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This is an e -permit. To learn more, scan this barcode or visit northandoverma.viewpointcloud.com/#/records/20689
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TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that Peter G Ashworth
has permission for gas installation REPLACED FURNACE
in the buildings of BRICK STORE COMPANY
at 1 JOHNSON STREET, North Andover, Mass.
Lic. No. 13456
Date: June 24, 2016
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PETER ASKMRTH I JOHNSON STREET, NORTH ANDOVER,
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The Commonwealth of Massachusetts
z f Department oflndustrialAccidents
1 Congress Street, Suite 100
t
Boston, MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Name (Business/Orgm&ation/Individual): Aej—c ��'po `�.5 Cc 0-04- /1/ AL
Address:
City/State/Zip: glk ".fv`'► /fin` 03 F kone
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with ! employees (full and/or part-time).*
-753Lam a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3.. FJ I am a homeowner doing all work myself. [No workers' comp.. insurance required.] t
4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance.#
6.E] We are a corporation and its officers have exercised their right of exemption per MGL c.
152, § 1(4), and we have no, eiriployees. [No workers' comp. insurance required.]
Type of project (required):
7. [] New construction
8. 0 Remodeling
9. ❑ Demolition
10 Building addition
I Ln Electrical repairs or additions
12 Plumbing repairs or additions
13.0 R f repairs
14.0 Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who subriiif this af6davit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
#Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
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. Lie. #:.
Expiration Date:
/ Job Site Address: / S 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 MGL c. 152, §25A is a criminal violation punishable by 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 $250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pains and penalties ofpetjury that the information provided above is true and correct.
Date: (9 — 2 -Y "/�
9$ 13 lz -
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
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 fbi 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 permit/license 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 bum leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
June 11, 2013
Brick Store Company
-11 Johnson Street
North Andover, MA 01845
Dear Customer:
I_
71\
Columbia Gasp
of Massachusetts
A NiSource Company
995 Belmont Street
Brockton, MA 02301
During a recent visit, our service technician detected a safety problem with your gas
heating system at 1 Johnson St., North Andover, MA 01845 — water leak. Accordingly, we
have issued a Warning Tag because of this situation.
Under the circumstances, we strongly urge you to correct the code violation. In addition,
the Massachusetts code pertaining to the installation of gas appliances and gas piping,
established under Chapter 737, Acts of 1960, requires that the condition be remedied.
If you have any questions, please call our Service Department at 1-800-677-5052 and ask to
speak with the Service Supervisor.
Please disregard this notice if the condition has been corrected.
Sincerely,
Customer Service Department
Columbia Gas of Massachusetts
Location
No.
Date 9
&ORTN TOWN OF NORTH ANDOVER
'A
Certificate of Occupancy $
Building/Frame Permit Fee $ Mo
.Is 14U
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # I/) � r
i 75u5
Building Inspector
1.1 Property Address::
Jh
FjIbLurlu LASUICL.Y
1.2 Assessors Map and Parcel
Map Number K,
Number:
Parcel Number
_L— Lwin )A.+A
Name (Print) ,[ /
gfLtc,v SI `'� CC/VtPAnl
1.3 Zoning Information:
Zoning District Proposed Use
Signature Telephone
1.4 Property Dimensions:
Lot Areas
Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard
Side Yard
Rear Yard
Required Provide
Required Provided
Required
Provided
SECTION 3 - CONSTRUCTION SERVICES
3.Z nsedConstruction
1.7 Water Supply M.G.L.C.40. 54)
Public ❑ Private ❑
1.5. Flood Zone Information:
Zone Outside Flood Zone ❑
1.8
Municipal
Sewerage Disposal System:
❑ On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
FjIbLurlu LASUICL.Y
2.1 Owner of Record
_L— Lwin )A.+A
Name (Print) ,[ /
gfLtc,v SI `'� CC/VtPAnl
J, mso
Address for Service:
Signature Telephone
2.2 Owner of Record:
Name Print
Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.Z nsedConstruction
Not Applicable ❑
�Supervisor:
U(� � Y x/211 ZniZ
Licensed Construction Supervisor:
? ��
el G low" Gl /
Address
�J
License Number
Sign re Telephone
Expiration Date
3.2 Fegistered Home Improvement Contractor
M, 1(-) S ✓Lr'PS �n C
Not Applicable ❑
�� 3 a J
641pany Name
Registration Number
_
Address
Expiration Date
Si nater Tel hone
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SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes .......❑ No ....... 0
SECTION 5 Description of Proposed Work check all a Ucable
Failure to provide this affidavit will result
New Construction ❑ Existing Building OL�- Repair(s) ❑ Alterations(s) ❑ Addition ❑
Accessory Bldg. ❑ Demolition IT Other ❑ Specify M4< <
Brief Description of Proposed Work:
– - — - 'd- rSt (/'y , _ , / - ,/
cam(2Ail do-hr��C
I SECTION 6 - RSTIMATFn CONSTRurTION COSTS I
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
OFFICIAL USE ONLY
1. Building
ip 0-0
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
/ oc/
3 Plumbing
Building Permit fee (a) x (b)
/ D
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, , as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
I, as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
Print Name
Si ature of Owner/Agent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 1 2 ND 3 RD
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHRvMY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Name Please Print
Name:
Location:
City Phone #
I am a homeowner performing all work myself.
�Idm a sole proprietor and have no one working in any capacity
I am an employer providing workers' compensation for my employees working on this job.
Address %' f-�,P e.1
Company name:
Address
:e
3s-6 -71:
IJilili��L�1�i1lr - - • _ Siff'`-�3�
City: Phone #•
Insurance Co. Policy #
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to $1,500.00
and/or one years' imprisonment_as. as.civic.penaltiesin.thefnrmofa..SIOP.WORK ORDER..and_afire.of_(.$1.00M)Ajday against -me. I
understand that a copy of this stet TAybe f3warded to the Office of Investigations of the DIA for coverage verification.
Ido herebycert' under Bins q li)p f , ry
fly nal. � perju that the information provided above is true and correct.
Print
Official use only do not write in this area to be completed by city or town official'
City or Town Permit/Licensing
Building Dept
[]Check if immediate response is required ❑ Licensing Board
❑ Selectman's Office
Contact person: Phone #: ❑ Health Department
❑ Other
Town of North Andover
Building Department
27 Charles Street
y ci
North Andover, MA. 01845
Mme,
S
D. Robert Nicetta
Building Commissioner
(978) 688-9545
(978) 688-9542 Fax
HOMEOWNER LICENSE EXEMPTION
Please print.
DATE
JOB LOCATION
Number Street Address Map / lot
"HOMEOWNER
Name
Horne Phone
PRESENT MAILING ADDRESS .
City Town
State
Work Phone
The current exemption for "homedwners" was extended to include owner -occupied dwellings
of two units or less and to allow such homeowners to engage an individual for hire who does
not possess a license, provided that the owner acts as supervisor: (State Building Code Section 108.3.5.1)
DEFINITION OF HOMEWOWNER:
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 dwelling, attached or detached structures ac-
cessory to such use and/or farm structures. A person who constructs more than one home in a
two-year period shall not be considered a homeowner.
The undersigned "homeowner" assumes responsibility for compliance 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 No. Andover
Building Department minimum inspection procedures and requirements and that he/she will
comply with said procedures and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING OFFICIAL
Zip Code
North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
Number is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c11,S150A.
The debris will be disposed of in:
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
A660.
PRODUCER
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
DAVID E ZELLER AGENCY
370 LYNNWAY *
HOLDER. THIS CERTIFICATE DOES NOT AMEND EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
LYNN MA 01901
COMPANIES AFFORDING COVERAGE
COMPANY
25DSD
A ST. PAUL FIRE AND MARINE INSURANCE COMPANY
INSURED
COMPANY
H G M INDUSTRIES INC
B
COMPANY
9 HEROLD ROAD
W PEABODY MA 01960
C
COMPANY
mownD
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CEFiIIFJC�TE MAY B {S§LIEA MAY PERTAIN, THE IN`SURANCE-AF�OROED Bi THE POS DESCRIBED HEREIN IS SUBJEOT TO -ALL THE TERMS, - -
D O
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO
LTR
TYPE OF INSURANCE
POLICY NUMBER POLICY
DATE
EFFECTIVE
IMM OO\YY)
POLICY EXPIRATION
DATE (MM=VV)
LIMITS
GENERAL LIABILITY
GENERAL AGGREGATE $ _
PRODUCTS-COMP/OP AGO. $
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE F� OCCUR.
PERSONAL & ADV. INJURY S
EACH OCCURRENCE S
OWNER'S & CONTRACTOR'S PROT.
FIRE DAMAGE (Any one fire) $
MED. EXPENSE (Any one person) S
AUTOMOBILE
LIABILITY
ANY AUTO
COMBINED SINGLE $
LIMIT
BODILY INJURY
(Per Person) $
ALL OWNED AUTOS
SCHEDULED AUTOS
BODILY INJURY
(Per Accident) S
HIRED AUTOS
NON -OWNED AUTOS
PROPERTY DAMAGE $
GARAGE LIABNITY
AUTO ONLY - EA ACCIDENT $
OTHER THAN AUTO ONLY:
ANY AUTO
EACH ACCIDENT N
AGGREGATE S
EXCESS LIABUM
EACH OCCURRENCE S
UMBRELLA FORM
_
AGGREGATE $
A
WORIER'SCOMPENSATION AMD
EMFWVER'S UABWW
THE
PARAR PROPRIETOR/R!TNERSlEXECUTIVE X INCL
(UB -794X632-6-03)
09-22-03
09-22-04
STATUTORY LIMITS
EACH ACCIDENT 100.000
DISEASE—POLICY LIMIT is 500,000
DISEASE—EACH EMPLOYEE S 100,000
OFFICERS ARE: EXCL
OTHER
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE.
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUDIG COMPANY WILL ENDEAVOR TO MAIL
r 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAND TO THE
r LEFT, BUT FAILURE TO PAIL SUCH NOTICE SHALL IMPOSE NO OBUGATION OR
UABILM OF ANY KIND UPON THE COMPANY ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
nrtnirtion - CS.
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 067992
Birthdate: 05/2411965
Expires: 05/24/2006 'Tr. no: 21835
Restricted: 00
LOUIS L VAZQUEZ
9 HEROLD RD
PEABODY, MA 01960
A C mis over
�� ✓1ze �anv�rnomu�P,a:� o�'✓�aaacrs/ruaella
�-- Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
i Registration: 123289
s Expiration: 1/22/2005
Type: Individual
LOUIS VAZQUEZ
I LOUIS VAZQUEZ
S/� O
.0
I.G.M. INDUSTRIES INCORPORATED
Nine Herold Road , west Peabody , MA 01%0
.►......... **......... too .....I.►-....►N.....►...................►o...N.....►0......................I.►.I..1.....►►I.IM....►III..II..I►.►III►
Telephone (978) 535 - 6712 Fax No. (978) 535 - 0127 Cell .phone : (781) 771.- 7859
/�/a..2 Tot► h s�r� �5�: /V, ,�, �=v�2, h�,�
Brick Store Company June 25, 2004
North Andover Historical Society
Att: Mike Lenihan ( 978) 828 - 3798 fax # (978) 470 - 0217
Contract No. 062504 - 2 R
ITEM : Roofing and flashing PROJECT.- #J36huson St., North Andover, MA
Scope of work includes the following; ( Front and hear side of property)
• Strip ofall existing wood shingles and dispose of properly and legally.
• inspect existing roof deck boarding for Rot / damage to boards, replace rotted and damaged
roof deck boarding using same thickness as existing roof deck boarding ( Limited to approx.
100 lin. ft. of I" x 6 - 8 " deck board replacement ) .
• Install new 36" Ice and water shield to all eve edges, behind existing chimneys and around
existing sky -Utes located on roof areas.
• Install new .Roofing Under- layment ( vapor barrier) to all remaining roof surface( s) .
' Install new Lead coated 16 oz. copper drip edge to all Rake and eve edges of roof areas.
• Install new selected roofing shingles to all roof areas fastened according to manufacturer's
details.
• Rework all existing chimney flashings and all ousting sky - light flashings, seal as required.
• Rework all existing working vent pipe flashing, seal as required.
• Install new cap over style ridge venting system to all main ridge area, a (2") air passage
way will be cut for venting.
• Clean all debris pertaining to roofing work by MGM Industries only.
• A Ten year Roofer's guarantee by HGM Industries Incorporated.
• A Pro- Rated manufacture's materials warranty by GAF Roofing materials CorDwatim.
PRICING : I ff / aV Co 16
• Based on i (`►"Cl Q,
5,e -(e,( e5 Ll 6 oto'" /Vq+0 ("Ct j
nstaWng G year architectural too ng shingl
• Based on installing G F 4 year architectural roofing shi es 16,600.
• Based on installing C .F etiwe Arcbitectural roofing ingi
ptance by, Sub
YD
;ZBrick;=Store Com is L. V u P. M.
Historical Society HGM Indus es Incorpors
/ Mia Coast. Supry Lic # 067992
Print Name of Personnel Date Signed 04
Deposit Received Date Od Priwrn•a
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August 8, 1989
Town of North Andover
Robert Nicetta, Building Inspector
120 Main Street
North Andover, MA
RE:Historical District Commission
1 Johnson Street, Travel Agency, Barbara Sullivan
Dear Mr. Nicetta:
Enclosed please find for your file a copy of the certificate
of appropriateness relative to the above captioned with
conditions as noted. Any questions and or concerns please
contact me.
n
BUILDING DEPARTMENT
TOWN OF NORTH ANDOVER. MASSACHUSETTS
_OFT,
r
O � �..i i•L. O
HISTORIC DISTRICT COMMISSION
Application for Certificate of Appropriateness
oP-
Application is hereby made for the issuance of a CERTIFICATE OF
APPROPRIATENES under Chapter 40C for proposed work as described below
and on plans, drawings, or photographs accompanying this application.
CHECK CATEGORIES THAT APPLY:
1. Exterior Building Construction: ( ) New Building
( ) Addition
( ) Alteration
Type of Building ( ) Home
( ) Garage
( ) Commercial
( 1 Other
2. Demolition or Removal of:
3. Signs or Billboards:
4. Structure:
(Type or print legibly)
( ) New Sign
( ) Existing Sign
( X ) Other
( ) Fence
( ) Wall
( ) Other
Address of Proposed Work: nraF: jnj4NsnN -qT NnpTH ANDQVER Date: JUNE 1 1939
Owner: BRICK STORE INC. Telephone: (508)688-4116
Home Address (if different from above): 405 SALEM ST. NORTH ANDOVER
Agent or Contractor: NONE Telephone #:
Address:
Assessor's Map tt' Lot :
en�
Detailed Description of Proposed Work: Give all particulars of work
to be- done (see 18 below), including materials to be used, if
specifications do not accompany plans. In case of signs, give
locations of existing signs and' proposed locations of new signs.
(attach additional sheet if necessary.)
REQUEST VARIANCE FOR DISPLAY OF A COT1T-4ERCIAL FLAG APPROXIMTELY
9 SQUARE FEET IN AREA WITH LETTERING ( TRAVEL ) OF APPROXIMATELY
2 SQUARE FEET, AT ONE JOHNSON ST., NORTH ANDOVER, 2ND FLOOR RIGHT
SIDE OFFICE.
BARBARA M. SULLIVAN, CTC
Owner (Agent, Contractor)
DO NOT WRITE BELOW THIS LINE
RECEIVED FOR HISTORIC DISTIRCT COMMISSION:
TIME: -/.'o D
DATE: G-I-cPI
APPLICATION alt: 191 -9,
THISAPPLICATION FOR CERTIFICATE OF APPROPRIATENESS:
( t� APPROVED GoNJ17-14W " .V,S `r.I1---O
( ) DISAPPROVED
Reason for Disapproval:
( ) NO CERTIFICATE OF APPROPRIATENESS REQUIRED
i�IJP�.�y of F�6
A CERTIFICATE OR PROPRIATENESS is �',2yvT�q for -ra de=(-ri �r E
in the applica on abov a attached documents j �,,lTy FpLCL/✓/N� ca�•o�;/ova,
Chairman: Secretary: u �lze
vice Chairman:-
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