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HomeMy WebLinkAboutMiscellaneous - 115 BARKER STREET 4/30/2018 (2) 115 BARKER STREET 2101035.0-0001-0000.0 1 i {1 r Date.................................. .' NORTM t"'° '° ° TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ,SSACHUSEt This certifies that ..... .. ......................................... has permission to perform..,--4 'i wiringin the building of.............. .................................................................. at �_/A' �---.:Q'. ............. .North Andover,Mass. Fee`.S`s.............. Lic.No 17,92 C... /.............. ELECTRICAL/FNS?- r Check Al 5651 1rmWivlrilulyYrr.9"n yr trlrit,�,arit,nv uSl1 w��- �, DF,PAR71b1F1YP0FPUBIlCS4FElY a permit No. � BOARDOFFMPREVF1 MONREG.f,';FITTONS527(MR12:00 Occupancy&Fees Checked APPLICATIO OR PERMIT TO PERFORM ELECTRICAL WORK ALL WORK TO BE P ORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 /a (PLEASE PRINT IN INK OR E ALL INFORMATION) Dat r V Town of North Andover To the Inspector of Wires: The undersigned applies f a permit to perform the electrical work described below. Location(St tt&Num r) �� Owner or Tenant kv Owner's Address �- Is this permit in co ' ction with a building permit: Yes ED Nojzr (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps 4ol f�OVolts Overhead a Underground No.of Meters I New Service 2== Amps-2410/ Volts Overhead Underground No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work h No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total KVA No.of Lighting Fixtures Swimming Pool Above Below Generators KVA round and No.of Receptacle Outlets No.of Oil Burners No.of Emergency Lighting Battery Units No.of Switch Outlets No.of Gas Burners No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones Q Tons No.of Disposals No.of Heat Total Total No.of Detection and Pumps . Tons KW Initiating Devices No.of Dishwashers Space Area Heating KW No.of Sounding Devices No.of Self Contained Detection/Sounding Devices No.of Dryers Heating Devices KW Local Municipal Other Connections No.of Water Heaters KW No.of No.of Signs Bailasis No.Hydro Massage Tubs No.of Motors Total HP OTHER• ]iutmtceCovmw Aasi>atimthett+gtmarlet>tsda> sC�erle�llavus .< IhaNeaamatliahT0yhmaa=FbLyi rb&gQnjft0ppmbmsCamyqXcr9sq dfivalat YFSNO a IhaNesubmdtadvafidpmdofsamebthe0ffi=YES ff}vutEndrdWYES ppasemdr thetypecfoNwVby dtedingtheboot NARANCE BOND p t p ) D Est nrkdVairofEbcmeal Wcik$ WodcmSrmt kWad tD*ReQr-dyd Rough Final sig�taaunda�ie) of /, R MNAME rC IimwNa Signawo r>o � 1 Bt>SmessTdNa ./V// AIL TdNo. OWNER'SINS[JI2ANCEWAIVER;Iamlawaethat Iio=doesmthavetheirmnaloeoove a9s rldaleWvalatasmgtmedbyIvlassad>rMGeneralLaws andthatmy,%Vrhaecnftpwrd ffbcat mwa'rcsdnta p*mlett (Please check one) Owner Agent �- f Telephone No. PERMIT FEE$ Signature ot Uwner or Agenr i 1110 LvlvlwlVw yy d j"n yr jyltL ML,"ULIL. 110 DEPARMEN70FPUB UP—EM.11 Permit No. BOARDOFFIREPREVCMONRDGULAHONS5l7O RIZ*W Occupancy&Fees Checked APPLICATIO OR PERMUTO PERFORM ELECTRICAL WORK ALL WORK TO BE P RMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 /� (PLEASE PRINT IN INK OR E ALL INFORMATION) Dat Town of North Andover To the Inspector of Wires: The undersigned applies f a permit to perform the electrical work described below. Location(St t 8i:Num r) Owner or Tenan I Owner's Address J� - Is this permit in co ' ction with a building permit: Yes Q No (Check Appro ox) Purpose of Building `-fid lily` u onzation No. 1 I Existing Service Amps U61 /:20Volts Overhead a Underground o of%Ietets / / I New Service 2�� Arnps.2410�d Volts Overhead Underground No.of4ldeters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work h No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total KVA No.of Lighting Fixtures Swimming Pool Above Below Generators KVA ground and No.of Receptacle Outlets No.of Oil Burners No.of Emergency Lighting Battery Units No.of Switch Outlets No.of Gas Somers No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones Tons No.of Disposals No.of Heat Total Total No.of Detection and Pumps . Tons KW Initiating Devices No.of Dishwashers Space Area Heating KW No.of Sounding Devices No.of Self Contained Detection/Sounding Devices No.of Dryers Heating Devices KW Local Municipal Other Connections No.of Water Heaters KW No.of No.of signs Bailasis No.Hydro Massage Tubs No.of Motors Total HP OTHER- ES lnirartoeCo�Asanrtbthetec}mar�ofMa�adiu�GataalLaws IhaNeaa=1Lb atlt 1m=reFbLyind*gCarQlele CAr�aris�2nWegtrivalent YNO Iharesubrri"' 1va1dPw1cfs=lDd 0ffm YES ffyouharedrd®dYES, a en tteetNr fa by )[� RANME 1 1 BOM CrifIDt Y) LJ D* EluriabdValleefElectdcal Wodc$ WC&IOSlat kWecfimD*Rgz*d Ra* Film Sigle NAIn SieAmaldies A" rd I Lioat�eNa bq J A FIRMNAME i irnmsm Siwe - No Btsi{mTdNo. �7 �r � Jv � A1tTelNa q,ddr� W�It'sIIV.SURAN(�wA1VER;Iamawated>at Lioawaoesmtttavetheirmranecrnsa�orislCaleglrivalentastagtli[edbyNla�achGaletallaws andthatmy*aMernftpaniffkatimwanesftreg mmito (Please check one) OwnerAgent < � Telephone No. PERMIT FEE$ signatureof Uwnergen Jim(,UIVMUIV WLSALI H Ul' ' cHwEl i s Office Use only DEPAUAfflff0FPUB1,CS4MY Permit No. v p BOARDOFFNEPFNONSM7(M]2.W Occupancy&Fees Checked �..� APPLICATTONFOR PER1V� RM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCEWITH ELECTRICAL CODE,S27 CMR 12:00 kPLEASE PRINT IN INK OR TYPE ALL INFORMATIO Date Town of North AndoverTo the Inspector of Wires: undersigned applies for a permit to perform the electriw. Location(Street&Number) 1 S 13Q f ker S Owner or Tenant O Owner's Address 5 S cL fe c r Is this permit in conjunction with a building permit: Yes® No (Check Appropriate Box) Purpose of Building 31-,J Fc',f-7;(c f �� ���� S Utility Authorization No. _ Existing Service Amps �Volts Overhead E] Underground No.of Meters New Service Amps Volts Overhead 1:3 Underground No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work -'Pe-to 0 o 1-e No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total KVA No.of Lighting Fixtures Swimming Pool Above BelowGenerators KVA round round No.of Receptacle Outlets No.of Oil Burners No.of Emergency Lighting Battery Units wr„ f Switch Outlets No.of Gas Burners Rangesi No.of Air Cond. Total FIRE ALARMS No.of ZoneJ=r Tons DisposalsNo.of Heat Total Total No.of Detection and Pum s Tons KW Initiating Devicesf Dishwashers ` Space Area Heating KW No.of Sounding Devices No.of Self ContainedDetection/Sounding Devicesf Dryers Heating Devices KW Local Municipal Oth (dro Water Heaters KW No.of No.of Connections Signs Bailasis Massage Tubs -No.of Motors Total HP R- SMG (( UUMP C7 c, f— lD MC(I,- Imo%f CL,c:.� IC, r/c,e- / 1 Jr G Li4Ltlti",J If C Putsuarttr�thetaqttQarlls�GalaalLaws a amentLiabl7rtyIE==FbILyinchtdalgComplete OmngecrZmbstan6aleglriv k t YES ® NO a�rr>rt�dvalidptodofsmneoothe0ffice YES Ifyouhawd�ad¢BYES,pimseirtdCm[beMvofaAaaWby the box �•�..:1 F71 BOND p 0TH f7 ExpkonDate D r��L o� BM-,mdvah&ofE1xftxal Wotk$ UDSM h>Spe0mD*Rapc9ed Rough FSI NAME Pew "(;J�s C e c�,���� �PP�;ccs F r'y�JS LioawNa C d - ?lig cr Signaaae Busit=TeLl%. 1 7 raPz bl("-,(aJ�—,J � ,�fa�� /U H d 30 K Alt Tel rTa �0 3 (0 S' 9'2-ok 'ER'SINSLRANCEWAIVER,IamawatedxttheLimwdoesnothmedrirmaarloe oritsab :�tmysigtr�aeonttuspemritapplicalicinwai�esthistagtritana�t �� ale�asm�by ==WIaws 1 (Please check one) OwnerAgent r a*� Telephone No. PERMIT FEE$ IRJ lgna ure o wner Or gen �l �i Kt, • Location //,5- 3 A F � No. © � Date 16 - OV- I F NORTH TOWN OF NORTH ANDOVER 4L I IL Certificate of Occupancy $ Building/Frame/Frame Permit Fee $ � S t s,aMuse 9 i Foundation Permit Fee $ Other Permit Fee $ f TOTAL $ a S� F check # 17450 Building Inspector TOWN OF NORTH ANDOVER j BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOTLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER @ DATE ISSUED: SIGNATURE: Building Commissioner/InTector of Buildings Date Z SECTION 1-SITE INFORMATION O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: //S 64W,12- S �QSs ®/* u� Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area s Fronta e ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required I Provided Required Provided 1.7 Water Supply M.G.L.C.40.1-54) I.S. Flood Zane Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT m 2.1 Owner of Record Name Print) Address for Service 3457 Sig re Telephone Owner of Record: Nadie Print Address for Service: z M Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 i3.1 Licensed Construction Supervisor: Not Applicable Licensed Construction Supervisor: License Number Address Expiration Date i Signature Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ Compar`4ame m "'� Registration Number r Address Z i Expiration Date 1 Signature Telephone !!� s SECTION 4-WORKERS COMPENSATION(NLG.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.......0 SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Descri of Proposed Work: rk/S]'xd G Z f P4)AAZe-F,� 1C/OQ 1L 4T G SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction a 6/ 0 O 3 Plumbing Building Permit fee(a)X (b) 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 BUH DING PEFMT I, ��O/�j�/(� G• �p/� �iV as Owner/Authorized Agent of subject property Hereby authorize to act on My beh n all att s re ve to work authorized by this building permit application. v -Signap0of6Nmer Date SE ON 7b OWNER/AUTHORIZED AGENT DECLARATION + I' 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 ST2ND 3RD SPAN DM ENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS I>EIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 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. I a a Woman am was am■Enovnmaommomwas unman*man■■■soas Boa SEES amen now a■Nam so am■■am no APPLICANT c��' ti� ��/ PHONE '�7f— ASSESSORS MAP NUMBER 0 LOT NUMBER b0 SUBDIVISION LOT NUMBER nn i STREET 115 +7/� I Z_.�% STREET NUMBER �� �....m..m.—ms...aura.wow some ansoma a*Wawa.emago aeaaaSea aSomas ONE ass m's amama.iaa OFFICIAL USE ONLY �meammia■aaomfmao:our-ammnfinenamsmmemmamm*umuuaa■uminmmmmmamuaaammaeuo■■oam■■m■ i RECOAI}ViENDATIONS OF TOWN AGENTS � t DATE APPROVED C NSERVATION AD TRATOR DATE REJECTED 6 a COs f� 1 F le DATE APPROVED TOWN PLANNER DATE REJECTED COMMENTS I DATE APPROVED FOOD INSPECTOR-HEALTH DATE REJECTED SEPTIC INSPECTOR-HEALTH -DATE APPROVED DATE REJECTED CONQVff NIS PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPARTMENT DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR DATE Town of North AndoverNORTH 0 /? 6x6"Y Building Department o y 27 Charles Street North Andover, Massachusetts 01845 ?, 0h O ^. (978) 688-9545 Fax (978) 688-9542 4 `°`� ~'~�• ��SSgcHus���y I DEBRIS DISPOSAL FORM I 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 el 1, s156a. I I The debris will be disposed of in/at: 4/0 FLTN- 61f r ,01 S PGS 4/_ R F C,yc L l,v G /-,f 7?-5y/- Qd Facility location j /6 yo cp �s Signal re of Applicant Date ' I it � I NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. ' rR Air ! - C/Piv— 1 Y • 1 •1 J• YJe1 I� � sAkTO-RYy 1 .Hi&mucr6' 1• L.... .,,,... V. 1 1.. e r . . - i-•e - mLl N, 1 I.I.1.. 1tl 1 .y1•• '1 d far �•' i.JIT. 'Y. .y e 1 a LL1 •,a. c-. e. •1 I 1 j' •1. i. A. •i r 1� S —I M - - �I r..+■+r SL—a Y 1 r t 18 6:-D - -- 4.0 /1 p 7y ,dam re f 7 tauO—Ipm/ate/ tom• CRA 77/1 P- iz iz 00 l6 /ZWYy Z- /U 12. 00 LIVI �I G AR 'A 2 sq ft �I - -C2003 ti 16 I� 1 00 LL7l GE ^LcI / ' ° t (3.LI5 SGB Z-3 - ���E I to w36 t3 J9/iOZAia6X ;"A ®at 444 _ _ � g� / 4IXA) U�36 -3, � I r a r rA C44, FL` fw er Fvvr cc.t lre .-Lr �• c s --= - = FO � ti . Et-'J I 66 0 r 3 _. �E bI -- — — — — Fe — r E 9/-/�% i yG� 3y/ oc3i 9 8 aB 9/ UNRRCISTRRESD LAND MZ NUN=. 100277 DEED Hoax 2422 PAGE:238 A'1'PORNEY: LEONTIRE $ SHUB PLAN HOOIL• PAGE: LoT(s)•7 T METRO BOSTON MORTGAGE CO. INC. pLAN NUIM. 10121 OF 1985 titter JENNIFER & GEORGE H. WIGHTMAN PJGISTERED LAND AppUCANT. JOHN L. do MARIANNE GREEN RBG1NfRATlON HOOEi PAGE: DATE: 08/15/97 scALE: 1-=200' CERMCA79 OF Trfi& FLOOD HAZARD INFORMATION PLAN NUVM- LOT(s): FLOOD IUP ComwuN1TY NO.: 250098 ZONE: C ASSESSORS MAP PAM- 0005C DATED: 06/02/93 MAP:,4 3 ar mDC& PARCEL: MORTGAGE INSPECTION PLAN N/F BARKER,JR. 115 BARKER STREET, NORTH ANDOVER, MA • LOT 10 e • N/F BARKER,JR. ; I ca„ N/F JAYCO CORP. o= , Ar wAk A. o `� 7�9�`�`: LOT 739? LOT 8 3 0 136,025 S.F. O A LOT 10 '.'.. 2 STORY DECK• J �� DWEWNG� 572.97 ,No. 1,15 1 762.39' 20' WIDE EXISTING SEWER EASEMENT MORTGAGE LENDER mQ LOT 6 LOT 5 USE ONLY THIS IS THE RESULT OF TAPE MEASUREMENT, NOT THE RESULT ������� j OF AN INSTRUMENT SURVEY AND IS CERTIFIED TO THE TITLE INSURANCE COMPANY AND ABOVE LISTED ATTORNEY AND LENDER. & a E� LNC 130 WEST STREET, WALPOLE, MA 02081 THERE ARE NO DEEDED EASEMENTS IN THE ABOVE REFERENCED TEL:(800)287-8800 FAX.:(508)668-4512 DEED OR ENCROACHMENTS WITH RESPECT TO BUILDINGS SITUATED ON THIS LOT EXCEPT AS SHOWN. TUC I APATIA►1 AC TIIC nWCI 11\I/• Cu/1W\I 11ACC MAT CAI l WI TLII\I �eu�rar Town of North Andover A y Building Department 27 Charles Street �o North Andover, MA. 01845us� �ss�ati �-0 SACI, `�14ar D. Robert Nicetta Building Commissioner (978) 688-9545 (978) 688-9542 Fax I HOMEOWNER LICENSE EXEMPTION Please print. q L DATE d JOB LOCATION / V Number Street Address Vap I lot "HOMEOWNER 0 r� 2 6f 313 �) � Name Home Phone .Wor�hone PRESENT MAILING ADDRESS /t/1 A140,14A City Town 8tate Zip Code The current exemption for"homeowners"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 j 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. I 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 NORTH TOV M ® Andover No. 0/0 ' n0 Y 0 _�--= :0 dover, Mass.,- 13 e? T D L KE If, COCMIC ME W IC AK ' %,d DRATED AP�t�� 7 S u ` BOARD OF I iEAI.TH j Food/Kitchen Septic System PERMIT T BUILDING INSPECTOR THIS CERTIFIES THAT..... �.. .!V...... ......I.�l4 �� , N N C� ......................................................................... .................... Foundation A.R s� has permission to erect...y ......... buildings on ......1.1...��.......�.... ......K�.R...................................... Rough t , 1��r�r N v% {�1S� 0% I a 4 Chimney N Z �w tobe occupied as.... .............r........ .......................................V....... ................................................................................... provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the spection, Alteration and Construction of Buildings in the Town of North Andover. c3 5 j l PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION ST TS t Rough .... .............. ..... ..... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burnet Street No. SEE REVERSE SIDE Smoke Det. Date. ,� C9 rl NORTH TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACHUSE� This certifies that ?. . . . . . . . . . . . . . . . has permission to perform � "--�. . . . . . . . . . . . . . . . . plumbing in the buildings of . . , „ ... ... . . . . . . . . . . . . . . . . . . . . . . . . . . r at . .J!- . < . . . . . . . . . -?YI . . . . . . .:1. . . . ., North Andover, Mass. Fe 611f . .Lic. No. .� -y! �,� . PLUM91tYPNSPECTOR Check # �.�� Z/ 6405 i MASSACHUSETTS UNIFORM APPLICA ION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS F p Date Building Location IJ Wci�- Owners Name �l� lJ�/'e�� Permit# 1&4, Amount Type of ccu anc New Renovation Replacemit nt Plans Submitted Yes ❑ No ❑ MPRES ri sisasviC S�IVIIVI' 1ST FIDQt 1 � aII)HIDQt -4n NJ" 4M Hi" sm FlaR PII HDM 7M R" SII3 >E j" (Print or type) _ Check one: Certificate Installing Company Name SC) t�$ P�UI�, El Corp. Address � 62kA 7VC( Y1A 41�usmess a ep one . Name of Licensed Plumber: _1� I54�- Insurance Coverage: Indicat the of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ i Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance signature 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 installation performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusethapter 142 of the General Laws. By: Signature of icenSeU r1UMDer Type Plumbing License Title ;10 L/S ricense Numoer Master Journeyman APPROVED(OFFICE USE ONLY I A Location/ No. U _ Date kOftTol TOWN OF NORTH ANDOVER Certificate of Occupancy $ x ; ; Building/Frame Permit Fee $ S Foundation Permit Fee $ s�cHust Other Permit Fee $ � r Sewer Connection Fee $ Water Connection Fee $ i TOTAL $ 1 O Building Inspector Div. Public Works s' Location j No. Date I NORTN TOWN OF NORTH ANDOVER 0� tao •� so Certificate of Occupancy $ p I } Building/Frame Permit Fee $ i CMUs t� Foundation Permit Fee $ E tU Other Permit Fee $ i Sewer Connection Fee $ Water Connection Fee $ R TOTAL $ 6ti i i r Building Inspector i Div. Public Works L ,51REZ ->r- o K i PXRMIT NO. APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 MAP Y-4O.0y;'/1 I LOT NO. J/� 7 2 RECORD OF OWNERSHIP (DATE (BOOK 'PAGE — ZONE 77 1, SUB DIV. LOTNO.y I A. LOCATION /!,�} 65,e S/. Ae/40 PURPOSE OF BUILDING _�`` OWNER'S NAME �U�%!!,/C�/ /' /' pNO. OF STORIES SIZE OWNER'S ADDRESS //-<' "RUER Si oV, X6/AQ711ja BASEMENT OR SLAB - ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME 7 ©A/2 L I� � - SPAN _— DISTANCE TO NEAREST BUILDING "9D/ DIMENSIONS OF SILLS --_ DISTANCE FROM STREET r n SO � POSTS L�X� DISTANCE FROM LOT LINES – SIDES /D/ REAR GIRDERS �y / �l y ri/ �X Q' �(/D AREA OF LOT „ 5- S !/ FRONTAGE HEIGHT OF FOUNDATION /1 THICKNESS IS BUILDING NEW SVd ,L.6 �e sSIZE OF FOOTING /'/ / X �I IS BUILDING ADDITION y/!S _l�C� p D(IF(=YJ MATERIAL OF CHIMNEY IS BUILDING ALTERATION r f_ fl /� IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODEV�S IS BUILDING CONNECTED TO TOWN WATER y�O BOARD OF APPEALS ACTION. IF ANY / IS BUILDING CONNECTED TO TOWN SEWER �0 IS BUILDING CONNECTED TO NATURAL GAS LINE y 3 PROPERTY INFORMATION INSTRUCTIONS LAND COST �! SEE BOTH SIDES EST. BLDG. COST / PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT. - EST. BLDG. COST PER ROOM PAGE 2 FILL OUT SECTIONS 1 - 12 SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE .FILED BUILDING INSPKCTOR dIGNAT E OF OWNER OR AUTH IZED AGENT F E E OWNER TEL.N PERMIT GRANTED CONTR.TEL X 19 CONTR.LIC.N H.I.C.d - a TOWN of NORTH ANDOVER Ar^FIDAVIT ,-.. Ebre lUrGmtractrr Iaw aRaimmt m, Permit AaAicatirn to c: 142-,A regsrzs that tip ' alb, , ,,`ramc,al, d®nlittrn, cc o rrs�� of an aiiityu to aay pce- easter ' � - irg ca�nrg at: lest un h.ct not m�dmfar daelli�g zm. s---CC to s==X!es �� are ad��t b soh Lsd :e cr bLr'be.dam by � Vis, cin , ala-9ath rens. I�rpe of Wor!c: �Q Y Est.. Cost X260 Address of Work Owner Name:—' Date of Permit Application: I hereby certify that: Registration is not required for the following reasor,(s): Fcr office the a- y Work excluded by -Iasi. mit No.: r. Dara . . Job tinder $1,000 Fh,ilding not owner-occupied .: : Owner.n''l i rid oma Permit (specify) Notice is hereby given that. OWNERS -PUUJ NG T=R CWN PEPMIT OR DEALING W= UNREGISTERED CIJNIRACMRS_ flDR APPLICAHIE HOME IMFROVEMR?T DARK, DO NOT HAVE ACCESS TO UE ARBTTRA- TION PROGRAM: OR GUARANTY FGM UNDER ICL c. 142-A- TION hereby apply fora permit as the agent of the owner: Date Contractor Name Registration No. OR. Notwithstanding the above notice, I. hereby apply for a permit as the owner of the above property : Dat er Name OR Town of Andover No. 170 over, Mass, 19 LAKE ;C.CHICNEWICK E C) BOARDOF HEALTH Food/Kitchen PERMIT T D Septic System k THIS CERTIFIES THAT...... BUILDING INSPECTOR .................................................... Foundation has permission to erect.......Ar.0.41.76PAJ.. buildings on ...)*...I..(..S......13-A.R.-K-e-P.................r................... Rough to be occupied as................................... C. ....................................................................I......................................... Chimney provided that the person accepting this permit shall'in every respect conform to the terms of the application an file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUCTIONT ELECTRICAL INSPECTOR Rough .................. ... ..... ....... ....................... Service BUILDING �i&6i Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or -Dry Wall To Be Done FIRE DEPARTMENT Until Inspected. and Approved by the Building Inspector. Burner Street No. Smoke Det. FORM U - LOT RELEASE FORM i INSTRUCTIONS: This form is used to verify that all necessary approvals/per6tts from ; Boards and^Apartments having jurisdiction have been obtained. This does not relieve F, the applicant and/or landowner from compliance with any applicable or requirements. APPLICANT FILLS OUT THIS SECTION APPLICANT L . (_-, i2 F/=2/ PHONES 7� ` LOCATION: Assessors Map Number PARCEL I SUBDIVISION LOT(S) i I _ STREET_ ST. NUMBER 4: *'***"OFFICIAL USE ONLY RECqrJIfNDATIONS OF TOWN AGENTS: s" CONSERVATION ADMINISTRATOR ' DATE APPROVED o2 j DATE REJECTED R COMMENTS (S qd k� TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS M ' FOOD INSPECTOR-HEALTH QDATE APP APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS j . PUBLIC WORKS -SEWERIWATER CONNECTIONS DRIVEWAY PERMIT • FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE,,_,__ 74- ir r! �� �✓ R�� fir.,✓' r 1110.11 r' fr r to t -:zz 41 11-7 ZI ,,, -- ' '� � 1 { r'r oG � , u rA / 45.4_5 j � � LOO Q ,� 0 ... Town of North Andover t MORTM 1 OFFICE OF o?o+`•`• °oma COMMUNITY DEVELOPMENT AND SERVICES ►- - 146 Main Street North Andover,Massachusetts 01845 WH LIAM J.SCOTT US Director SWIMMING POOL REGULATIONS NOTE: PERMIT CARD SHALL BE POSTED IN A VISIBLE AND ACCESSIBLE LOCATION FOR OBTAINING THE VARIOUS INSPECTORS' SIGNATURES. ALL SWIMMING POOLS IN EXCESS OF 2 FEET IN DEPTH ARE REQUIRED TO HAVE A BUILDING PERMIT AND CONFORM TO THE FOLLOWING REGULATIONS: 1. ELECTRIC: An electrical permit must be obtained prior to an application for a Building Permit to install a pool. 2 . ZONING: Pools shall be located to the rear of the front building line of the house and no closer than 10 feet to the side or rear lot line. 3 . HEALTH: a. Location from subsurface disposal system must be approved- by the Board of Health. b. Semi-public and public pools must have plans approved by the Board of Health prior to construction and must also have an annual operating permit from the Board of Health. 4 . SAFETY: Pools .must be enclo-ed by a suitable wall and fence, at least 4 feet in height with self-closing and- latching gate that meets the approval of the Building Inspector. * No water allowed in pool until fence is erected. Pool cannot be used until inspected and approved by the Electrical Inspector and Building Inspector. *Fencing on corner lots must be erected 20 ft. inside lot line. FEES: ELECTRICAL PERMIT - $35.00 BUILDING PERMIT - 6.50 per thousand on estimated cost; 35.00 minimum permit fee :1 D. Robert Nicetta, Building Inspector BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 UNREGISTERED LAND Fay x» too277 DEED Booz: 2422 PAGE:238 ATPORNEY; LEONTIRE & SHUB PLAN BOOK:__ PAGE:- WT(s)•7 METRO 0 BOSTON MORTGAGE CO. INC. . pLAN x; 10121 pg 1985 ons JENNIFER & GEORGE H WIGHTMAN REGISTERED LAND APPLICANT: JOHN L. $ MARIANNE GREEN DATE; 08/15/97 REGL41'lliA1'ION BOOK: PAGE: SCALE: 1'=200' CE>;TB+'ICATE OF TM& FLOOD HAZARD INFORMATION PLAN N01MER: LOT(s): FLOOD W COIOIUNITY NO.: 250098 ZONE: C ASSESSORS MAP pANEL: 0005C DATED: 06/02/93 IAP: BLOCK: PARCEL: MORTGAGE INSPECTION PLAN N/F BARKER,JR. 115 BARKER STREET, NORTH ANDOVER, MA �ti by LOT 10 eY� N/F BARKER,JR. 45 N/F JAYCO CORP. w ,� `� `� ��9�`7`• LOT LOT 8 3 ;:S 136,025 S.F. Zr LOT 10 �^ 2 STORY DECK •' DWEWNC� 572.97' ,No. 1Ls �1 762.39' Y 20' WIDE EXISTING SEWER EASEMENT Q LOT 6 , LOT 5 MORTGAGE LENDER � USE ONLY I THIS IS THE RESULT OF TAPE MEASUREMENT, NOT THE RESULT ��jLA A����.� �. RS OF AN INSTRUMENT SURVEY AND IS CERTIFIED TO THE TITLE i INSURANCE COMPANY AND ABOVE LISTED ATTORNEY AND LENDER. &&%OMTF,S INC ! 130 WEST STREET, WALPOLE, MA 02081 THERE -ARE NO DEEDED EASEMENTS IN THE ABOVE REFERENCED TEL.:(800)287-8800 FAX.:(508)668-4512 I DEED OR ENCROACHMENTS WITH RESPECT TO BUILDINGS SITUATED ON THIS LOT EXCEPT AS SHOWN. _ _ THE-LOCATION_OF_THE-0WE.LLIN_G_.SH-OWN-DOFS__NOT_FALL WLTHIN 1�4—ltlT Location No. 6v Date a. o� No"':,� TOWN OF NORTH ANDOVER C? �, . 0� p Certificate of Occupancy $ Is Buiidin /Frame Permit Fee $ Foundation Permit Fee $ s�CHU 01her Permit Fee $ �-- YU C Sewer Connection Fee $ Water Connection Fee $ TOTAL $ Building Inspector I6:14 ` FAIR Div. Public Works 06L APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1 MAP 4-40.©3SLOT 1 2 RECORD OF OWNERSHIP IDATE BOOK ;PAGE — ro I NO. �s ZONE SUB DIV. LOT NO. LOCATION PURPOSE OF BUILDING ! /TTl[C�lI(IL/( �(/, /T J �/ �/(� �0�L, /T/J f•- C'/'- OWNER'S NAME s�h/y G• /' ��'�� NO. OF STORIES SIZE OWNER'S ADDRESS S% BASEMENT OR SLAB ARCHITECT'S NAME / yJ/7/C/C K SIZE OF FLOOR TIMBERS IST 2ND 3RD 13UIJlZ' BUILDER'S NAME PdCL ��5�✓/LLf�T�0�1/ �y �� �© SPAN IU 1rT/tJF�EA/�!F DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS O '�-CI` !i DISTANCE FROM STREET ./L 7 COQ POSTS DISTANCE FROM LOT LINES —SIDESSo, REAR •' GIRDERS AREA OF LOT / '6�S �+ FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW I J SIZE OF FOOTING % IS BUILDING ADDITION) �D MATERIAL OF CHIMNEY IS BUILDING ALTERATION �O IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE d INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST �lies SEE BOTH SIDES EST. BLDG. COST PAGE i FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM PAGE 2 FILL OUT SECTIONS 1 - 12 SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS - MAY 3 1998 PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DAT LED IIIIIJILDING INBPKCTOR SIG TURE OF O NER O AUTHORIZED AGENT '�'�/ E E OWNER TEL.N - -[/ 3�/ PERMIT GRANTED g CONTR.TEL# 19 CONTR.LIC.# H.I.C.# - i A V I TOWN of NORTH ANDOVER AFFIDAVIT EJ=e apZwsi� Culactnr Ian W Fit Aq)iiratirn tI,c. 142 A re4=es tit t3�e ' ali�atiflo, � ranal, d=jitirn, cr carer r. cf an arjjj tirn to any pL eds a"rs bYL irg ding at lEest a-e hit not Sze tea for Aa-11 n ants...cr to stu:jj� Oddi are adjacent to st-di resi i re or bmJdJ 'be dzue by rEgisted a3at==m, waw cin ecq)Esrs, alag wth od-JEr; Type of Gloric: C Est. Cost Andress of Gloria 271 Owner Name Late of Permi. _li.cation: I *hereby certify that: Registration is not required for t,`ze followrirag reasor(s): Fcr of�.ibe Czly Work excluded by law - Job under $1,000 =lite. Building not awner-occupied - _ ner pulling" owes;t Ow Other (specify) Notice is hereby given that: MFRS PUL LING T� N-N PERM= OR DEALING WITH UNREGISTERED CONIRACMRS'" E FOR APPLICABU iKX I q?OVR_ENr WRK DO NOT HAVE ACCESS TO UE ARB=A- TION FROGRM OR GANTY FUND UNDr`R ISL c_ 142A_ UAR - 5ig)1 ur'� pe--Ities of perj zy: I hereby apply for "a „permit as the agent of the -owner Date Contractor Name Registration No. OR: Notwithstanding the above notice , I hereby apply for a permit as the owner of the above property : Dae 0 er Name a 41JNNEMAN %/I GTOR. JUL-03-97 TH U 12 : 18 PM / :31vo v idvw%01 03sn 38 of l 0O, 09 s j :giYoS AlNO 9350.1H 0 3�J,�r 10 1 I "ON NvIa a�'� �►No�,� 031 d00� 6 9Z ,319Vd i's�� f, s c -�tooa _ ld NOf13USN1 3JdJ1�30 �� LllL uu Nd SN3unsm 3'11110Nd rdv+1M m ivwZ g 3N101 7l�i�nN 3�0�� � �� a 3 J►OQfr 3 e sim3l aao R7r�p A� �w1a atlta altsllt��t+1►11n1 et NRONt 00011 O*�tOrlfi tMl M�O1lt�e110�1 /1 a IDulevM>111 1A11 aAafll�tlNaffll 1 rtsr OMRrM+oA t+1r1 OMM102)till OL 0+1ltl01*o7 • f0 t1117wa+ ■r+A a3l�Odf~� Q� iawAltsnlvi+f sstlu af1�iA or.ataMnt 4 APIIV12 +�neuo iMa wo oit 001 rr SAwiwMarolf7naf Orr SaNiwt+rt'So+aaens»•eMr'tti�wtri tMa 0iMA1Vi7+A11M 10,i0 tl�if to waa •tws worA trot twe�rHa tttl M�Qtits to�iorns� Slto�lln�wo�lmrt+� I , w Oa 0»uler 11 It't�n11""W "ri01f!L)1110 7111 a000'Ai4O illOAtlnA 130�O1MOA�Ol eliA t�OMOMf Owf�I�rM t lOM tt fMl 11011 it pal*of-114"1010M11t1tle A ►L94-CY9 3NOKd3l3S- 43*N3liMd1.SS 1►193uls Novi woo - �NI'S31tl1ZOSNOS'1►3S -I- A 01 mi k �V s c:, � `�.. � •r two n� S _'cr1 r r2 AL - �o /Z/< c-� ' FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and _ oa ds a _,partments haven jurisdiction have been obtained.9 J ne . d This doe snot relieve the applicant and/or landowner from compliance with any applicable or requirements. '"APPLICANT FILLS OUT THIS SECTIONktAm APPLICANT-az-A m F rti PHONE�fj,;�/ LOCATION: Assessors Map Number PARCEL j l SUBDIVISION LOT (S) 1 STREET %R r lZ S/ ST. NUMBER OFFICIAL USE ONLY I � • RECO NDATIONS OF TOWN AGENTS: ' I 1 CONSERVATION ADMINISTRATOR DATE APPROVED c2 DATE REJECTED COMMENTS (S q6 , � a Al IGo o-e TOWN PLANNER DATE APPROVED � DATE REJECTED COMMENTS i i FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS -SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE C) ���_ F tAORT Toivn o _ - over No. )6 _ . _ m * - - 177 -r - LAKE dower, Mass., 19 A 94.COC M ICH EWICK iY�• �S A;rEo pP �J fG BOARD IDF HEALTH PER.M IT T Food/Kitchen Septic System T BUILDING INSPECTOR THIS CERTIFIES THAT..............................................V.....,.........:... ..R. .a.14 ............ ........................................... ............ Foundation i has permission to erect............ .. ..�............. on-...).... ........8 . ...........S=............ Rough to be occupied as 1Y.40 - ...z-..s` .............. ............................... Chimney p ...:...... ....... provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION T S Rough ................. ..... t. ............................................... Service B LDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. 11 i Electrician Wiring Unlimited ROGER AMARAL Lic.#N.H.9235J (603)898-9658 Lic.#MA 34647E 'w PROPOSAL ELECTRICAL SERVICE ROGER H. AMARAL 19 DANDRIDGE AVE SALEM,NH 03079 (603) 898-9658 PROPOSAL SUBMITTED TO PHONE DATE J-00, i4/ STREET JOB NAME _ CITY,STATE& ZIP CODE JOB LOCATION ARCHITECT JOB PHONE We hereby submit specifications and estimates for: l�p " We Propose hereby to furnish material and labor-complete in accordance with above specifications,for the sum of. Payment to be made as follows: dollars v Authorized Signature Note: This proposal may be withdrawn by us if not accepted within days. ACCEPTANCE OF PROPOSAL: Signature r Signature Date of Acceptance: I � I '� i T Date.... .... ......... w "ORT" to TOWN TOWN OF NORTH ANDOVER p PERMIT FOR WIRING s _ r K to ,SSACMUS� This certifies that .....�2,�� -.:,4 .........t-.:�.-<'.......................... has permission to perform ��- ' - �` wiring in the building of.... .x........'"I-V**"***"""***"**,*******.............................. at./ ........P.............16....... ..................................,North Andover,Mass. Fee',-. .. .... Lic.Not r.'...! .....�)...... 1-�.�!���........................ ELECTRICAL INSPECTOR Check lig- -- 55G9 I HE(,UMMUIV WEAI:LL1 UP' JACHUJt;l l s Office Use only DF.PAKIAIDVT'OFPIIB SAFELY Permit No. BOARDOFFIREPREVF1V170NJ ONS-527( 12:QD a, Occupancy&Fees Checked ..��. APPLICAT70NFOR PERNIlT T 1'ERFORMELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCEWITH T MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 j (PLEASE PRINT IN INK OR TYPE ALL INFORMATIO ) Date Town of North Andover To the Inspector of Wires: The undersigned applies for a permit.to perform the electrica ork described below. Location(Street&Number) 11 S Owner or Tenant 0 G-/ Owner's Address l l 5 c-r K e.r S Is this permit in conjunction with a building permit: Yes® No (Check Appropriate Box) Purpose of Building 3�A IC F<�-f-7 pWe- l/,`� 9 Utility Authorization No. Existing Service Amps �Volts Overhead Underground a No.of Meters New Service Amps / Volts Overhead Underground No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work Re-oo 0C._+-e- /��� f-, c No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total KVA No.of Lighting Fixtures Swimming Pool Above Below Generators KVA round ground No.of Receptacle Outlets No.of Oil Burners No.of Emergency Lighting Battery Units No.of Switch Outlets No.of Gas Burners No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones Tons No.of Disposalsj No.of Heat Total Total No.of Detection and I Pumps . Tons KW Initiating Devices No.of Dishwashers i Space Area Heating KW No.of Sounding Devices ( No.of Self Contained i Detection/Sounding Devices No.of Dryers Heating Devices KW Local Municipal Other Connections No.of Water Heaters KW No.of No.of Signs Bailasis No.Hydro Massage Tubs No.of Motors Total HP OTHER" S MG I t}UMP Our 16 Mcc GGe_ k-t-f cl,,� hts.ranoeCovetage.REMIlDdEmWmicMdMamdusoZGax2WLaws IhaNea=utLiablhtyll>Sur =PblicymkiJTCornplete CoNaageoriLswbgm alt Y YES © NO IbaNesubni,wdvalidptoofofsm etothe0ffiee YES Yy mhavectadodYES,pleaseindic*thetypeofcoveaWby dtx%gthe box. KWRANCE BOND r7 GIHER M (PleaseSpcciy) EViratimDale O l)ec d� Estirr&d VakrOfEbcbcal Wolk$ WodctnS4rt h>SpearorlD&Regt� Rct# Final Signed underTr Pt3taldes ofpujtuy RRMNAME pp &r�,Jurl�s t I ec�-r"-C,,.l / �ea F�o�s lizrwNo. Licerme U K s�LfN u PA Signalule ���1� _ ���� � L No _ ��� c1 .l /e - - BusitmTeLNo. j 77c/ Z/O? A 1frr�t Peyi`� [�JV�-J �t�/ f4� N 0 K At Tel.No. O 3 6 a S 912-Ok OWNER'S INSURANCEWANFE;IamawarethattheLxffwdoes nothavetheirmmmmv$ageoritsstbsUrtWopvalernasogmedbyMassadxiceasGu>ffalLaws anddiatmysignahueonthispemlaapplicatimwaivesthistegt m1elt (Please check one) OwnerED Agent .o*% Telephone No. PERMIT FEE$ Signature of Owner or Agent