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Miscellaneous - 100 CRICKET LANE 4/30/2018 (5)
TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received ✓� �d Date Issued: f IMPORTANT: Annlicant must complete all items on this page I LOCATION /l6 Ch/C� �rfl N� - Print PROPERTY OWNER �� J NArJt9 -- hh Print 100 Year Old Structure yes MAP NO: PARCEL4- ZONING DISTRICT: Historic District yes Machine Shop Village ves TYPE OF IMPROVEMENT PROPOSED USE 496774zl ^) 4"A Residential Non- Residential ❑ New Building ❑ One family 3 ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition >rOther CCK peptic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed. District E! Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: rZ&PJ(A6 /IT/nJ(s- Z)E(k - - 8(J/C0 N4 Ise `mak Identification Please Type or Print Clearly) OWNER: Name: /Z5AJ AIA[ 4A Phone: -27Je1/ -4 ?3-- ro 65 3 Address: CONTRACTOR Name:'Dg92EA✓ M1-VZT//U0 Phone: irf-9dZ'3--m-66 Address: � �'ly l f �IV� ��'T 496774zl ^) 4"A Supervisor's Construction Licenser, 3 Exp. Date: Home Improvement License: / .) `i SG / . Date: 9-f7- "� /3 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: $ 12 ku FEE: $ Check No.: e52-72 Receipt No.: a6-� (F9 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ,Sgnatiare of Agent/Owner Signature of contractor l Plans Submitted ❑ Plans Waived 11 Certified Plot Plan 11 Stamped Plans ❑ Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Ari ❑ .. _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 ❑ ❑ COMMEN CONSERVATION Reviewed on COMMENTS HEALTH Reviewed on p o ` COMMENTS � 10 11 -1' Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes_.. Planning Board Decision: Commen Conservation Decision: Comments Water & Sewer Connection/Signature &Date Driveway Permit DPW Towz Engineer: Signature: Located 384 Osgood Street FIRE -DEPARTMENT - Temp Dumpster on site yes no Located at-124.Main' Street Fire Departineritsignature/date; COMMENTS 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.$10041000 fine Kin-raq .,.,i neY® _ IF:nr ripnartment use) 1M%A1 &_ 6d.." VTI. 1. ji ---'----- --- - f ® Notified for pickup - Date j3 I Doc.Building Permit Revised 2010 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 o 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 a Photo Copy. of H.I.C. And C.S.L. Licenses o 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 appal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm:¢ted with the building application Doc: Doc.Buil-jing permit Revised 2012 Location l �f%1 K No. % K I _ Date T TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 26389 Building Inspector E x J W LL O O 02 CD c °' v Y O LL v N u U. N O V O z Z m c 0 m -o 7 LL t 7 d' (d N c U _ t0 LL cl: p W !A Z C7 Z co j a t to 7 d' f0 LL- c p W N Z U V J ui s CO 0 u i N N ! O C LL p U Wa H ? Q C7 t bD O w C LL wWc C Q W uj a _ LL v i CJ O Z ,, y ai .{ j v Y O (n f� cv Cj-.` V. �_ C o cc F--1 K 2 o v. m a Cc V�� N • L d 4>1 �1 rn 2 ' V .l bV�V • . L P ,NGOP f O CO 2 z m co Z W x ujW a- r-' C-. %7 .ti LLI U) U) 19 W W OC W U) cv E y J i v. m a V�� N • L d 4>1 �1 rn N.aL z f > V�=10) o c �a CLI— CL O = .= c .O Q 2 L O L Id '0 CL N co �' y °' •� m O °' LLJLL W .N •a +�+ p d� N C c; O cr-OW N •E CL :20 c� v Z U m C o .0.o _O I-- to CL cn d•>= H m o c a J O t=- s .$ aoV > CO 2 z m co Z W x ujW a- r-' C-. %7 .ti LLI U) U) 19 W W OC W U) The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): DARREN MARTINO Address:44 ADDISON AVE EXT. METHUEN, MA 01844 Phone #:978-685-3037 Are you an employer-? Check the appropriate box: 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 2. Q I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any Qowily, employees and have workers' [No workers' comp. insurance comp. insurance.: required.] 5. [] We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, §1(4), and we have no employees. [No workers' coma. insurance reouired.] Type of project (required): 6. ❑ New construction 7. 0 Remodeling 8. 0 Demolition 9. ❑ Building addition 10. Electrical repairs or additions 11. [_] Plumbing repairs or additions 12. ❑ Roof repairs 13.R) OtherDECK *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners 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 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. Lic. #: Job Site Address: Expiration Date: 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Phone ##:17, %?-vva-12u91 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Y8,2013 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 #: Estimate Submitted To: Construction Supervisors License 66342 Ben & Beth Nassar Home Improvement Registration 124961 110 Cricket Lane N. Andover, MA We hereby purpose to furnish the materials indicated and perform the labor necessary for the completion of: Construction of a new deck (See specifications sheet & drawings) All material is guaranteed to be as specified, and the above work to be performed in accordance with the drawings and specifications submitted for above work and completion in a substantial workmanlike manner in the sum of Twelve thousand nine hundred dollars- $12,900.00 Payments to be made as follows: $1,000.00 Upon execution of the contract. $4,000.00 When work begins Remaining payments as work progresses. Respectfully submitted: Darren Martino � Any alteration or deviation from the above specifications involving extra costs will be executed only upon written order, and will become an extra charge over and above the estimate. All agreements contingent upon accidents, or delays beyond our control. Note -This proposal may be withdrawn if not accepted within 10 days. Proposal Date 04/30/13 ACCEPTANCE OF PROPOSAL The above prices, specifications, and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payments wil a made as outlined above. Date: s / Signature: Date:_ Signature: >,—�`� �— DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES DM Construction Building with the QUALITY and Character of yestetyear. 44 Addison Ave Ext. Methuen, MA 03.844 (978) 685-3037 Estimate Submitted To: Construction Supervisors License 66342 Ben & Beth Nassar Home Improvement Registration 124961 110 Cricket Lane N. Andover, MA We hereby purpose to furnish the materials indicated and perform the labor necessary for the completion of: Construction of a new deck (See specifications sheet & drawings) All material is guaranteed to be as specified, and the above work to be performed in accordance with the drawings and specifications submitted for above work and completion in a substantial workmanlike manner in the sum of Twelve thousand nine hundred dollars- $12,900.00 Payments to be made as follows: $1,000.00 Upon execution of the contract. $4,000.00 When work begins Remaining payments as work progresses. Respectfully submitted: Darren Martino � Any alteration or deviation from the above specifications involving extra costs will be executed only upon written order, and will become an extra charge over and above the estimate. All agreements contingent upon accidents, or delays beyond our control. Note -This proposal may be withdrawn if not accepted within 10 days. Proposal Date 04/30/13 ACCEPTANCE OF PROPOSAL The above prices, specifications, and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payments wil a made as outlined above. Date: s / Signature: Date:_ Signature: >,—�`� �— DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES NASSAR RESIDENCE Specifications Sheet Scope of work: Demolition of existing deck, construction of a new deck approximately 12'x 20' with one set of stairs and a landing. See drawings for details PERMITTING DMConstruction is responsible for obtaining the following permits required.• building and debris removal. The cost of all permits necessary is not included in this estimate and will be billed separately. DEBRIS REMOVAL DM Construction is responsible for all debris generated. A container will be placed on site to ensure a clean work site. The container is for debris generated by DM Construction only; it is not intended for homeowner use. DEMOLITION Remove the existing railings, decking, stairs, and lattice detail under the deck. Remove the existing rim joist. Some of the existing framing members, main beam, and support posts may remain. FRAMING Frame new deck, stairs, and landing per submitted drawings. Frame area under deck to receive lattice trim detail. All framing members will be ofpressure treated lumber. CONCRETE New footings will be poured to support the new deck. The existing footings will remain in place. Footings will be poured to support the landing. DECKING Installation of cellular pvc decking on the deck, .stairs, and landing. One row of decking will be installed around the perimeter of the deck forming a border. All decking will be fastened using stainless steel color matched screws. The deck fastners will be visible. Decking will be Azec - colors to be selected from Slate Gray, Brownstone, or Clay. Any other colors will increase the cost of this proposal. RAILINGS Steel post anchors will be fastened to the deck. Installation of white Timbertech Radiance railings, consisting of composite post sleeves, skirts, caps, rails, and balusters. TRIMDETAIL Installation of a pvc trim board under the existing slider. Installation of pvc risers and skirts on the stairs and landings. Installation ofpvc trim boards covering the pressure treated rim joists. Installation of vertical and horizontal pvc boards to frame in area below deck to receive pvc lattice. All pvc trim boards to be fastened with stainless steel ring nails and all joints to be secured with bond & fill adhesive. NASSAR RESIDENCE Specifications Sheet MISCELLANEOUS Construction of a door made of pvc and lattice to access area under the deck, location to be determined. The door will have black hinges, handle, and latch. This estimate does not include relocating the electrical box under the existing deck This estimate does not include any painting. This estimate does not include any landscaping or hardscaping. Note: Due to the nature of wood and plastic and the drastic temperature and humidity changes in our region, you may notice the movement and shrinking of the interior and exterior trim This is typical of the region and is not due to defective installation. Change Orders Any changes from the existing plans or increased scope of work involving extra costs will become an extra charge over and above the contract price. Change order agreements must be signed before any work commences The following schedule will be adhered to, unless circumstances beyond our control arise: Time frame for completion: From start date to completion 6-8 days All work to be done Monday -Friday between the hours of 7.•00 am — 6: 00 pm. If deemed necessary to work any other times, the homeowner will be consulted first. MEMBER OF THE BETTER BUSINESS BURSA U HOME IMPROVEMENT CONTRACTOR: 124961* CONSTRUCTIONSUPER VISOR LICENSE: CS 066342 *All home improvement contractors and subcontractors shall be registered Any inquiries about a contractor or subcontractor relating to registration shall be directed to: Office of Consumer Affairs and Business Regulation Ten Park Plaza, Suite 5170 40 Boston, MA 02113 Phone: (617) 973-8700 MUM. DM Construction Building with the QUALITY and Character of yesteryear. 44 Addison Ave Ext. Methuen, MA 01844 (978) 685-3037 NOTICE OF CANCELLATION 04/30/13 You may cancel this transaction, without any penalty or obligation, within three business days from the above date. If you cancel, any property traded in, any payments made by you under the agreement, and any negotiable instrument executed by you will be returned within ten business days following receipt by the seller of your cancellation notice, and any security interest arising out of the transaction will be cancelled If you cancel, you must make available to the seller at your residence, in substantially as good condition as when received, any goods delivered to you under this agreement; or you may if you wish, comply with the instructions of the seller regarding the return shipment of the goods at the seller's etpense and risk. If you do make the goods available to the seller and the seller does not pick them up within twenty days of the date of your notice of cancellation, you may retain or dispose of the goods without any further obligation. Ifyou you fail to make the goods available to the seller, or if you agree to return the goods to the seller and fail to do so, then you remain liable for performance of all obligations under the contract To cancel this transaction, mail or deliver a signed and dated copy of this cancellation notice or any other written notice to: NAME OF SELLER: DARRENMARTINO ADDRESS. 44 ADDISON AVE EXT METHUEN, MA 01844 NOT LATER 7R4N MIDNIGHT' OF: May 3 2013 I HEREBY CANCEL THIS TRANSCATION Date.- Buyer's ate: Buyer's Signature. I (we each) acknowledge receipt of two copies of this form. Buyer: Buyer: DM Construction Building with the QUALITY and Character of yesteryear. 44 Addison Ave Ext. Methuen, MA 01844 (978) 685-3037 CONTRACTOR ARBITRATAION AGREEMENT The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action (as an alternative to court action) if they have a dispute with a contractor. The same right is not automatically afforded to a contractor however. The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below. This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. The Contractor (Darren Martino) and the Homeowner (Ben & Beth Nassar) hereby mutually agree in advance that in the event the contractor has a dispute concerning this contract, the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as provided In Massachusetts General Laws, chapter 142A. Homeowner's Signature Homeowner's Signature Con c ors Signature �_ ._..:.-..tip.:._ .... - ._.✓ 1hssachusetts - Department (►f Public Safet% 9Board of Building Regulations and Standards Construction Supervisor License License: CS 66342 DARREN MARTINO 44 ADDISON AVE EXT METHUEN, MA 01844 ��- Expiration: 8/15/2013 ►►mmiai►�ncr Tr#: 20456 0MCC�0 Columr Aiaires�Bdsines�ati� on a HOME IMPROVEMENT CONTRACTOR Registration: ter -124961 Type: Expiration: V17J2013 Individual D EN MARTINO, Darren MARTINO _._ 44 A D D I S 0 N AVE f-XT:y METHUEN, MA 0184'4::, Undersecretary Client#: 968806 DARREMAR2 ACORD.. CERTIFICATE OF LIABILITY INSURANCE D /DDlYYYl� TYPE OF INSURANCE 5108/ 5/08/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the pol(cy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this Certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME:Ginger Marszalek USI Insurance Services LLC-SCL ac°NN Ext : 800-403.4159 ac Nol: 413-733-7722 PO Box 406 A o Ems , ginger.marszalek@usi.biz Portland, ME 04112-0406 X COMMERCIAL GENERAL LIABILITY CLAIMS MADE � OCCUR INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Nautilus Insurance Company 17370 INSURED Darren Martino dba INSURER B INSURER C D M Construction INSURER 0: 44 Adison Ave Ext INSURER E: Methuen, MA 01844 INSURER F: VVYCKAOGA UPUTIFICATF NIIMRFR- DC%11411 1W AIIIMoto. 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INS.LT TYPE OF INSURANCE ADDL S SUB POLICY NUMBER POLICY EFF MMIDD POLICY EXP MMIDD/YYYY LIMITS A GENERAL LIABILITY NN260323 9/21/2012 09/2112013 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY CLAIMS MADE � OCCUR PREMISES Ea NTE ence$100,000 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 s2,000,000 PRAT LOC POLICY Ij $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident BODILY INJURY (Per person) $ ANY AUTO ALL OWNEDSCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ HIRED AUTOS NON -OWNED AUTOS PROPERTY t DAMAGE $ Per acciden 01M9.RELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED I I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITYER ANY PROPRiETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDED? ❑ NIA WC STATU OTH- E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ Mandatory In i f yes, despite ander und E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS ! VEHICLES (Attach ACORD 101, Additional Remarks Schedule, H more space is required) Ben Nassar SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 110 Cricket Lane ACCORDANCE WITH THE POLICY PROVISIONS. North Adnover, MA AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) 1 of 1 The ACORD name and logo are registered marks of ACORD #S9718291/M9718273 VAMCX Location�� * Ilk ,?� i V fro. Date NORTh TOWN OF NORTH ANDOVER s Certificate of Occupancy $ �'�s'^•"°' E<� SA Building/Frame Permit Fee $ MUS Foundation Permit Fee $ Other Permit Fee $ • TOTAL $ f Check # I i �J I Building pector V' TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING i BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: csow�� Building Commissioner/I for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 0 Cnr-y,. 1.2 Assessors Map and Parcel Number: G Map Number Parcel Number 1.3 Zoning Information: Zoning Disftid Proposed Use 1.4 Property Dimensions: A - Lot Areas Fronta e ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided R red Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public 0 Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Address for Service Name (Pr' i a�* Signatu Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: �IG�Yi� �t✓� 'J '�' Licensed Construction Supervisor: Ai3dre �f 2 T-7 -Cb -tel ��� Sign r Telephone Not Applicable ❑ C S d SA License Number q! Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check au a Ucable New Construction ❑ Existing Building k�F— Repair(s) ❑ Alterations(s) B' Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify s \k rc"r, ktnon Brief Description of Proposed Work: ` V rrr i- Con, 4 r e-1, cn 0--- 4� S 6F U a V'(A C:k "r -i SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY 1. Building GG v (a) Building Permit Fee Multiplier 2 Electrical cG (b) Estimated Total Cost of Construction 3 Plumbing ocu Building Permit fee (a) X (b) 4 Mechanical HVAC ,SGU 5 Fire Protection 4 0. d 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 �as Owner/Authorized Agent of subject property LL C - 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 3 co Si ature o wner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIlVMERS 1ST2 No 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Cricket Development LLC MEMO FROM RICK WELCH To: Board Of Health Building Department From: Rick Welch Subject: application for playroom /bath in basement Of lot 9 Cricket Lane(home is currently under construction) Enclosed please find the following information which is required to apply for a permit to finsh a playroom And bath in the basement of lot 9 Cricket Lane(#110). (1) applications (2) proposed sketch of playroom (3) specs of finished playroom (4) first floor plan (5) second floor plan. Please call me at (978) 664 4886 or (617) 921 3623(cell) if you have any questions or desire any further information. BUILDING DEPARTIV= DEBRIS DISPOSAL FORM In accordance with the provW'ons of MGL c 40 S 54, a condition of Building Permit Number Is that the debris resulting form this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150A The debris will be disposed of in: Location of Facility V Signature of Permit Applicant Date NOTE: Demolition . permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector FORM U -LOT RELEASE FORM INSTRUCTIONS: This farm 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 or requirements. APPLICANT FILLS OUT THIS 7Y APPLICANT �ilc��� �evc� PP«� PHONE 696'(—`{ ke6 LOCATION: Assessors Map Number SU£DIVISION STREET _LL e✓ tcVe-4 11�e OFFICIAL USE ONLY RECOMMENDATIONS OF TOWN AGENTS: CO PARC'_ LOT (S) ST. NUMEER 1 10 ATION ADMINISTRATOR DATE APPROVED (,J OCA A , DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR -HEALTH OR -HEAL DATE APPROVED DATE REJECTED_ DATE APPROVED DATE REJECTED COMMENTS r1k--- -7'�L IL�51, /) P-61-:11 PUELIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVE, EY EUILDING iNSPECTCR Revised 9197 im DATE i 4 Lot 9 Walnut Ridge Finished Basement Specs 1). Finished basement shall be approximately 16' a 46' 2). Hallway to be finished, including carpeting allowance 3). Approximately 8 windows can be provided in the rear, upper 2' portion of the rear wall. 4). Approximately 3 larger windows can be provided in the upper 4' portion of the side wall. 5). All finishes to match upstairs, including moldings, paint, carpeting and lighting, walls to be plastered as the rest of the home. 6). Approximately 10 recessed lights will be provided. 7). Bathroom, size and location will be determined after planning with plumber, framer and heating contractor. 8) Bathroom to have tile floor, same as upstairs. 9). Fiberglass shower to be included. 10). Vanity to be same quality as upstairs. 11). Heating/cooling system to be upgraded with a damper system which will work off a 80,000 BTU high efficiency unit with 5 tons of cooling which is • provided for the first floor and basement, proper duct work will be provided. 12). See 8x 11 sketch for further explanation of basement plan. 13). All warranties provided by builder will apply for lower level family room. 14). Plan needs to be submitted and approved by town authorities. . 0 0 cn n 0 O C C�- Om 2 O -• N O Q N CL y =t CoaO m n CM yc)aC 3 m Z =r -0N =r C n r-4- m C T -+ a m m .4 O ® m y o -1 O Z' O W a 7 O -0 G : -� CC O C a C=2 to c mmy: a� m 71 C» m c co m O N d y H OW d N m V .► lE m N gn O m -� m d N CD gam: CD: CD S-9 CO) n : .` :• -o o o Im =m :. CD 3 n ate.: 4 US 1 0co Cn Cn CO) C o M C/)�7 'r1 ;z m n 'Jd CO) n (n CD Z y CD O �� a C 7 O C C/) d �' y m n� L7 O ..� CD mCCD rD CL s _ Cf) V// m Q •C 0' � CD Cl) ? ?r p CD o c� m v W C CD C'n CD d y O I co CD a y v O 1 CD Z a C) n CDo r) CD 0 0 cn n 0 O C C�- Om 2 O -• N O Q N CL y =t CoaO m n CM yc)aC 3 m Z =r -0N =r C n r-4- m C T -+ a m m .4 O ® m y o -1 O Z' O W a 7 O -0 G : -� CC O C a C=2 to c mmy: a� m 71 C» m c co m O N d y H OW d N m V .► lE m N gn O m -� m d N CD gam: CD: CD S-9 CO) n : .` :• -o o o Im =m :. 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Town of North Andover Building Department 27 Charles Street North Andover, Massachusetts Ol 845 (978) 688-9545 Fax (978) 688-9542 NORTH OL O r+ 1 lb 'Q� [O[MI[WwKR APPLICATION FOR CERTIFICATE OF OCCUPANCY / INSPECTION ADDRESS � �Q CrLIY,_ ' U,4P,, LOT NUMBER 1 SUBDIVISION Wn�k �Z•�� e� DATE REQUEST FILED 113Ldd DATE READY FOR INSPECTION JA&-) FIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED ALL WORK SIGN-OFF'S MUST BE COMPLETED WITHIN THIS TIME FRAME. A PECTION FEE OF TWENTY-FIVE ($25.) DOLLARS WILL BE CHARGED IF,/TBA STRUCTURE DOES NOT MEET ALL APPLICABLE CODES. SIGNATURE U OFFICIAL USE ONLY ROUTING CONSERVATION �Z'� DATE PLANNING DATE D.P.W. — WATER METER lv a3���A DATE D.P.W. MUST INDICATE THAT THE WATER PRIOR INSPECTIONN RE ST AN. SIGNATURE / DPW AUTHORIZATION HAS BEEN INSTALLED r TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE: 7/6/00 This is to certify that the individual subsurface disposal system constructed (X) or repaired ( ) by William Sawyer at Lot 9 (#110) Cricket Lane has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. Board of Health Inspector CERTIFICATE OF USE &OCCUPANCY Building Permit Number THIS CERTIFIES THAT Date %7-7,—o d THE BUILDING LOCATED ON /O /- � #//D C%Pleke -l- i ,�? e- �l �.SIC� UL �G� MAY BE OCCUPIED AS f IN ACCORDANCE /.Ex of S /,/a, 5*4 S cs� WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. O �1.O o7N ,. CERTIFICATE ISSUED TO ADDRESS /ue) '�s,C"„sBuilding Inspector m m m 0 m v y .0 C go SCD d '0 O e7 Z y CCD O 'O ar c � � c CL = y 0 0 CD CDCL O Q CD CD CCD O CCD c CD co) CD =0 y �C COD C2 CO) O 'D CD Z O CD a O CD '1146k afto 3 cn n O cn n .z cn d n V 2 ON K O cn t O O CD O _ _ m O C CL um CD coO _ O iA W CA C m = d OO F a o C/! Cl) CE CA CO d C �= H H T m co CA y -.1 O O� O m(� � ? Om �I ' O d O yCC2 • .Z. O CP Nab a-+,.• W C* CD CD �om:� 03 d = N O. d C � CD CC,. N N C O :� y = CO CD C A CD FS t caa� CD ~� o o CD = 1, Cs'% n A H 0 ow T A. cn x o� c E� v No 2u55 Date.............. / ........ : .......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that ... X ......................................................................................... has permission to perform ................................... 7 wiringin the building of ................................................................................... at ..................... ; ............................ 4 ................................ . North Andover, Mass. Fee..................... Lic. No.............: ................................................................ ELECTRICAL INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Office Use Only �/ �y+ �r,�. Permit mm � G 5775 P-" Shay Occupancy & Fee Checked �yYwrrve.t � BOARD OF F)R€ PREVENTION REGULATIONS 527 CMR 12:00 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All wait to be performed M accordance with the Massachusetls 8ectrical Code U7 CMit I Z-00 (pwase Print in ink or type all informaidon) Town of North Andover D*ft �- /2 -U0 To the Inspector of Wiles; The undersigned applies for a permit to pplarrn the electrical work descriilmd bellow. Owner or1- Owner's Addrrss q,;Z- lti /N lS this permit in counctismm -__building p�►m� _ / ( Yes , No H (Check Appropriate Bok) P of Rn .,Affh - AAt2/ O . [ W.c Q ,I�AA� �2 Utfllty AU nUFLO &AI NO. u�U v I rpos e EvssfiM Ser AM Amps Nuw Service Amps Vaits Number 4f Feeders and Ampacdy - y Leeadon and Nature of Proposed Eletxric_ai I Overhead ❑ Undgmd ❑ Na of Meters O%erhead ❑ Undgmdd No. of Meters P,�D. r"111C,9— OTHER: - INSUFU94CE COVERAGE. Pursuant to the requiremen to of Massachusetts General Laws I have Liability insurance Policy incl '!NtbM meted Operations coverage or its subsiarttial equival Y = NO = -- _-- s___ _ -- _ valid proof of same to the OI6rYES`= NO = It you have checked YES �e indicate the of coverage by checking the appropriate tic BOND = OTHER = (Please Spacihl) (Enpinttlon Date) Esdmated Value of tical Works Work to Stert / ate- �'Tl) Inspection Date ftsaquested Rough Final Signed under -the Penalties of perjury, FIRM NAME /tom a t o � 4- r;r ,-1 C„ - Sj _ Ue. NO. X/ 91 alk j NO. Bus. Tel No. V Addm+essffli'iLcc/1y'(�P>f !�I anti - Alt Tel. No. OWNER'S INSURANCE WAIVER: I am aWars that the Llseneee does not have the mntlyrahce coverage or its substantial equivalent as required by paaeyachuaetts Gen" Laws. And that my signature on this permit aPpucattan waives this requirement. Owner Agent (Please Check one) f U- PERMIT FEE $ Total No. of UqMng Outlets No. of Hot fuse No. of Transformers KVA - Above ❑ In ❑ No. of Lighting Fixtures Swimrmnq Pod gmd B grnd ❑ Generators KVA - No. of Emergency UcjMttg No. of R Outlets NO. of Oil Bumeis Battery Units No. of Swtteh Outlets No of Gas Burners FIRE ALARMS No. of Zone Na- of Detection and - Total Ne. of Ranges No of Air Cord Tons Initiating Devices Heat Total Total Nit% of 01posal Pumps Tens KW No. of Sounding Devic Noi of Self Contained Of Dishwashem SoacelArea Heating KW DetecliowSoundmg Devices 0 Munigpai 0 DOW No. of Dryers Heang Devices KW Wcat Connection No. of No. of law Vdtage No. of Water Heaters KW signs Batlases Wiring No..HWro Massage Tuds No. of Motors Tamm HP OTHER: - INSUFU94CE COVERAGE. Pursuant to the requiremen to of Massachusetts General Laws I have Liability insurance Policy incl '!NtbM meted Operations coverage or its subsiarttial equival Y = NO = -- _-- s___ _ -- _ valid proof of same to the OI6rYES`= NO = It you have checked YES �e indicate the of coverage by checking the appropriate tic BOND = OTHER = (Please Spacihl) (Enpinttlon Date) Esdmated Value of tical Works Work to Stert / ate- �'Tl) Inspection Date ftsaquested Rough Final Signed under -the Penalties of perjury, FIRM NAME /tom a t o � 4- r;r ,-1 C„ - Sj _ Ue. NO. X/ 91 alk j NO. Bus. Tel No. V Addm+essffli'iLcc/1y'(�P>f !�I anti - Alt Tel. No. OWNER'S INSURANCE WAIVER: I am aWars that the Llseneee does not have the mntlyrahce coverage or its substantial equivalent as required by paaeyachuaetts Gen" Laws. And that my signature on this permit aPpucattan waives this requirement. Owner Agent (Please Check one) f U- PERMIT FEE $ Date.... ate.....L(...1U L1-68 °:t•``D '• ."� TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....... .........1 has permission to perform ........ V ....... ......................... �.......uwiring in the building of ..�......:..................... at ..�lli� .......(.... Z -.IV... ................... . North Andover, Mass: Fee.. .A -civ Lic. No..�.!..��.7J .......... a,�.=,.. . ELECTRICAL INSPBCT6R WHITE: Applicant CANARY: Building Dept. PINK: Treasurer N2 2337 Date.... � —/&/p -0. TOWN OF NORTH ANDOVER 0 0 PERMIT FOR WIRING 544 ,7 This certifies that ........ ............ . ............................ has permission to perform .......... .................................... wiring in the building of ..... ........ ..................................... C� A/ at..6 at ... ........ k.f North Andovs, MAss. -;7 Fee...Lic. No. ........... Z A1ECMCAL1NSPECr0R Check # % �0 ) 5 WHITE: Applicant CANARY: Building Dept. PINK: Treasurer TBE COAMONWE4LfHOFA MUSLTI'S` Office Use only D.EPARTA1EW0FPUBDC&4F=PennitNo. 33 7 d BOARDOFF7REPREVEIVI70NREGUTAHOAS527CAM12 I Occupancy &Fees Checked M APPLICATI0NF0RPFRA1flT TOPFRFORMELEC'TRICAL WORK No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total r ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 I I _ �` ` (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date J Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. AP PARCEL or & Number) C & - l -141-//b 0- r c � Location (Street itiA Owner or Tenant J2.Q Owner's Address Is this permit in conjunction with a building permit: Yes rNo (Check Appropriate Box) Purpose of Building / Utility Authorization No. Existing Service 2CJ"(J Amp4 ZO / 2YVolts Overhead E] Underground M No. of Meters New Service I Amps / Volts Overhead [= Underground r --J No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work N 1,5 u_5 TBE COAMONWE4LfHOFA MUSLTI'S` Office Use only D.EPARTA1EW0FPUBDC&4F=PennitNo. 33 7 d BOARDOFF7REPREVEIVI70NREGUTAHOAS527CAM12 I Occupancy &Fees Checked M APPLICATI0NF0RPFRA1flT TOPFRFORMELEC'TRICAL WORK No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total r KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA ground ground No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipal a Other No. of Dryers Heating Devices KW Connections No. o Water Heaters KW No. of No. of Si s Bailasis No. Hydro Massage Tubs No. of Motors Total HP i OTHER- - hnl==CaAnW pmmgtothrm4manai3c'fIvbmdmg&Calaallaws lba,e%hT,fkd,abdproofefsffmtotbeOffim YES I-V 1 NO ar>b afivalalt YES NO T)atthawdm1,xdYES,P1easenhmJVll7&tA e4wx:'aWbydiedx gthe WciktoSlatt DAexeqiesbd sigt>aduldatTie) orpgpT / r FIRNINAME �a.1AJ r --e XJ C -9—E4 QG MIR EstiValuedEbJ ical Wolk $ F -mal Lioawilb / l 7 9 7 Alt.Te.1sici OWNER'S INSURANCE WATdIIt;IamawatetlBtlheLioaisedoesmtlrm+ethein�aatreca<aa�crils subsfa�lec�rivalartastac�madbyl\h�adasdLsGa�+lLaws atrithafmysigrlaaaecntlrisPMIA pp}sat v4musdnstaclmamart (Please check one) Owner Agent Telephone No. PERMIT FEE $ Signature o er or Agent Office Use Onty Permit No- Depvrrbc ea Faef![e Sa6erq . Occupancy & Fee Checked BO A FZ TK)N-REGLI ATIONS-52-7 EMR -1-2:00 I APPL1CATKWFOi� PERMff TE}PERFORiU!-EECTR{CAL WORK All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00 (Please -Print lm ink- or'type-ati-kdocmatiorW - The undersigned applies for a permit to perform the electrical work described below. Owner or CL9-+- //0 CriGLe.f LRNe- t - 3 - 010 To the Inspector of Wires: O..W .address-- Y9- >/�%L,c�S �W Cn..�1 2kJXA%tee T is thispa nd7 rr Yea- iota- Q, (Check Appropriate Boz) No. of Hot fuse Purpose of Building C ii )Jj_�d ATL � � Utility Authorization No. 001-2-55/ ❑ In -0 E�esting��erNce = Amps- Veils-- OVeFhSad-❑- Undgrrtd- ❑ No. of Meters New Service d Amps yats M Number Feeders Overhead ❑ Undgmd No. of Meters of �- Locatian and Nature of Proposed Electrical Work No. of Emergency ligating N > t� l l i t.j z Battery Units - No: of Switch Outlets- lNSutiANk:>: EIJ�iEAAGE Total No. of Ughtling Outlets No. of Hot fuse No. of Transformers KVA ❑ In -0 No. of Ughting Fixtures SwimmingPcol m ❑ gmd ❑ Generators KVA No. of Emergency ligating No. of Receptacles Outlets No. of Oil Sumers Battery Units - No: of Switch Outlets- NoofGas-Bumers FIRE ALARMS- No. gtj!one No. of Detection and Total No. URqe, No otAirCond Tons lnitiating Devices " Heat Total- Totar No%of Diaosai No. Pumps Tons KW No. of Sounding Devices NoJ of Sell Container; No. of Dishwashers SoacelArea'Hem" KW DetectioniSounding 114vices Q Municipal ❑ Other No. of KW Loral No. of No. of Low Voltage No- of Water Heaters KW Siam Barlases- Whin No. Hydm Massage Tuds No. of Motors Total HP PursuarrttotheFequ of Maaaadwsaft General Laws, J a liability Insurance Policy i -Operations -Coverage or its -$u�tantial-equhw NO = aVI subm valid proof of same to the Offlce ES = = it you have checked YES please indicate the type of coverage by checking the appropriate box IN = BOlYi2 = OTHER (Expiration Date) Estimated Vahre-of ElectricatWork3 ( Work to Start 17- 3 ` C� z Inspection Date Rasquested Rough L - r r �� Final Signed underthe Penalties of perfury: �j FIRM -NAME ( p." r- ` ° i � �i Cf c4v-', u� LIC. NO. G 1 / s %/?` — t.icensae UC. NO. `' Sus. Tef No. g % �— G E S7 Address r�� //' ,.c`e , ( n Alt Tel. No. 011111MMS, WAVERt t amt am aware tfixt the Ucenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws. And that my signature an this permit application waives this requirement. Owner Agent (Please Check one) TM—h— Nn PFPRAIT FFF 5 ��� Date!. /1-11.. � . N° t.3J3 TOWN OF NORTH ANDOVER ' PERMIT FOR PLUMBING This certifies that ... ?`......... .... T' `-L ............... i has permission to perform.............. . plumbing in the buildings of .d.. ..... . . .......... at //�'.I�f .........; North Andover, Mass. Fee,. ..... Lic. No.7. ..... . _ `. `. �" Ei' ���� ........ ' PLUMBING INSPECTOR -r7 WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS � f U� Building Location i� C r t %t.�' d/i�Owners Name � `�"'' D� �� Permit #__J _ Amount New 10 Renovation Type of Occupancy Replacement 0 Plans Submitted FIXTURES (Print or type) s� Check one: Installing Comp any Name �v I G 0 Corp. 11 Partner Lj Firm/Co. Name of Licensed Plumber w N l S S U S g t G Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate bor. Liability insurance policy a Other type of indemnity 0 Bond ❑ No 11 Certificate 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 rgnamm Owner ri 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 M efts State Plumb' Code C 142 of the General Laws. By: signaturef Licensea riumoer Type of Plumbing License Title Ot (t ( k a— City/Town ►cense um er Master Journeyman APPROVED (OFFICE USE ONLY 6 7Date .. TOWN OF NORTH ANDOVER `p PERMIT FOR GAS INSTALLATION This certifies that ... -�.... .. `.. ................... . has permission for gas installation�...�.................. . in the buildings of ............ . fur......... at ........ n "e ........ .... ... , North Andover, Mass. Fee., % . �� . Lic. No.. ! ':- ..? .;l ....... . GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATON FOR PERK TO DO GAS FITTING 11Type or print) Date _ � Jr_ NORTH ANDOVER, MASSACHUSETTS Building Locations Owner's Name New! -71 Renovation ❑ Replacement ❑ Permit # C��7 Amount w Plans Submitted ❑ (Print ort�) J!G �( ��` % Check one: Certificate Installing Company Name j -t- nO ❑ Corp. Address / r ❑ Partner. Business Telephone 393—(9(1 ❑ Firm/Co. r p dame of Licensed Plumber or Gas Fitter C �.) 1N t S SU �- J r C C INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No ❑ If you have checked ves• please ndicate the type coverage by checking the appropriate box. Liability insurance policy �'— 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 ivlass. 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 i llations per tbrmed under Perm Issued For this application will be in compliance with all pertinent provisions of blas usetts State Gas Clize and Chyfer 143�#e General Laws. Bv: Title City/Town APPROVED (>FFCE USE ONLY) Signature of Licensed Plumber Dr G ' Fitter t®--P{umber e �� ❑ Gas Fitter Lcense:vumoer ivlaster csarnevman