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HomeMy WebLinkAboutMiscellaneous - 100 ROSEMONT DRIVE 4/30/2018�z Date ............. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SSACMUS� � This certifies that .....1.L .:.f.l!,...`..``...... has permission to perform .. jr plumbing in t be buildings of /k\ ���' �3 /-7 at . ���/,'G�%���cy..... , North Andover, Mass. Fee. Lic. No..r�J� . ............................. . 4�� 4!�Z/ PLUMBING INSPECTOR Check # v6173 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING �'35 1-1 (Print or Type p ass. Date o 2v_ C4 _ Permit # f.WINJ Building Location Ugj Owner's Name a Z/A Type of Occupancy, :2t'-51 Dtr— New ❑ Renovation ❑ Replace 1 MIld' Pians Submitted: Yes ❑ No r-1 FIXTURES IN Installing Company Name "'A . 1meT e - '�JperM14T A? -G Check one: Certificate "CC ACmn) ' ❑ Corporation IYi E TW U EnJ , Al rA 01 rFVL/ [3_ Partnership Business Telephone �� Z - `i9 -7 1 I�'FIrm/Co. Name of Licensed Plumber Fe— T hi SAM Ai r9 req e INSURANCE COVERAGE: I have a current Il(ty 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 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: 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. � re o oen um r � L Title Type of License: Master % Journeyman ❑ CityRown IC License Number q 3 � 5 v V • • • • ■■■■■■■■■■■■■■■■■■■■■■■■■■ Installing Company Name "'A . 1meT e - '�JperM14T A? -G Check one: Certificate "CC ACmn) ' ❑ Corporation IYi E TW U EnJ , Al rA 01 rFVL/ [3_ Partnership Business Telephone �� Z - `i9 -7 1 I�'FIrm/Co. Name of Licensed Plumber Fe— T hi SAM Ai r9 req e INSURANCE COVERAGE: I have a current Il(ty 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 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: 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. � re o oen um r � L Title Type of License: Master % Journeyman ❑ CityRown IC License Number q 3 � 5 v v 14 r FORM U - IAT RELEASE FORM 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 law, regulations or requirements. ****************Applicant fills out this section***************** '�3APPLICANT: /��� 2AS 2 S ,,�w0Phone, LOCATION: Assess is Map Number. Parcel q Subdivision§-O(Z/A Audby4tl � �/�- Lot(s) Street St. Number 00 ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: zv `h• Date Approved 2 Conservation Administrator Date Rejected Comments 9D/ 4�oa Town Date Approved 7 C� Planner Date Rejected Comments Food Inspector- ealth Septic Inspector -Heal Comments Date Approved Date Rejected Date Approved - Date Rejected 'Public Works - sewer/water connect ions - driveway permit Fire Department Received by Building Inspector Date ffir �1 4 c v z < Cn rn 'T1 D � 1< D Z O �{ Z m T z P CA .0 c z CD O Cr d n� O v CL c��C CD o CO) -o CD 0 O O CD Cl) CO) S C) O CO2 LW d CD 0 CD CD y CD Pty 0 ` m m co �'O m n n� -. 3, Z Er CDy .« m a t o O y tD -� O W N O -1 ?COD o m n > > !� � c -1 cc 0. o oycc? wi CTE CN, t4to a �0 �n =r IC O � Wo m N w •U►, • N ami. ' D1 N C O .W :N41C d O O N i � O SO �m o :• w CA 00 - CO o40,COC. i Cl W 'o► +�ia m CD d ^� o w G ti d Y O g O G a � - C/) � rD O G rte., n z w O G '� C 0 Z w O G O G a w o. W C z C/)al D ^ y O O a ?C O d ci z 0 G9 0 c CERTIFICATE OF USE & OCCUPANCY Building Permit Number 185 Date NOVEMBER 5, 1993 THIS CERTIFIES THAT THE BUILDING LOCATED ON, 100 ROSEMONT DRIVE - LOT #8 (Type B) MAY BE OCCUPIED AS SINGLE FAMILY DWELLING W/2 -CAR GARAGE,IN ACCORDANCE LIBRARY ON REAR OF GARAGE, & DECK WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. CERTIFICATE ISSUED TO Toll Bros., Inc. Huntington Valley, PA ADDRESS Building Inspector l �o W l z � Z O !J z t i 1 C D r CD Z �CD O ' CL r IN �rt O CD� cr �Q n CD O _ y 10 CD 0 v CA 10d _ IN l'. d CD O rF� CD CD cn CD y r., kp�r !ls- Cs G cg-�o C = Q _•N O C N C, .o V1 Go Co. C o y m a n 0 3, mgMR.d-► m T CA O N O � o � ?co -0o!� C co o o � 0 ccDj CO) a CO � o.tcao5�� co o ? �_ = CD O N C7'O c CL O O 07 N Ncr O. d C N s C s I O CD N ' O Cc ;; O O � ow CD o rz CC/! 0 ir CD Co �•4 �'S_.. m r.� r r cm El ET� + rt �o W r O !J i •�ci . t i N 1 L r cm El ET� + rt �o W �o G ^ a^ �• QC G r� " rr �o0 G O G a^ 04 G 5 � CL rD rt (o b O �• CL tzY ►A F! 1 A '�L.ocation No. �r/-� Date NORTH TOWN OF NORTH ANDOVER of ? ^ 0� `• Certificate of Occupancy $ + + Building/Frame Permit Fee Also SSACMUSE Foundation Permit Fee $ Other Permit Fee $ S4 r Connection Fee $ J %% Water Connection Fee $ , +► TOTAL • { ��! ! ,* ,- ` Building Inspector �� Div. Public Works Location/—P') No. - Date��t; 3 N°RT" TOWN OF NORTH ANDOVER t 3?o'•,do 1. % Certificate of Occupancy $ n- v • > = ' Building/Frame, Permit Fee $ S sA�NU ACH' Foundatid ,P'elrm1t Fee S $ /6 Other Permit Fee- r Sewer Cpinection Fee Water qgn nect'on Pee $ �� TOTAL `�' �\ U � o A � �� �f►���s,`7 Building Inspector f' U ► Div. Public Works Location /Ob -No. + Date "GRT" TOWN OF NORTH ANDOVER 3?�.`t�0 0 G p Certificate of Occupancy $ w$ Building/Franie_P.ermit Fee FoundatiFn.Permit-Fee $ 5766 Other Permit Fee $ Sewer Connection Fee $ �G Z5� Water Connkcion F'�e? X93 TOTAL __-5yilding Inspector Div - u is Works k eft _-l;—_ N m C N W C N m i N m m C. i O m 0 O 9 2 0 0 A > v 0 O G� o m i r Wm Z v c m ?, t� > O T � 0 i m / J r _c r _c r 0 z 0 Z Z m z q 0; r n = znnn5m z Q c z > m O TI A ,Oi q r m m ° L1 41 G1 Oi O m uAi Vr� r N O 0 A z > 0 z 0 > v m 3 A m ti ° N n A i N r O 0 r > F> A D i i In 0 -� z N r z m r z " i z 'N-1 � . n � n x z 1 (w < D p CJ CD O zE V m tr M o � a��3 W 'S � � O a z i Q 0 0 4 , . V A > > m Q Q m m m m N - O r r W v m c c N n n z z N N N W g t N IfIl INEIF-91 C N N m to m C N m C N W C N m i N m m C. i O m 0 O 9 2 0 0 A > v 0 O A > r O= '� m A r Wm Z v W m N r c_ O T � 0 i > i s m r _c r _c r 0 z 0 Z Z m z q 0; r n = znnn5m z Q c z > 0 A O TI A ,Oi q r m m ° L1 41 G1 Oi O m uAi N r N O 0 A z > z 0 > v m 3 m ° f n A i N r O 0 r > F> A D Z v In 0 -� z N r z m r z " i z n N IfIl INEIF-91 C N N m to m C N m C N W C N m i N m m C. i O m 0 O 9 2 0 0 A 0 v 0 O A > r O= '� m i 0 O z z N O Z v a a o 0 Q O T � 0 i 0 U) 0 Z Z m 0 z Z m 0 Z Z m z q 0; r n = znnn5m z Q c z > 0 A O TI A ,Oi q r m m m 0< i Z O m uAi N r N O 0 v 0 O 0 A z CZ=° N 0 r > F> A D Z v J 0 M ra N r z m " i n x z o � � � O N IfIl INEIF-91 C N N m � m0 z � v N 0� r 3 1 i O m 0 M Z� G� 0 0 A A N 0 N m C A v = m M W O z O o Z v `, Jam' Q f Z m O T � N Z v 00 �I I I I I ix I—I W ^III I I I w u Z <0: N0 I' a o= aha 0uiIL .I 0 F- U. z 0 Ooa N Tl— Z50 Omu � U. z0a low oZ0: F0� rrj �a } i J� rt1 Wim 3: 6 to0,0 -i ell i S NQF r 8 Oz w wIL D rt 0:3 ZQN..� 0 Z = U WZ_ w N N FOS Z a� D u u 0 �I I I I I I—I ^III I I I I I I' Tl— = 8 Oz Z = O m I o u a Z z _ W u d III pl a� 3 T f N YC%w% _ Z< W0aoNe O f H V Y .� N W G O N m O LL 0 0 O OC p S Z NW Z W pJ.- v~i _OQ n°cuOZ°Nz9< LL p `v�p ~OZx 3 oew y U o N b__ Q x< x a- o J u Q < uix a�. u x N0 a xa° Z ° Z z o 0 LLa.z i 01 O uW c a 2u< O� � o N< ¢ O< mf Q ��YZN�HF t 0 F 0�� a 0 a W 0° SQoe�c90W Q Z O Z �ITrN Z 0 X z C < Z F N 0 ° Z ON F > Z Z W Y m m W O W �` 0 < N a< X: p w v l7 Z O� u 0 0 a 0� v j m O Q ; Z Z C7 Z O C� < :E �< <C < <.Z<< O N Q < O a Ir� y w C7 U i Y. .� U = <<W LL o ��°C N O J �O O °`°SNNOOOZZ°`ZZ <NN~ Z° N Z Z Z< LL U 2 "x Z_ LL oac0 Op N 0 N mN< LL W i W W O LL= i ON 0V 0V 0000 �N H I O[ N V V O Y N m a m a p< N Y Y U W O W O lig Tflil W ^C J t0 n F< O m a <= ZI S V O>« N N m m Ou < 3 N o0e 3 i 3 m= L o T '7G ml.*iiMuM REAR sCraACK FoR L.07-6 0 PEN 5 cE' ARE,q - <Co L arm 7 C �, f �f, 'kjil-Di Ni�Ei~�.F� �•E FLANUF LAND I N NORTH ANDOVER SHOWING "AS BUILT" FOUNDATION LOCATION DoT °8 R 0 5E MoNT aR. PREPARED FOR TOLL BFROTHEIRS, INC SCALE: 1"=40' DATE. J U NE 2 9. (g 93 ZONING DISTRICT : - RE SI DENCE -2-DIST .,o (PLAlYNE70 REc-rpEN-F(A1 ►)tEVELOPMEKjT'' N 0 T E PROPERTY --LINE DATA TAKEN FROM, A PLAN BY THflNiAS E, W E V E ASSpCIA-rr= !4 INC., DAT EC> APRIL 21, 135?- AND REVPSeD TO JUNE 2G) 1.992, I HEREBY CERTIFY THAT THE FOUNDATION ON THIS PROPERTY IS LOCATED AS SHOWN ON PLANS AND COMPLIES WITH THE ZONING REQUIREMENTS OF THE TOWN OF N©R7-H ANDOVER) MASS, IN MY OPINION, _THIS FOUNDATION IS NOT IN A FLOOD NA-ZrARD ZONE AS SHOWN ON THE U. S. D. H. U. D. FLOOD HAZARD BOUNDARY MAPS. THOMAS E. NEVE, ASSOCIATES, INC. ENGINEERS -SURVEYORS -LAND USE PLANNIERS 447 OLD BOSTON ROAD - U. S. ROUTE # 1 TOPSFIELD, MASSACHUSETTS /uc) ' I US e/V a U / -26,e;✓,' Location No. y 7S Date W11 -/a L MORT,y TOWN OF NORTH ANDOVER Of �"O ,•1h•G O - w F p + ; , Certificate of Occupancy $ �'�'•�•°'t` Building/Frame Permit Fee $ Foundation Permit Fee $ "Y,pv dee Other Permit Fee $ /�f 1(A TOTAL $ Check # ,+ 5 4i. 3 Building Inspector L,. s_ F— TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING � � M ;m BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissio22E for of Buildings Date CF VT'lAV 1 _ CTTIi TMV r%DM ♦ T7/►AT 1.1 Property Address: /00 �Se MO I/n/T 1.2 Assessors Map and Parcel Map Number Number: Parcel Number CH/L/S ,�/M 9 ✓Qv s c MUyiYT Name (Print) Address for Service 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Name Print Address for Service: Front Yard Side Yard SECTION 3 - CONSTRUCTION SERVICES Rear Yard Rapired Provide Required Provided R red Provided Licensed Constriction Supervisor: / S 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zone ❑ C' /�Tlrf%%T % TTATnTT�)__ ____ 1.8 Municipal Sewerage Disposal System: 0 On Site Disposal System ❑ 17—AAw" & - rnwr-K1 x vw1v1�,.KJrilY/AUTJff0KIGI�;D AGENT 2.1 Owner of Record CH/L/S ,�/M 9 ✓Qv s c MUyiYT Name (Print) Address for Service 07-q 3 3'Stgg ature Telephone 2.2 Owner of Record: Name Print Address for Service: Si nature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Constriction Supervisor: / S License Number /.0,0 pNoL—Yty'� _ C�O �.r c i/ �� Add ess Signature Telephone Expiration Date 603 flhly 95ff 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name /I Q.,, / • n_� /DO J /�i✓O� / S �iT�[' G /fes` . Registration Number Add Expiration Date Si nature Telephone T M X Z O 0 z M 90 0 r z G) cFrTrnnt d - WORKT.Rs COMPENSATION (KG.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 .......0 No...... X A -AX ire /" � h-Ei✓7' SECTION 5 Description of Proposed Work check au applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ T55ition 1�9 Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: A00 ah32- 4>E1 -k �6; Sn'✓5 u+//Vod%W bv/ Sri o €R., 2>412�2S .90-gc ANT. 7-t'M. SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant ,'0 1IAL USE (J�+II.Y, '.. 1. Buildinga� �� w (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 9 4D Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1 S q "V '001 N o E S / , as Owner/Authorized Agent of subject property Hereb thorizeto act on M ehalf, 'n Matters relativ o work authorized by this building permit application. 9/,t'i of AGer Date _tiwe SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, CSS-'Q-•'� 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 int e i atur f Own r/A ent Date NO. OF STORIES SIZE • ' BASEMENT OR SLAB ND RD SIZE OF FLOOR T VIBERS O � yc 2 3 SPAN DEVIENSIONS OF SILLS DM ENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING O XV 4% 1 ry 01r -f X t_2540 MATERIAL OF CIINMY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Town of North Andover Building Department 27 Charles Street North Andover, Massachusetts 01845 (978) 688-9545 Fax. (978) 688-9542 DEBRIS DISPOSAL FORM Na R T} Of�s�ec �6�4 �^ }y COCwL1CM1W1C■ 1 AT In accordance with the provisions of MGL c 40 s 54, and.a condition of Building permit# the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL cl 1, s150a. The debris will be disposed of in /at: —rr e-.rVT Facility locati 144awlltl X/// I S'k j na re of Applicant 9 Date NOTE: A 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 form is used to verify that all -necessary approval /permits from Boards .and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. /........................................................................... APPLICANT M C -,11—'�C.PHONE 72 V ASSESSORS MAP NUMBER 6 LOT NUMBER 20 SUBDIVISION LOT NUMBER STREET ��� Q sc/Uiou�T ��^ , STREET NUMBER PR b OFFICIAL USE ONLY RECO A, NS OF TOWN AGENTS 1 1 . ■ ■ ■ . ■ ... ■ ■ i ■ ■ ■ ■ ■ ■ ■ . ■ . ■ .. ■ • . ■ ■ .. ■ ■ • ■ ■ ... • . ■ .. ■ ■ .... ■ ■ .... ■ . ■ . 7 ■ .. ■ . ■ . ■ DATE APPROVED d C SERVATION MINISTRATOR DATE REJECTED COMMENTS DATE APPROVED TOWN PLANNER CON M ENTS DATE REJECTED DATE APPROVED FOOD INSPECTOR -HEALTH DATE REJECTED DATE APPROVED SEPTIC INSPECTOR - HEALTH DATE REJECTED CON*AENTS PUBLIC WORKS - SEWER ! WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPARTMENT DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR. DATE q ♦o 7,013 100ROSE DAVID FLEMING & ASSOCIATES I"D SURVJnWM W POND STREET FAx pat) 4n -o t 3s SMERM, MASS. (781) 279-0725 MORTGAGE INSPECTION PLAN This plan was not done with an instrument survey and is to be used for mortgage purposes only. DATE:- 10-23-00 SCALE 1 "= 60' / certify that this dwelling is located approximately as shown and conformed to the zoning bylaws of the Town of NO. Anodover. MA when constructed and is not located in a flood plain hazard zone. Deed & Plan Reference Essex County Reg. of Deeds T BOOK 3890 PAGE 55 PL. 12097 ROSEAfONT DRIPE 9 �� ✓iia {j�mnta�uuea� a�„/�vaac�uraella BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number. CS 064759 x.. Birthdate: 07/14/1969 Expires: 07/14/2002 Tr. no: 374 Restricted To: 00 SEAN C MINDES 41 DEVINE AVE G'i"»"`► LOWELL, MA 01852 Administrator ✓/e �omUmo�z.�seall! 0/'/4 0acl�ueeltc Board of Building Rquiations and Standards< . HOME IMPROVEMENT CONTRACTOR Registration: 128f47' Expiration: 05/11/2003 TYPe: Private Corporation MADISON CONSTRUCTIONCO, I SEAN. MINDES A1.DEVINE AVE _ LOWELL, MA 01852 x Administrator f Driver's Licensee 10744-69, 07-14-02 M 6'02" Diass S61196 1 Date of Birth Expires Sex Heigh class i g MINDES, SEAN C e 100 SANDERS AVE LOWELL, MA 01852 11 typical deck 2x8 joist dbl outside rim dbl 2x8 beam 10"x4' sonotube footings 2x12 stringers 5/46 decking lagged, flashed, & hung to existing typical rail section 2x4 cap and stiles 44 posts 2x2 balusters 4" o. c. ({� MADISON CONSTRUCTION INC. 41 Devine Ave. L:::=r Lowell, MA 01852 (G'M 454-8840 fax (G'M 454-6984 BILL TO: Howard Family 100 Rosemount DR. N. Andover, MA 01845 Estimate DATE INVOICE # 6/29/'01 167 P.O. NUMBER TERMS PROJECT ESTIMATE QUANTITY DESCRIPTION RATE AMOUNT remove 2 windows, reframe opening for new sliders, install 2 6' anderson perma shield sliding doors 2 labor and materials 1,600.00 3,200.00 deck approx 348 sgft to include: footings to code, 2x8 p/t frame to code, 5/4 x 6 mahogoney decking, mahogoncy rails and square balusters, primed pine wrap vinyl lattice skirt 200.00 200.00 348 labor and materials 17.00 5,916.00 161 stair to grade w/ concrete pad 150.00 150.00 13' stair to grade w/ concrete pad 75.00 75.00 move spicket 50.00 50.00 44 add chair rail 2.50 110.00 68 add shoe molding (customer to supply molding) 1.25 85.00 remove existing island counter replace w/ new (customer to suppy counter) clean up and debris removal this estimate does not include paint and or wood treatment. Thank you for your business. TOTAL $9,786.00 cov� Cl) m 7) 'm VJ 0 CA 10 ,0�7„♦ Z CD 0 �r o Co CL �• a� � O o p CL Q CD O ff-j CA CD .0+ O CO) d d O CA n' 0 CA d cl) CD O rM• CD CD CA O CCD 0 Q �1 b O z =� 0 z O �• HEL 0 ` C N �: m O m C' O y 0 d n � m Im •O•► m N T m n CL CD as y CD O O N p 114 0 � �m CD = O O © A 0 WN N N ^ �`U — oZyC N CS C � CA m to CA N C CD t0 O c° C° N :^ L , m to cra ' nCD ni n o C ~ trf CD O I O oGc 4) rA L IN O C WN N N ^ �`U — Q C• C O oo — CS y� CD m to CA N CD Cc, , u CD to w •� O ni n o C ~ trf CD O I O oGc Nl p7- O •a Y Y tz w O °�° ►� r e O. O 7 o d CD O 7C a m Da nom•' 4) rA L IN O C o C ~ trf 0.7 O oGc p7- fD O w tz w O °�° ►� r e O. O 7 o d rD , O 7C a t� 4) rA L IN O C w MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO 00 GASFITTING (Print or Type) NORTH ANDOVER Mass.Date D S �uilding Location / Ln) , s � ezv jo�� Permit # Owners Name_16 �, c OT 4rX • New Renovation Ej Replacement Plans Submitted p `_. IXT 1 cc Check one: Certificate Q Corp. Partner. Firm/Co. • V • Omni smommommmoommommom ... ■otmommommonomn0nSOMEONE MEN nommommossom Check one: Certificate Q Corp. Partner. Firm/Co. Business Telephone: Name of Licensed Plumber or Gas Fitter k/" -"1'A Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Eff0ther type of indemnity 0 Bond Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. Signature of owner/agent of property Owner 14 Agent 11 1 hereby certify that all of the details and information t 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 wW-be in compliance with all pertinent provisions of tho Massachusetts State Cas Code and Chapter 142 of tho General Laws. By Title City/Town: APPROVED (OFFICE USE ONLY) .. TYPE LICENSE: 1/�t C.r! zf •c°-� Plumber Gasfitter Signature of Licensed Master Plumber or Gasfitter Journeyman (- r O Z License Number r Date..................... NORTH nn T TOWN OF NORTH ANDOVER A PARMIT FOR GAS INSTALLATION This certifies that ..................... .................... . has permission for gas installation ..`....................... . in the buildings of .................... _ ................. . at .. . ... . ...............:.......... . North Andover, Mass. Fee... :. Lic. No........... .......................... GAS INSPECTOR WHITE: Applicant ,� CANARY: Building Ddpt. PINK: Treasurer GOLD: File