HomeMy WebLinkAboutMiscellaneous - 130 MARIAN DRIVE 4/30/2018 (2) / 130 MARIAN DRIVE - _ �-
210/107.C-0053-0000.0
I
Datel.. f!2 o................
�NowrM,
TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING
auj • •
88�CHU
(6W
Q46 Q
Thiscertifies that ...................................................................�............... ................................
has permission to perform . .(t�...(? ......de.lez ... ..................
wiring in the building of.............. ,..1 "U
. ...................................................
at ..........�. C7 .H +/�.- `��'��— o Andover,Mass.
........,.... .............
Fee....5.'�>............Lic.No.[W1.7.. ... .. .. ... ....
ELE CAL INSPECTOR
'Fee
11850
A Official Use Only
Commonwealth of Massachusetts y
Department of Fire Services Pernut No'.
a
BOARD OF FIRE PREVENTION REGULATIONS OV 1 0cy and Fee Checked
� j (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),5 CMR 12.00
(PLEASE PRMTWINK OR TYPEALL INFORMATION) Date: l a 12
City or Town of: NORTH ANDOVER To the InsActor of Wires:
By this application the undersign gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) J f )A/L� v Gv
Owner or Tenant + c,1C- l9 Telephone No. 7 ?3Rv
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: `'
Completion of the following table may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans VG
of Total
nsformers KVA
No. of Luminaire Outlets No,of Hot Tubs erators KVA
No. of Luminaires Swimming Pool Above ❑ In- ❑ o mergency lg tmg
7 rnd. rnd. er Units
No. of Receptacle Outlets No.of Oil Burners T'of
E ALARMS No, of Zones
No. of Switches No.of Gas Burgers Detection and
InitiatingTotaDevices
No.of Ranges No.of Air Cond. Tonsl No.of Alerting Devices
No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
Totals: ...................
Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other
Connection
No.of Dryers Heating Appliances KW Security Systems:*
No.of Devices or E uivalent
No.of Water KW No.of No.of Data Wiring:
Heaters Signs - Ballasts No.of Dvices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
No.of Devices or Equivalent
y OTHER:
Atiach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURA-PABOND ❑ OTHER ❑ (Specify:)
t certify,cinder the pains and penalties ofperjury,that the information on this a plication is true and complete.
FIRM NAME: . 2SYcv3 c C �' A �- LIC.NO.:
Licensee: G' v Signature LIC.NO.:l `l
(Ifapplicable, ter "ex t"in the license num r e.
F �` - Bus.Tel.No..6gs 2"i R/911
Address: �' -b,fu-) 04 03b /J Alt.Tel.No.:_�'r 979`103
*Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner'sagent.
Owner/Agent
Signature Telephone No. PERMIT.FEE: $
❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c.143,§3L,the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed ,
on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§ 32,an
electrical permit shall be issued to the person,firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L.c.143,§3L.
Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written
application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With
limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was
"in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012.
❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑
❑Permit Extension Act—Permit/Date Closed:
Trench Inspection
Pass 0 Failed Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
SERVICE INSPECTION:
Pass 0 Failed Re-Inspection Required($.) ❑
Inspectors Comments: .
a
Inspectors Signature: Date:
I
PARTIAL ROUGH INSPECTION:
Pass F?1 Failed 0 Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
ROUGH INSPECTION:
Pass M Failed Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
FINAL INSPECTION:
Pass 0 Failed 0 Re-Inspection Required($.) ❑
Inspectors Comments:
I
Inspectors Signature: Date:
DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com
ryCXThe Commonwealth of Massachusetts
UfDepartment of Industrigl Accidents
Office of Investigations
600 Washington. Street
Boston,MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organi'zationgndividual): Coa.�,�4-', SVC
Address'
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: Typo of project(required):
1.[_1 I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.F] I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and'have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9, ❑Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its
equired.] officers have exercised their 10.E]Electrical repairs or additions
3.❑ IT a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself. [No workers'comp. c. 152,§1(4),and wehave no 12.❑Roofrepairs
required.)' insurance re employees.[No workers'
� 13.0 Other
comp.insurance required.]
'Any applicant that checks box#1 must also fill out the section below showingtheir workers'compensation policy information.
1 Homeowners who submit this affidavit indicating they Are doing all work and then hire outside contractors must submit anew affidavit indicating such.
tContractors that checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. �S
Insurance Company Name%
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: )_�56 �' �� 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 requiredunder 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 maybe forwarded to the Office of
Investigations of the DIA-for insurance coverage verification.
X do hereby ce nd t al penalties ofperjury that the information provided above is true and correct. -
L
Signature:
Date:
j Phone#:
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other - -
Contact Person: _ Phone#:
a
Information and Instructiolms
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract ofhire,•
express or implied,oral or.written."
An employd is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced.acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if '
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the r
members or partners,are not required to carry workers'compensation insurance. If an LL C or LLP does have
employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial
Accidents for confirmation-ofinsurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only.submit one affidavit indicating current
policy information(ifnecessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or'-permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
Tho CornmonwealthofJ\4_assa h1MMtts
Depaftent ofIndusidal.A,ccidonts
office OfIuvestigatlous
604 Washington Street
Boston}MA 0. 111
TO #617-727-4900 oxt 406 or 1.-87WASSAFF,
Revised 5-26-05 Fax#617-727-7749
1
COMMONWEALTH OF MASSACHUSETTS
nT o 0
. . o 0
CtAN
BQARC�
ISSUES THE FOLLOWING LICE<N�E AS A
..
TERED MASTER :.E ECT,R,I C I AN, F
t
CROTEAU
44 CROSS S
I .
SsA
rai :.03079 410
4 331
I
Date..`. ..z ..�.. �...............
7 �NORTIy
a°.• "':;';,tia TOWN OF NORTH ANDOVER
0 0�
PERMIT FOR WIRING
,gsACHUSE
j This certifies that
................... ...................................................
has permission to perform . e u-�
t ................................................................................
wiring in the buildingof. U'P
..............................................................................
...............
at
...................... .......... ... , Mover,Mas .
F .49—
.........Lic.No�................
LECTRICALINSPECTO
Check#
I �
L�
Commonwealth of Massachusetts Official Use Only
r �
Permit No. � (.4
o Department of Fire Services
" Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07) (leaveblank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00
(PLEASE PRINT WINK OR TYPE ALL INFORMATIOl 9 Date:
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) 1�p ' \,W"k,:lh N
Owner or Tenant Telephone No.
Owner's Address -50^^-e
Is this permit in conjunction wi(h a building permit? Yes � No [j (Check Appropriate Box)
Purpose of Building tr5r Cvj.0 e Utility Authorization No.
- Existing Service 160 Amps f / agDVolts Overhead Undgrd❑ No.of Meters r
New Servic J00 Amps )-)d / �4D Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: 5+ec-UfA �6A f-en-b rnc,�e, �ti r a� ref
Y\tieV\-f-w -serijv
Completion of the following table may be waived by the Ins ector of Wires.
No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total
Transformers KVA
7 No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o mergency Lighting
/ rnd. rnd. Battery Units Q
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No, of Zones
No.of Switches No.of Gas Burners No.of Detection and
Initiating Devices
Total
No.of Ranges No.of Air Cond. Tons No.of Alerting Devices
No. of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
Totals: .".""'." """"""""""""""' Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other
Connection
No..of Dryers Heating Appliances KW Security Systems:*
No.of Devices or Equivalent _
No.of WaterKW No.of No.of Data Wiring:
Heaters Signs Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
No.of Devices or Equivalent
;ETHER: "
Attach additional detail if desired,or as required by the Inspector of Kres.
Eptimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: I l'F 15 Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE j< BOND ❑ OTHER ❑ (Specify:)
r
I certify, under thepains and penalties ofperjury,that the information on this application is true and complete. —
FIRM NAME: _ LIC.NO.: V'
Licensee`wn v-k, �tiM. Signature LTC.NO.: 903-)q
(If applicable,enter "e e p "to the is se nit er 1E'ng1 Bus.Tel.No.-
Address: rj � t�b6r k\�n C3�� Alt.Tel.No.:
*Per M.G.L c. 147,s.51-61,security work requires De rtment of Public Safety"S"License: Lic.No.
�
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE. $ � --
❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance.with the provisions of M.G.L.c. 143,§3L,the c
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed
on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G:L c. 166,§32,an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L.c.143,§3L.
Permits shall-be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he }
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written ,r>�
application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written l
request of either the owner or the installing entity stated on the permit application. t
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With
limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was
"in effect or existence".during the qualifying period beginning on August 15,2008 and extending through August 15,2012.
❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑
❑Permit Extension Act—Permit/Date Closed:
Trench Inspection
Pass 0 Failed 0 Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
SERVICE INSPECTION:
Pass Failed Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Signature: Date:
PARTIAL ROUGH INSPECTION:
Pass F?1 Failed 0 Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
ROUGH INSPECTION:
Pass n Failed Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Sig ature: Date:
FINAL INSPECTION:
Pass Failed 0 Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Signature: Date:
DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com
44 The Commonwealth of Massachusetts - -
Department of lndus€rigl AccW nts
Office ofluvesfigations
600 Washington Sheet
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affrdadt:Buffeters/Cont°actors/ElectricianslPliimberp
Applicant Information Please Print Legibly
Name(Businessiorgauization&dividual): 1
-
M�-�-Phone
City/Stake/Zip:
Are your an employer?Check the appropriate box: 'Type of project(required):
I.❑ I am a er with employer 4. ❑ I am.a general contractor and I
p y 6. New construction
employees(fall and/or part time)* have hired the sub-contractors
2.,0•I am a sole proprietor or partner- listed on the attached sheet 7. Remodeling
ship and'haveno employees These sub-contractors have 8. ❑Demolition
worldng for me in any capacity. workers'comp.insurance. 9. Building addition
[No workers'comp.insurance 5. ❑ We area corporation and its 1011 Electrical repairs or additions
required.] officers have exercised.their
3.[+ I am a homeowner doing all work right of exemption per MGL I1.[]Plumbing repairs or additions
myself[No workers'comp. c.152,§1(4),andwehaveno 12.❑Roofrepairs
insurancerequired.]i employees.[No workers' 13. ]Other
comp.insurance required.]
xAny applicant that checks box#1 must also fill outthe section below showing their workers'compensation policy information.
i-Homeowners who submit this affidavit indicatingthey ke doing allwork and then lure outside contractors must submit anew affidavit indicating such.
tContractors that checkthis box must attached as additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
p am are employer that is providing workers'compensation insurance for my employees Below is the policy imd job site
information.
Insurance Company Name:
Policy#or Self ins.l.ic.#: y ®� I �D Expiration Date: �a/ 16-7
Job Site Address-J�Q ayisah D,-- Pity%State/Zip: N r N,—wPr
Attach,a copy of the workers'compensation-policy declaration page(showing the policy number and expiration date).
p'&,&a to secure coverage as requiredunder Section 25A ofMGL o.152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/oro- imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
ofun to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office o£
Investigations of the DIA for insurance coverage verification.
X do Hereby cert&under
nthe pains andpenalfies ofperjury that flue information provided above is true and correct. -
Si�natare•
Date:
Phone#• 33cj–X03— �7a(�
Official use only. .Do not write in this area,to be completed by city or town official.
City or Town: PermitlLicense 0
I '
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#:
1
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an efl',ployee is defined as"...every person tri the service of another under any contract ofhire,•
express or implied,oral or written.."
An employes is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a j oint enterprise,and including the legal representatives of a•deceased employer,or the
receiver orirr stee of an individual,partnership,association or other legal entity,employing employees. Ifowever the
owner of a dwelling house having notxmore than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in,the commonwealth for any
applicant who has not produced-acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states `Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapterhave been presented to.the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
no'cessaM' supply sub-contractors)name(s),address(es)andphonenumbers)along with theireer0cate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the ,.
members or partners,are notrequired to carry workers'compensation insurance. If au LLC or LLP does have
employees,a policy is required. Be advised that thisaffidavit maybe submitted tothe Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the,permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a•workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self insurance license number on the appropriate he.
City or Town Officials
Please be sure that the affidavit is complete andprinted legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be-sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
thatinust submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town).,,A:copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit-is on file for future permits or licenses. Anew affidavit wrist be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license orpermit to burn leaves eta.)said person is NOT required to complete this affidavit.
a
The Office of Investigations would Moto thank you in advance for your cooperation and should you have any.questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
Tho Coir onweath o Z1�!aSSarhus-t,q -
JDepaxi el t ofl adwftiaX Accidouta
( fte QUIRVestigAt'tona
6 G Washbp
a S#xa t
Boston,MA 02111
TO,#GM21,7,4900 ext 406 0.r 1-877-:NtA S
Revised 5-26-05 `ay, 617-727-7749
_WWW=Ss,gov1dja
li
COMMONWkAaL OF M A. A IiUS�TTS <`
• j IOU a 9081 •
>~ E T IA t-:,!A M S.
«.
ISSUES,.THE FOLLOWING LICENSE
AS p R1=C JOURNEYMAN ELE
TIMOTHY S GRANTHAM
53 H I G HWOOD D RR�'� ^
f :A_IVKL I N MA 02038 2973`
30329E 07%3l/�6 40075Y�
1
10 153 Date
b
• 7
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that .(2,C ?roil
_has permission to perform . . `� ,r .. (?t4 ,..-1`. . . . . . . . . . . .
plumbing in the buildings of. . . . .
at . . ?�.C�. !(!HJT��t �n ,North Andover, Mass.
Fee- Lic. No. .
PLUMBING INSPECTOR
Check# 3 d
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORT(
�IITY , _ ' MA DATE O 3 PERMIT#�I 1�� --
JOBSITE ADDRESS f �/ � OWNER'S NAME
OWNER ADDRESS ! TELPJ]FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL f EDUCATIONAL Ell RESIDENTIAL
PRINT
CLEARLY NEW: F11 RENOVATION:Di REPLACEMENT:id PLANS SUBMITTED: YES NOD
FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM T i�- f f ._.._.___i ------i __ _I ! _____.__ ._____1 .___-.
DEDICATED GREASE SYSTEM -[ ---_-.-..I- E _----! ---.__f __.___f f _..__._.-f --.--._.1
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER f _.....__._( _f .--._..__I ..-. ( ! ___---_I J .m.._._1 ! 1 --.f __..-.__-( f _._.... !
DRINKING FOUNTAIN �i ..._..._.i ._.._ __..i _____._I _f ........
FOOD DISPOSER �_! .__.__I -f .-___.f. __.._.-_ ► ( ._____i ___....__I .--.-_- - -___f .___..__I .-.__......_f ., _._.f I _..__--f
FLOOR/AREA DRAIN f ___._....1 ..-_-._! f ._...___f -____f
INTERCEPTOR INTERIOR
KITCHEN SINK _—! -S ----f -- --i --I ---' - --i - -I -- E -----I ---I - . ._( _ ....---I I ---------I
LAVATORY
ROOF DRAIN .,____1
SHOWER STALL
SERVICE I MOP SINK ..i .___._.J ( i .._-.__� i .__-_.-( I ! --..-_ 1 ___1
f
TOILET f I
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES -
WATER PIPING
i
OTHER
-�-__- T_ INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[ NO 1
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Lr! OTHER TYPE OF INDEMNITY Q BOND
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER Ej AGENT
SIGNATURE OF OWNER OR AGENT
B hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co liance with all Pertinen ro ' ' n of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 4 —
PLUMBER'S NAME ___ -,r LICENSE# _. i S GNATURE
MP 10" JP _I CORPORATION . # - PARTNERSHIP EA# ;LLC U
COMPANY NAMEd �1 61i ' e_ DRESS
CITY .� U. /y --.-..__...__ STATEI ZIP ��� _ TEL -----S- 33_ -FAX ELL _ ; EMAIL Q oteF' .._IC/ial�7ii;i. Q_ Yi4i,(• - - - ...... ------
,. —
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
S-'
1
The Coninioinvealtli of Massachitsetts
Departn:eiit ofIiiditstrial Accidents
Office of Investigations
j . 600 Washington Street
Boston,MA 02111
n ' i mvw.niass gov/dia.
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business!Organization/Individual): I� Weg ,/ (r` 6. ��•
Address: ad
City/State/Zip: f/,�. V - Phone#:.4 zw
Areyou an employer?Check the appropriate box: Type of project(required):
1.MI am a employer with & _ 4. ❑ I am it general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. El New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g, Q Demolition
working for mein any capacity. employees and have workers'
9. E]Building addition
(No workers'comp.insurance comp. insurance.1
required.] S. Q We are a corporation and its 10.El Electrical repairs or additions
3.❑ I ant a homeowner doing all work officers have exercised their I I.[6lumbing repairs or additions
myself[No workers' comp. right of exemption per MGL 12.Q Roof repairs
insurance required]t c. 152,§1(4),and we have no
employees. [No workers' 13.Q Other
comp.insurance required.]
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 hive
employees. Irthe sub-contractors have employees.they must provide their workers'comp.policy number.
I ant an employer that is providing tporkers'contpensatioii insurance for niy employees. Below is the policy and job site
information. 7n
Insurance Company Name: (/�' ! �r� < C ��� C_(/ •
Policy#or Self-ins.Lic.#: �f�D l.��Cl� Expiration Date:
Job Site Address: /`1�oI �' City/State/Zip: A0'�/�� �/� • GYB�S—
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as requited 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 hereb y certi an •the ains and enuI u er a that the information provided above is trite and correct.
3 .f3' P P fP J �' .f
Signature: Date:
Phone#:
Official use only. Do not write in this area,to be completed by city or totvit official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.EIectrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
i
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An enrployer is defined as"an individual,partnership,association,.ccirporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership,association or oilier legal entity,employing employees. however the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer"
MGL chapter 152,525C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required"
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority"
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificates)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. if an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of.
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be surethat the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permittlicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"nil locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on.file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
i.e. a do license or permit to burn leaves etc. said person is NOT required to complete this affidavit.
� g P ) P q P
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not lresitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel.# 617-727-4900 ext 406 or 1-877-NIASSAFE
Fax#617-727-7749
Revised 4-24-07
www.mass:gov/ilia
=COMMONWEAL O 1AC4iUSETT V-17
-ZEN
PLUMBERS
PLUMBERS AND GASFITTERS "
REGISTERED ASIA PLUMBING CORP
ISSUES THE ABOVE GCENSETO.-
-GEORGE. R LAROSE r
ANDOVER--PLUNBING & HEATI:NG.:C :. # r•
r20 " AEGEAN'DR
-N IT 0-1 ;: c
t1
bETHUEN. HA. 01844:-1580 ": =
-21.22 05/01/14
COMMONWEALTH OF MASSAGH • ' =AMMO
�DSE�i ;~__^ NWEALTH OF MASSACHU -
PLUMBERS AND GASFFTTERS ' " , ' ' : � f=== -°• °EN
LICENSED AS A MASTER PLUMBER:' ' PLUMBERS AND GAS ERR
L - = tCENSED AS A JOURNEYMAN PLUMBER
ISSUES THE ABOVE LICENSE TO:=
ISSUES THE ABOVE LICENSE 70:
GEORGE R LAROSE '-
=f
GEORGE R .LAROSE -
44 ODILE ST OD.ILE .ST
METHUEN NA 01844-423:3'; .• -91 THUEN MA 01844-4-23V='
'
9983 05/01/14 1725b3- _
1@40,Y'�=:�:,�: c�•�• _ fi8723 05/01/24 272562 V
_91 Q_rirk
Location
No. Date
NORTH TOWN OF NORTH ANDOVER
Certificate of Occupancy $
4F Building/Frame Permit Fee $
Foundation Permit Fee $
SA MUSE
r er Permit Fee $ (;71,
Sewer Connection Fee $
����i� ���►- Water Connection Fee $
Building Inspector
Div. Public Works
PER111T NO. I5 O S APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1
MAP*40. LOT NO. 2 RECORD OF OWNERSHIP iDATE BOOK 'PAGE —
ZbNE I SUB DIV. LOT NO.
i
LLOCATION Y ��1�1 / p"p ` PURPOSE OF BUILDING ��oA
OWNER'S NAME / l� ei NO. OF STORIES / SIZE
e li
OWNER'S ADDRESS / �� f�^ 1/� r �y �1,a� BASEMENT OR SLAB -
,r 1L �T (JAL � _
ARCHITECT'S NAME 'j
e- Q J SIZE OF FLOOR TIMBERS IST 2ND 3RD
BUILDER'S NAME - g x c ,e SPAN 6- C9 1 r ✓ r/ —
DISTANCE TO NEAREST BUILDING V DIMENSIONS OF SSIILLS�O,�.
DISTANCE FROM STREET POSTS
DISTANCE FROM LOT LINES—SIDES REAR GIRDERS
AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW SIZE OF FOOTING / 2 ' AuAIA x
IS BUILDING ADDITION MATERIAL OF CHIMNEY
IS BUILDING ALTERATION 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
INSTRUCTIONS 3 PROPERTY INFORMATION
LAND COST /
SEE BOTH SIDES /EST. BLDG. COST V G� •�q
PAGE 1 FILLIOUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT. Jci
PAGE 2 FILL OUT SECTIONS i 12
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY
xATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
��PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
DAT
LED � d
(1J� BOARD OF HEALTH
SI NATURE "NERHORD AGENT
FEE / a
PERMIT GRA
OWNER TEL.# 0�J� j�/�3 PLANNING BOARD
CONTR.TEL.# d
19 --�-�— CONTR.LIC.# D
BOARD OF SELECTMEN
R
BUILDING INSPECTOR
+ r
BUILDING RECORD
1 OCCUPANCY 12
SINGLE FAMILY _ STORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM
MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA-
APARTMENTS I RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN.
CONSTRUCTION
2 FOUNDATION 8 INTERIOR FINISH
CONCRETE d t 2 13
CONCRETE BL K. PINE
BRICK OR STONE HARDW D
PIERS PLASTER
_ DRY WALL
UNFIN.
3 BASEMENT 11
AREA FULL FIN. B'M'TAREA _
'/. 1/7 FIN. ATTIC AREA _
N_O B M FIRE PLACES _
HEAD ROOM MODERN KITCHEN
4 WALLS 11 9 FLOORS
CLAPBOARDS B 1 2 3
DROP SIDING CONCRETE
WOOD SHINGLES EARTH _
ASPHALT SIDING HARDW'D _
ASBESTOS SIDING _ COMMON
VERT. SIDING ASPH. TILE _
STUCCO ON MASONRY
STUCCO ON FRAME
BRICK ON MASONRY ATTIC STRS. b FLOOR _
BRICK ON FRAME T
CONC. OR CINDER BLK.
STONE ON MASONRY WIRING
STONE ON FRAME
SUPERIOR I� POOR
AD _
EQUATE NONE
5 ROOF 10 PLUMBING
r
GABLE I HIP BATH (3 FIX.) _
GAMBREL MANSARD TOILET RM. (2 FIX.)
FLAT SHED WATER CLOSET _
ASPHALT SHINGLES LAVATORY
WOOD SHINGES KITCHEN SINK _
SLATE NO PLUMBING _
TAR 8 GRAVEL STALL SHOWER _
ROLL ROOFING MODERN FIXTURES _
TILE FLOOR
TILE DADO
6 FRAMING 11 HEATING
WOOD JOIST PIPELESS FURNACE
FORCED HOT AIR FURN.
TIMBER BMS. &COLS. STEAM
STEEL BMS. & COLS. _ HOT W'T'R OR VAPOR
WOOD RAFTERS _ AIR CONDITIONING S�
RADIANT H'T'G
UNIT HEATERS
7 NO. OF ROOMS GAS
OIL
B'M'T 2nd _ ELECTRIC
1st 13rd NO HEATING
,
|
DOES NOT INCLUDE STRIPPING OF EXISTING
FLOORING OR LAYING OF AN[';!l�ER^LAYER OF PLY ~ �
PAINTING INTERIOR & EXTERIOR / $NONE REQU
CLEAN UP & DEBRI REMOVAL / $ 225. 00
DEBRI REMOVAL FROM SITE
,
/
TOTAL COST TO COMPLETE THE ABOVE MENTIONED JOB $7, 325. 0(:,-,
�
�
PRICES LISTED ABOVE ON CERTAIN LINE ITEMS ARE THERE TO GIVE
ALOTTED PRICES TO EITHER DELEIT, UPGRADE OR DOWN 8RADE
�
OTHER ITEMS ARE LISTED AS SUB CONTRACTORS
�
PAYMENT SCHEDULE
DEPOSIT ON THE DAY WE START $2, 500. 00
�
IST PAYMENT ADDITION WATER TIGHT $2, 000. 00
�
2ND PAYMENT WHEN CABINETS ARE
STRIPPED OUT $1 , 500. 00
BALANCE UPON COMPLETION $1 , 325. 00
NOTE SHOULD ANY CHANGES ARISE DUE TO UNCONTROLABLE
CIRCUMSTANCES OR ADDITIONAL WORK REQUESTED By THE HOME
OWNERS A CHANGE ORDER WILL BE PRICED OUT AND SIGNED
PRIOR TO COMMENCEMENT OF THAT CHANGE.
PLEASE SIGN BELOW AND RETURN 1 COPY UPON ACCEPTANCE
OF THIS PROPOSAL. �
X-----------------------------��/ /92
�
THANK YOU VERY MUCH
`
BRADLEY J JONES
�
|
|
Suggested Affidavit for Home Improvement Contractor Permit Application
For orrice Use only NAME OF CITYffOWN
Permit No.
Date
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
MGL c.142A requires that the"reconstruction,alteration,renovation,repair,modernization,conversion,inprovement,removal,demolition.
or construction of an addition to.any pre-existing owner-occupied building containing at least one but not more than four dwelling units....or
to structures which are adjacent to such residence or building"be done by registered contractors,with certain exceptions,along with other
requirements. / /S/Wl
IType of Work: 2-✓6G/) o �r /Uo� `y`�r��e ( G� Est. Cost /iry SOD 6 0
Address of Work/DC7 i/�lil/ �G//�� /� i� �/,;,�p� ✓f -
Owner Name:��(�/
Date of Permit Application: /6/'5�/ ' 2--
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law
_Job under $1,000
Building not owner-occupied
_Owner pulling own permit
_Other (specify)
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL
c. 142A.
Signed under penalties of perjury:
I hereby apply for a permit as the agent of the owner:
/d Z� Z
Da t,6 Contractor Name Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property:
Date Owner ame
COMMONWEALTH 40 l" O WAVE.EALTH _
OF I•�rft MASS.02215 ,
� � e
`
MASSACHUSETTS
a`fi
ENCLOSE CHECK OR MO
NEY #
ix° 1 LICENSE
S1 PERVFSOR = ,FOR REQUIRED FEE 'Y
-l4,,'.,_
yt `-_� '
` EXPIRATION DATErrr y MADE PAY
„ ..{ 06/30/1993 6`�e`�S0 rkQ CTIVE..t)tTE '•=:'ui N0. _:. AB�E,TO ;.
A AY y 5 L
t 3
RESTRICTIONS x` 30`/199 . `-0 6863. l "COMMISSIONER OF PUBI'�.�'
NONE 1 �.
p, ray A L+ DO NOT;SEND.CA t
��t'�P'LE'•Y!� J�i•..�ONES' t. ° .'� .. ..r.. Q
RW l'N LLBRD � "'3� q .
. w4 ;u
�i 1g-48—,1281' r D� }: y SASE NO TF,,_ FEE 4
gT'I^ 'Ii �l SS
�•* �- -'' VHOTO(BLASTING OFR ONLY) FEE: rti M1 - <
100.00 � t ,, � , E1 FECTIVE FEB, !�
v it -.V IED.411-i CENSEE AND OFFICIALLYj`�`
5 f �• ¢ a HEIGHT:.— l NATURE eTHE COMMISSIONERDOW
I#, 'v' 't •f r••S v U
ObfO=x./1969 ? ;
NOT
O
ETACH,Ll
THIS DOCUMER MUST 6• ..- v y `
CARRIED O^T� NRENf;!" `` ei 4- NRE OF LICENSEE u ,« GN NAME IN FULL•ABOVp$I¢
THE
OTHERS RIGHT THUMB giNi ED IN
Y. 41 / Ci •i, ..5 - 'Ikt P,,ql'..iF
29
1�i4
14
1.4
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*>�' �,b..''r�•`A.,,,.,,;�'��a9E6.,��.�Fes.: a � 1 �. -y''�r y �I T:
Jr S r
.. � ���„��i�Ka.b ;•rlr.r'4 S y��rw�
ter•+f'F� "`c» ".,.."b�- waM"a v�+ve�'.+.'4 ,� � tVf_'
�� � ��- fj,�Y �\ ,�YAr4o�,x£R�i+�.^h� � • .. 4 Y>t•LT� ��.��1� yS1
74
;R'i�.,,S {.r= kA+'M1-. ,A•,,.'. ,rte '�: +� '?} ..,.t �I.j. _ F '
,r a
1 d ,Ly,;'yl•'�ra � j •
r:�=.�„ '�• a�. x{, �,� is w.N (. , - y - ,f,. a�•„h�bs y F
i,rr'r., E•YT. � .• "5 w.tt'"i, �'.'a '1' - .l - �' .rT'F��� �.
A i
�F-yah, *s<.Wf •.'". ° .r�� .�, L' .^a r. d,, ,,, _ < -�'6. �y, ! - "'
.',�' .�,. T 8 '. ,L '�)ynF r.may R �• b+IFt
FORM U - LOT 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.
****************Appl`icant fills out this section*****************
Zi r �al�APPLICANT: �ZPhone / 3 d
LOCATION: Assessor's Map Number Parcel
Subdivision
Lot(s)
Street3U f��
1 U/� d2
� � St. Number
************************Official Use Only********* **************
RECOMMENDATIONS OF TOWN AGENTS:
Conservation Administrator Date Approved
Date Rejected
Comments
v �
Date Approved
Town Planner Date Rejected
Comments
Date A
Health Agent Approved
Date Rejected
Comments
Public Works - sewer/water connections
driveway perm't
Fire Department
Received by Building Inspector Date
�ORTty
Town ofAndover .
No.
. . _ -1„l N pr Mass. 19
AC HE > >
�9�o'C? ?
I BOARD OF HEALTH
PERMIT T La
THIS CERTIFIES THAT..V104 0 A* r..ar*..4446..N..I..1r rIO.............•••
..............
BUILDING INSPECTOR
has permission to�e�It*&/r#WrVbjftildingso'n ..�J6 Rough•.• Chimney
to be occupied as . . •••• ••,• I •••••' Final
provided that the person accepting this permit shall in every respect conform to the terms of the application on file in
PLUMBING INSPECTOR
this office,and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Rough
Buildings in the Town of North Andover.
Final
VIOLATION of the Zoning or Building Regulations Voids this Permit.
PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
Rough
UNLESS CONSTRUCTION STARTS Service
Y&4 Final
BUILDING INSPECTOR GAS INSPECTOR
Occupancy Permit Required to Occupy Building Rough
Final
Display in a Conspicuous Place on the Premises
FIRE DEPT.
Do Not Remove Burner
No Lathing to Be Done Until Inspected and Approved by Smoke Det.
� �� y Building Inspector