fiub��orks 7 a(lion z 42b N ba �e loh,91117 -ANDOVEF5- P, 140. TOWN OF NORTH 0 0. Certificate of Occupancy $ Btfilding/Frame Permit Fee $ Foundation Permit Fee C" - - - - - - -Gtkw Permit,Fee $ Sewer Connection Fee $ 7V water Connection -Fee g TOTAL - BuJV�ing inspe ytp 1, 312. 00 PAI Ij Div.. F�6bli�/>Ibrk� 0 j< 1= 1= I- 1> z z c 2 2 u w w 0 0 j J te I:L� ww L L U W z i v 0 -1 LU J w ci 0 LU z 3'. z o z o 0 (L) V x 0 L ILA z x W 0: W w W IL z 0 J 0. 0 u u Ld z w < lz a. 0 - . 1 i . 8 (L < J 0 u m J w J JWL u Z Ix a z 0 w *w we v F- Z 0 0 0 j< 1= 1= I- 1> z z c 2 2 u w w 0 0 j J te I:L� ww L L La uj UJ cc t"i 0�— U W i v -1 LU J w ci 0 LU z 3'. z o z o 0 (L) V x La uj UJ cc t"i 0�— U W 0 x .0 IL Ld z 0 14 z p T0 3 4A 4i C, z 0 Oli-4" 4 =! A 0 0 POO Z�< > 0 0 � m > > Lq In 00 0 z 0 > . - (j v c z > n z > 0 0 0 0000C � 6 > ZzmZZ0052 0 m m � x m 0 M M z � 6 2 a (A Z -M w LA w C-6 C) Z > 2- 0 (A 0 X 7:lr z z < .1! 0 z 0 > Z z z n c 5jj<>O, 0 > 0 0 M z z z 2 0 M 3: Z > > zl co c > -,;; x 6- n 3: () , , � � MI 2! C > C MM .201- > Z > 0 0 Z Ci n M:r - - 5? 0 0 x z '0 c 0 X LP 0 - rz, V I , > > Tj I IT- .0 I zim .0 a 0 -W z 0 Z: 'Im — ILI H H- z H I hO I 1 11 11 11 1- 1-1-1 1 '11111, 1, * IF M r -1 >OX 0 ZM �m n Ozz c a ?. c Inmo :a x -j 0 0 m m tj M . MX -iZ> l(An ii 6 ;a z M zo C 6.3 m Osz aro rOO 0 Zq z for 'a ul -1 > z m -10 0 0 m > nz xn mm :0 00 ?I x f Ek 46,766 i 4-. W cc uj c; OC-) co CL Cc 0 ID CD CL. tA. . . CD CO) .10 4D CM . . . CD IT - F CO) .k.2 CL CD r= s'o X 4'-� C/) cp cl r c" ti CL C*7- 4 OD CD 3: C/) cm Cm C* I'D ca :2 0 CD CD L- 0- Qj EpoI- CD 0 co 06C.3 a.: 4D cc a CDC* cr- co cm CL a CD lt:3 CO3 Z: C== CD CL M C.3 CIO CCM 06 CL.- 0 0 COD m JS CD cc L" 0 -0 '0 ce CL C—S Li C.3 DIE Ca. 0,4 0 0— CD CL Cc: -r- cc -6 x 79 r. X. U) 0 E V) uj c; OC-) co CL Cc 0 ID CD CL. tA. . . CD CO) .10 4D CM . . . CD IT - F CO) .k.2 CL CD r= s'o X 4'-� C/) cp cl r c" ti CL C*7- 4 OD CD 3: C/) cm Cm C* I'D ca :2 0 CD CD L- 0- Qj EpoI- CD 0 co 06C.3 a.: 4D cc a CDC* cr- co cm CL a CD lt:3 CO3 Z: C== CD CL M C.3 CIO CCM 06 CL.- 0 0 COD m JS CD cc L" 0 -0 '0 ce CL C—S Li C.3 DIE Ca. 0,4 0 0— CD CL i "I 11'r 'Ile Of PUBLIC fORSTRUCTIO, SUPERVISOR "vi n 411171190 cwRol Avg l-UI13 15 IA - linswy 1�nly IG H�Mes Growth Management Bylaw Exemption Statement Town of North -Andover Building Department This form shall be used to assist the Building Department in their determination of exemptions under section 8.7.6 of the Town of North Andover Growth Management Bylaw. The building applicant shall provide all of the necessary information as requested below, Name of Applicant on Building Permit (below) Address of Property for Permit (below) Purp�ose( f Applic in (check below) ap and Parcel : Phone, Number of Applicant: Sin I - (' - 1) !L.7 .6 1 g e Family Two Family I the undersigned applicant for the fab'ov-e property attest that the attached building permit for which this form is completed does comply with the EXEMPTION section 8.7.6 of the North Andover Growth Management Bylaw. I also understand providing this form does not absolve me or any party to this permit from the requirements of obtaining other permits required prior to the issuance of the Building Permit. Further I understand that my interpretation of the EXEMPTION status is subject to review by the Building Department and is only officially accepted when the Building Permit is, issued. Based on section 8.7.6 of the North Andover Growth Bylaw the above lot and the work as applied for on the above lot, in the building permit application and associated attachments, complies with one or more of the following sections as indicated by a check mark. This is an application for a building permit for the enlargement, restoration, or reconstruction of a dwelling in existence as of the effective date of this by-law, provided that no additional residential unit is created. /��/The lot(s) were/was created prior to May 6, 1996 are exempt from the provisions of this Section 8.7 of the Zoning a This application is for dwelling units for low and/or moderate income families or individuals, where all of the conditions of 8.7.6.c,are met and/or represents Dwelling units for senior residents, where occupancy of the units is restricted to senior persons through a properly executed and recorded deed restriction running with the land. For purposes of this Section "senior" shall mean persons over the age of 55. application is a part of a development project which voluntarily agreed to a minimum 40% permanent reduction in density, (buildable lots), below the density, (buildable lots), permitted under zoning and feasible given the environmental conditions of the tract, with the surplus land equal to at least ten buildable acres and permanently designated as open space and/or farmland. The land to be preserved shall be protected from development by an Agricultural Preservation Restriction, Conservation Restriction, dedication to the Town, or other similar mechanism approved by the Planning Board that will ensure its protection. This application represents a tract of land existing and not held by a Developer in common ownership with an adjacent parcel on the effective date of this Section 8.7 shall receive a one-time exemption from the Planned Growth Rate and Development Scheduling provisions for the purpose of constructing one single family dwelling unit on the parcel. This application represents a lot which is ready for building permits,(i.e. all other permits from all other boards and commissions have been received and the project is in compliance with those permits), and the Development Schedule does not accommodate issuing a building permit in that Year, one building permit will be issued per Year per Development until such time as the Development Schedule accommodates issuing building permits. Applicant must supply approved form U with this EXEMPTION. Please provide any and all information that would assist the Building Department in making a determination that your application is allowed one or more of the above EXEMPTIONS. By signing below I attest to the accuracy of the information provided and that the attached building permit is allowed an EXEMPTION as cited above. Further I understand that the submittal of misleading and or inaccurate information, or t�e checking off of an above item which does not comply, whether done to my kn e or not, is gr ds fo refusal by �the �Bulld'Department to issue a Building Permit. 0 Jz' If,2 _'dthe Afoched Building . natur 0 ed Agepr(Affio sigrie Permit Date to tl T h i s ) A'oPu s4t'b-er , , �he d' ,$,tAlding Permit-dpDh application for such permit. FORM U VERIFICATIOIN FORM A INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state lawl regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: Co q%e? � P h o n e 'tJ Y-7 V LOCATION: Assessor's Map Number �F- oF Parcel subdivision b9i -e 'Lot(s) 2, Street LA --w t-tqk- le- �-- - St. Number ficial Use Only************************ RECO DAT OF ENTS: 7�7 A 11-> Date Approved Conservat ToL Akdministrator Date Rejected Comments z �/� CS, f: i I k, Date Approved el/ iowninanner Date Rejected Comments L, Food Ins ector-Health 4 �Wz �e�-I�ic Inspector-He—a-l-th Comments Date Approved Date Rejected Date Approved Date Rejected Public Works <s:ewer/water connections _::D �0 - driveway permit Fire. Aepartment L,�e, i,Le 9 (Ai, o,,, A _ 4 UaIL JJC/ NL wvlt�,u 9/, Received by guilding Inspector Date T-/-,b,-LS^w0eJ/ ------ Yll AW 7;;D -4 (o 00, c )- U) Ul 4� (P LA -401(f) U) Ln. -3)8,2*09 0 W it It 0) It Do DO OD 121 6 7' s v C3 ov - v 6 ol zr Ai. -ino- 1 0 U) U3 1-4 9 C) bD 32 4�� 9 0 cr) /I 4 5-- 05 c) 88, p 0 �-j 771 "107'37" on 48 .. .. 1 39. 4' x q 0 oc.) -r' 73.92' 1 4'5 7-" W Z4 Aj 041, 0 S 7915 02 (pro I Of cf� I '-, I pb CA (0 0) L4 -11 C) 1 0 0) 'S 8 * 46" W Ln cfn 0 f') 124.86' n q 72. 74' '-4u)*Ii ),(/) ob 504 4 .71 5' 42 V 47. 0, 4, IG::: it ol Un At it > (f) C) Ul i 6'-� 71 P. 01) try 4 3 LO IV 22 i �.; '1 (0 "l, If N 'Do 7' Aq Cligg, 41 5 ; n 26" &j di 4 (�N k>-% A (,4(P ---1 0) 1 0 --z .— v 0) --y 0) SD U) 4k- Cb �Tj 0, "Jw A ;V� Y I LO t! 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(7) Mmm 3:OM>> M 0 m z > co < 0 -4 Z M =�-4 z m OD > -0 Ln 0 >Mzo(:) ) ;d > K -4 ;o w r - Z -4ZZ > - -4 > �4 -< > U) z 0 0 U) Z Lf) m z m m O>m O -n 0- K 0. am < 00(f) qk m M50 M-4-nZ > -0 M* C: C -4 :5. 3 .0 -4 Z ;OM m M M 0 -0 -< m M-4-710 0 M M 0 C- 0 0 3:00 0) m m -u a MZ r -Z> orrlm> (-4U) > 0) > 0 0 Z r- 0 C CD M m -4 Z N LI) M M 0 > r- M -< M (,/)0 0 0 ;O;K -4 Fn > m Z* m :9 OZ Z M2 -40 Co < r- C)Mz 00 (J) r- rri > 4 0 6 m z No 2798 Datez��. - - �)- � 9- .; ....................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING Ms certifies that ...... ............................................................. 0 1-) has permission to perform ..... :�V.-.. ......................................................... wiring in the building of ...... ......... ................... ............................... at .......................... ................................... . North Andover, Mass. .................................. ...... Lic. No?��X':?Ile .......... . .... (0 1741 �,x ELEcTRicAL INSPECTOR Check WHITE: Applicant CANARY: Building Dept. PINK: Treasurer TBE00W0AWE4LTH0FMAMCHUSFM Office Use only DEPARTAMWOMBLICS4FM Permit No. BOARDOFMEPREVEMONRWUATlOAS5rCM12-M Occupancy & Fees Checked C%q) APPUCATION FOR PERJff TO MWORM ELEOWCAL WORK PVA ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 cmR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date 4:�E Town of North Andover The undersigned applies for a permit to perfbrm the elep.)cal work described below. lei Location (Street & Number) Owner or Tenant Owner's Address gy 4-w,414e Is this permit in conjunction with a bp1dinVer7mt: Yes n No Purpose of Building To the Inspector of Wires: '.-, -4, g ,� , � � (Check Appropriate Box) Utility Authorization No. 40 Existing Service Amps Volts Overhead Underground No. of Meters New Service C;7c"e Amps,��a Piolts Overhead Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work 5-�942L-�s- -,9dkZ.1;E; No. of Lighting Outlets No. of Hot Tubs No. ofTransformers Total 4:51, KVA No. ofLighting Fixtures Swimming Pool Above [] Below Generators KVA 1-51" ground ground No. of Receptacle Outlets No. ofOil Burners No. ofEmergency Lighting Battery Units No. ofSwitch Outlets No. of Gas Burners FIRE ALARMS No. ofZones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. ofDisposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. ofSelfContained Detection/Sounding Devices Local Municipal r7 Connections Other No. of Dr4yers Heating Devices KW No. of 4fater Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER lnst=xeCaouW- Laws Iha%eaaxmtLmbfltyk&r&=PcbL.ymA&gCm#A*Opeoiorlscmerawcritswostgmafivaifft YES NO Ihawshniodvdbdp[COfOfSaMiDtheOffiop— YES r7l NO r7 1f3cu ha%ededW YES, p1meindc*tbetMxofwAWbydr"igthe Tprupri*box L.—A INSURANCE ff BON. OTHR ft.S,.ffy) it WorkIDSW hpxfiwD*Re*xsW Raigh Signal urlderlfi NmYa & FIRMNAME Z�l "I.-.) e, ExpramDak FAm*dV"dHechxalWc& $ Fff W LimlseNd Lic'm S P 'Ag �?,6 f - —IJ0=eTb &isirm Td Na '- 0 AiTdNh It -?-I"2Z— OWNM'S PqSURANTCEWAPM� I am ammdAftl-kmsedpa not 1heiram=o7mVoritssikAUW eqiwkitas regiiindbyNbmhusem Gard Laws anddEtnTysomhr--cnt�sparniWpfiatimwa*pAsdismw'mnat (Please check one) Owner M Agent M Telephone No. PERMIT FEE �,Sz 3454 Date. ....... 40RTN TOWN OF NORTH ANDOVER 04 PERMIT FOR GAS INSTALLATION ................ This certifies that . . ; ... has permission for gas installation ....... in the buildings of . ') . .,-. .......................... at ........ North Andover, Mass. Fee. . Lic. No. . ........ GASINSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer A/LASSACHUSETTS UNIFORM APPUCATON FOR PERIAITTO DO GAS F=G ype or print.) Date 2 NORTH ANDOVER, MASSACHUSETTS Building Locations /W- #,t 7 Permit 9 Amount S Owner's Name New Renovation Replacement Plans Submitted 4int or Check one: Certificate Inscalling, Company Niame— Ypk4&5 [a Corp. AF� Address 5—k Z F� Parmer. Business Telephone Name of Licensed Plumber or Gas Fi[te- 11 Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes F-1 No I f vou have checked ves the ty piease in)jcate pe coverage by checking the appropriate box. Li,bility insurance policy Other type of indemnity Bond 7 Owner7s Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 1421 of the i'viass. General Laws. and that my signature on this permit application waives this requirement. Check one: Sianature of Owner or Owner's A-ent Owner ALYent I herp�v (-.t--Tifv thnr ill Afthe dernils and Inthrmarion I have submi(ted for entered) in above aaa6cacion are true and accurate to [he best of my knowledge and that all plumbing work and installations perfizirmed under Permit Issued Cor this application will be in compliance with all pertinent provisions oFthe N/lassachusetts State Gas Code and Chapter 142 ofthe General Laws. By: Title Cicy/Town A-PPROVED (()Fi--ic;- usF- �)N[�Y) SlQnature ofLic,--nsed Plumber Or Gas Firte- r—'-T Plumber 19Gas Fitter Lic--nse `4umoer , i\�,Iasie� r7 Joumevrrian Date./.—. !� - r /. . N2 46 8 0" TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING I This certifies that ... ..................... has permission to perform ..... /L) C_ .--. / - .-e ........... plumbing in the buildings of ... /. 4.) ................. at ... `,-c u c- --t � n 1�f. . . .7 ....... . .. ......... North Andover, Mass. f ( -1 11 F D Lic. No.. . . .......... I ......... ee". PLUMBING INSPECTOR Check # WHITE: Applicant CANARY: Building Dept. PINK: Treasurer �cx S MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING 2– _4— (Type or print) NORTH ANDOVER, MASSACHUSETIS Date Building Locatio ArO �ga �/&O w n �er s N �am e aleap pwa — Permit Amount 47e Type of Occupancy New Er Renovation 0 Replacement [:] PlansSubmitted Yes No 13 A FIXTURES (Print or type) Installing Company Name 10'� Check one: Certificate Corp. Partner. U Firm/Co. Name of Licensed Plumber: 1XIed Insurance Coverage: Indicatj�the type of ir(surance-coverage by checking the appropriate box: Liability insurance policy [a Other type of indemnity 11 Bond Insurance Waiver: L the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner 1:1 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 performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massac setts tate P urn in ode and Chapter 142 of the General Laws. 92! By: signaTure of LicenRea Flum-ber Type of Plumbing License Title City/Town Master Journeyman APPROVED (OFFICE USE ONLY License Mumuer ff . 1:1