Loading...
HomeMy WebLinkAboutMiscellaneous - 157 LIBERTY STREET 4/30/2018 (2) 157 LIBERTY STREET 210/090.B-0063-0000.0 x y:..y+�.`�^.5.-wr.s.:M�a'.. ' 'felY�';Z`t'''''.Ktir—`�w.**"..°...,....P.:..w.- _�,....v.a. � ..,.•..._._.,r..—""1 Location IS � L4 oZ No. I M Date r� TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ SACMUSE lFee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ ('j[ Building Inspector 7272 Div. Public Works Location. No. /fes Date a NORTN A TOWN OF NORTH ANDOVER 6tiC0 Certificate of Occupancy $tt y"z -7, 93 + * . Building/Frame Permit Fee $ /7 n C Foundation Permit Fee $ ti-2 7.53 Other Permit Fee $ l Sewer Connection Fee $ i Water Connection Fee $ 0 ----TOTAL $ e G/5V Building Inspector 6159 { �" Div. Public Works Location No. Date NORTH i TOWN OF NORTH ANDOVER p Certificate of Occupancy $ l 0 U Building/Frame Permit Fee $ 'ss,C,,st` Foundation Permit Fee $ /�h .U U 0 Other Permit Fee $ �� �$ c' Sewer Connection Fee $ Water Connection Fee $ C t {c T TAL $ l 0 UU Building Inspector Div. Public Works APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. )OA IfPl �r'w �� PAGE 1 _'�AP 4-40. I LOT NO. 2 RECORD OF OWNERSHIP DATE BOOK :PAGE — 'ZONE SUB DIV. LOT NO. �I �L'OCA�TION PURPOSE OF BUILDING S' r _ SIN G►J� �hAILY >�J` .4 OWNER'S NAME ROD ;.,��. NO. OF STORIES ' SIZE01 OWNER'S ADDRESS 1 ••� BASEMENT OR SLAB c ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST.4AIX 2ND 4X% � 3RD 'O OAJFII BUILDER'S NAME u� _ SPAN 3a FBaN f- D��o,17�0 � --- � DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET r POSTS DISTANCE FROM LOT LINES-SIDES `� /3p'REAR GIRDERS jj y, P, /x a AREA OF LOT L/ dJ FRONTAGE 71/ HEIGHT OF FOUNDATION ��[ T' THICKNESS ./®it IS BUILDING NEW �✓� SIZE OF FOOTING '`' X w IS BUILDING ADDITION MATERIAL OF CHIMNEY �W - IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND ,J C O' 0 WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER VO BOARD OF APPEALS ACTION, IF ANY IS BUILDING CONNECTED TO TOWN SEWER �D _. IS BUILDING CONNECTED TO NATURAL GAS LINE N� INSTRUCTIONSSLt +Q' � 3 PROPE TY INFORMATION OG. t sT� ' '� SEE BOTH BIDES LESS FDA '*' ��r- LAND COST 7S (9�'! ' "" `" EBT. BLDG. COST ' PAGE 1 FILL OUT SECTIONS 1 - 3 UE FRAME PERMn$1 Z 72 ° - EST. BLDG. COST PER SQ. PT. �6'C) 0 EST. BLDG. COST PER ROOM PAGE 2 FILL OUT SECTIONS 1 - 12 R SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY I R ATTACH ED"-SARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE F E ~ BOARD OF HEALTH SIGNATURE O R AUTHORIZED AGENT FEE 7 ° U 0 G PERMIT GRANTED ee��rA owriER TEL. +� �� ��m 7/ PLANNING BOARD CONTR.TEL.# C2 A 19 CONTR.LIC. —i9St� BOARD OF SELECTMEN IFd t /�� BUILDING INSPECTOR r BUILDING RECORD 1 OCCUPANCY - 12 SINGLE FAMILY r2_1OF TRIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY ICES _ LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- APARTMENTS RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION ,I 8 INTERIOR FINISH CONCRETE �ylll d I 2 I3 CONCRETE 81.K. --{ PINE BRICK OR STONE HARDW D — ✓ ✓ PIERS PLASTER 7 DRY WALL UN IN, 3 BASEMENT AREA FULL FIN. B'M'TAREA _ '/ 1/7 1/1 FIN. ATTIC AREA ' N_O B M FIRE PLACES HEAD ROOM MODERN KITCHEN 4 WALLS 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE WOOD SHINGLES EARTH _ ASPHALT SIDING HARDIV D ASBESTOS SIDING _ COMMCN VERT. SIDING ASPH.TILE STUCCO ON MASONRY _ F=✓F '�"'y STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. 8 FLOOR BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME — i SUPERIOR POOR _ t ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE HIP W, BATH Q FIX.) / f GAMEIEL MANSARD TOILET RM. )2 FIX.) F FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY I. WOOD SHINGES KITCHEN SINK ,7 SLATE NO PLUMBING TAR & GRAVEL STALL SHOWER l ROLL ROOFING MODERN FIXTURES ./ TILE FLOOR TILE DADO 6 FRAMING 11 HEATING WOOD JOIST Zxl2, V PIPELESS FURNACE FORCED HOT AIR FURN. y 3 TIMBER BMS. 6 COLS. STEAM ^" ' t STEEL BMS. 3 COLS. HOT W'T'R OR VAPOR „_,... _.__ .•-— - WOOD RAFTERS Flo AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS �-- OI L B'M'T 40 2nd I& _ I ELECTRIC I t' 13rd O I NO HEATING 04/23/93• 15:58 $617 561 1421 PANGAEA INT'_L S Cf PUBIC SAF TK ` D�ARTIAEIC� 9 1040 t'ommoNWEALTH AYE. e a DRaV I BOSTON,Nv"g -02215 ' • i *sm1522--84 .: LICENSE ,'c r ::s ie� 10 I SUPERVISOR r EFFECTIVE DATE UC-NO. DF.UNDO •- - - 4r' F- /1991 055 b�FI 947 FRANC25 PQOV�? 3R"StiteaT 'r FRANCIS • Q I T O!�C O 7 Jr T�` . QRCHEs7ER MA ..1 tJi gai2:.-a: 947 ADAMS ST D ORCH ESTER MA 02124 ���,•��= - ' --' --. .�_ �j NQL VALA UNC*=NO By L=NSEE ANO o"oCMly y7µ�pp CA-$YlUNRE Of TME CONq I NER I $Y32LA�A£0 CENSE i r a� o ve's ,1 f 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 r landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: Phone LOCATION: Assessor's Map Number Parcel Subdivision Lot(s) 2 Street Lf bEPT Y ST St. Number �5 ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Date Approved Conservation Administrator Date Rejected Comments AM QWdQV Date Approved �F Ct2 Town Planner Date Rejected Comments { Date Approved Food Insp�erctor-Health Date Rejected Date Approved Septic Inspector-Health Date Refected Comments Public Works - sewer/water connections 020kA,14 driveway permit i S (� re Des rtment - � t-,t.•�-��Gtr ✓�- �t_►on'C'a t�!S'�t •s�a1 !l Q3 Received by Building Inspector Date 1 FO LINDA TION LOCA TION PLAN JUN i o DANA RODRI Q UEZ � CLIENT: 30 THIS CERTIFICATION -IS MADE AND LIMITED C^ TO THE ABOVE CLIENT. 3 ' I C �o �• I CERTIFY THAT THE PRIMARY STRUCTURE SHOWN CONFORMS TO THE HORIZONTAL SETBACK REQUIREMENTS OF THE LOCAL X60' APPLICABLE ZONING BY-LAWS IN EFFECT WHEN CONSTRUCTED. , (THIS CERTIFICATION DOES NOT CONSIDER ANY OTHER RESTRICTIONS SUCH AS COVENANTS,WETLANDS,EASEMENTS, 109,2' ORDERS OF CONDITIONS,ETC.) / THIS DRAWING SHALL NOT BE USED BY THE CLIENT FOR ANY 35.x' F PURPOSE OTHER THAN THAT OUTLINED ABOVE,EXCEPT WITH THE 1 ti�%> WRITTEN PERMISSION OF CHRISTIANSEN & SERGI INC. FURTHERMORE THIS DRAWING /S THE COPYRIGHTED PROPERTY OF CHRISTIANSEN & SERGI INC. AND ANY UNAUTHORIZED USE IS PROH/BITED.CHR/STIANSEN & SERGI TAKES NO RESPONSIBILITY OT 2 50.2' FOR THE UNAUTHORIZED USE OF THIS DRAWING OR ANY INFOR- LMATION CONTAINED HEREON. _ N X-5 A=4.0 ACRES 3' BASED ON SCALED DATA ONLY THE PRIMARY STRUCTURE SHOWN --� 366• IS NOT LOCATED IN A FLOOD HAZARD ZONE AS SHOWN ON FEMA FLOOD INSURANCE RATE MAP. COMMUNITY NO.:250098 0015B DATE:6/15/83 ZONE: (IF APPLICABLE) SCALE: 1 = 80DATE: 5/13/93 OF to MICHAEL /pn c J. Q ��HA N4 f ' 18.2' I, 156.8' CHR/ST%A NSEN R, SERGI PROFESSIONAL SURVEYORS ENGINEERS T Y ST* 160 SUMMER ST. HAVERHILLMA. 01830 T£L. 508-373-0310 LIBERQc 1991 BY CHRISTIANSEN & SERGI INC. cA CA RTH Tovvn of Ando 13 No. fee > , CPO M Aort dower, Mass., a if 1 goo �A COC M ICMEwIC K � %A ORATED !-I BOARD OF HEALTH PE Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT. . ....... . t '"' _ Foundation has permission to or .....ftilui s . ........ Rough _ to be occupied as :. ..... ......,�.... ................ Chimney provided that the pe so a p s spect c r s of the ap Final this office, and to the provisions of the Codes and By- s relating to the Inspection Iteration and Co r tion of a Buildings in the Town of North Andover. !� LPLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. PERMIT FOR FOUNDATION ONLY h I�OI� TH? PERI r E P ES IN 6 EGULATED BY PARA. 114.8-S. E C Final �I 4-1 L�' bL ELECTRICAL INSPECTOR UNLESS COI�IS RUC . 10 ' _,r� r PAI Rough PERMIT FOR FRAME/BUILDING Service UI - INSPEC OR DATE:�A FEE P t � �art� �� �ti Final MPermit Required t0 OccvPy Building- GAS INSPECTOR _ Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner PLANNING FINAL CONSERVATION FINAL Street No. �(C� ik Smoke Det. SEWER/WATER FINAL Ck V)s-b DRIVEWAY ENJ.R� P RM IT [lY r,U i I-A -" Y_ i t • - ® ofAndover 0 No.. 100 dover, Mass. 19 A°RA rE D s BOARD OF HEALTH DFood/Kitchen PERMIT T V Septic System /f ,Jt7. BUILDING41.PkPFC QR� v THIS CERTIFIES THAT.. .. .....s.... .... .. .iQ. !.................................. f I "' Foundation Ni N ��/ :-----has permission to erect.W�4.�����i�l� buildings on ...�..�..� �.�.���x.r,��x..r.�.Qr.�. Rou6t, s4 -�y t0 be occupied aS. ,. �. .�.�...Ir . ��®. ...... .. .... � Chimney JAI/ provided that the person accepting this permit shall in every respect conform to the terms of the application on iiie in pro P P 9 P Final this office, and to the provisions of the Codes and By-taws relating to the Inspet aa��i�r�and Construction of G��. s y r Buildings in the Town of North Andover. C K N P FOUNDATION ONLY PLUMBING INSPECTOR • REGULATED U PARA. 114.8 8,G / VIOLATION of the Zoning or Building Regulations Voids this Permit. otrU,i - 7-1 '�- PERMIT EXPIRES IN 6 MCWFt&43 FEEPAID .a v Final UNLESS CONSTRUCTION S i ARTS °9�` 0"Q O ELECTRICAL I SPECTOR R FRAME/BUILDING • °ust'`04 f �` jV --�- PERMIT. FOR Service DATE: G/v 3 FEE PAID ? BUILDING INSPECTOR Final Occupancy Permit Required to Occulry Building GAS INSPECTOR Display in a Conspicuous Place on the Premise; — Do Not Remove RoughFinal No Lathing or Dry Wall To Be Clone Until Inspected and Approved by the. Building Inspector. FIRE DEPARTMENT Burner PLANNINGFINAL d,.X- /s'd CONSERVATION FINAL street No. CKO� Smoke Det. _ SEWER/WATER_ FINAL S� 051 DRIVEWAY ENTRY PERMIT_ e CERTIFICATE OF USE & OCCUPANCY Town Of Forth Andover N Building Permit Number 100 (1993) Date JUNE 14, 1994 v THIS CERTIFIES THAT ' THE BUILDING LOCATED ON 157 LIBERTY STREET (Lot #2) MAY BE OCCUPIED AS SINGLE FAMILY DWELLING W/2 CAR GARAGE IN ACCORDANCE & DECK WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. ,ti CERTIFICATE ISSUED TO Mr. & Mrs. Dana Rodrigues " F • � °p 157 Liberty St. ADDRESS North Andover, MA JACNusCt Building Inspector ;t i- - t } Towno � �6doyer No. I f iro 46 �. :.; ,, rig# s �► �o ^� tart dover, Mass., 1 qd* L� COCWC-E WICK RATED PP c f S — BOARD OF. HEALTii aFood/Kitchen y Septic System ;f ILDIQJL THIS CERTIFIES THAT. ....... ... F _ f N� 1N�P5� ��� S PER ou ion0--� �'•S �� 9� " has permission to or s ... .�,. �........ .. Rough&//t'/,) (! 3--1,S-11K to be occupied a - .......... Chimney 4, ZJ(' provided that the a soacc p s spect c r sof the ap 9 Final this office, and to the provisions of the Codes and By- s relating to the Inspection Iteration and Co tion of Buildings in the Town of North Andover. !� PLUMBING 1I �ol�� C VIOLATION of the,Zoning or Building Regulations Voids this Permit. PERMIT FOR FOUNDATION ONLY h � BY PARA. 114.8-S. E CPERMIT EXPIRES IN 6 MONTH?EGULATED 4- —0 W �/ AL INSPECTOR UNLESS CONSTRUC�, [O TA� V PAIL? Rough �-- PERMIT FOR FRAME/BUILDING ........... :�....... .... Service U1 INSPEC OR DATE�'��� FEE P�Iu -7 7 Z' `N O P- ��SZ� Final lJCcu c urif ei7nt Required to ccu un � 7P - iRd O � �- y Building GAS INSPE TOR ,_ 01 sir Display in a Conspicuous Place on the Premises — Do Not Remove No Lathing or Dry Wall To Be Done ` Until Inspected and Approved by the Building Inspector. Burner FIRE DEPARTMENT PLANNING FINAL CONSERVATION 12� /U ( Street No. �- t SF F n� 1,30 ek�0►5Z� �4/,`� Smoke Det.W-01, W R /WATFR �� FINAL __ _ DRIVEWAY ENTRY,PERMIT ' ,/� t r Date.........../../.j1- 16 .15 p HORTN TOWN OF NORTH ANDOVER „ PERMIT FOR GAS INSTALLATION # CU °++n°•rr`4h �1SSAC14 This certifies that . . . . .l .. • 1 has permission for gas.installation :. } , .:.,�'. . . . .' in the buildings of 8 . s at . . . `` . . . ,: . : ` r.~•< . . . �. .; North-Andover, Mass. Fee�_2.•.S. . • • Lic. No.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . r t C 1 � GAS INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer GOLD:File 4ASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING t (Print or Type) �,,,�' C NORTH ANDOVER Mass. Date kuilding location C rrr Permit # a(131 .� wners Name 1 Y New - Renovation Replacement p Plans Submitted D �� FIXTUP=c —� W W z x C* t+r ul 0 `� a v m f' x m �_ � t- a >- z p t- cc o W-CC a sc a a a z H Z to01 C3 N r W W o a W I- N 4 N W z_ V W o7 W 't R FO- G > W W W (1) W d z tc C7 Q W W h x L7 � O F� z J F' Z F- W W O > 0. H W .t F- W Z 4 W G a f' Y- N m = a Z O N Z a ,u > a W z 4 a rr Gt x O O z W O O U ¢ y o c0. FW- o SUa—BSIMT. t BASEMENT IST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR (Print or Type) Check one: Certificate Installing Company Name �, .s � �2anr�w� Q Corp. Address 13-1 - S Partner. Mli-Al e- Firm/Co. Business Telephone: Name of Licensed Plumber or Gas Fitterf?e-Llk 4 ee Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Q Bond 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 coverages. Signature of owner/agent of property Owner 17 Agent 0 1 hereby certify that all of the details and information I have submitted (or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed underPermit issr:ed for this application will be in compliance with all pertinent provisions of the Massachusetts State Cas Cude and chapter 142 of the Genual Laws. By TYPE LICENSE: Plumber Title Gasfitter Signature of Lice sed City/Town: Master Plumber r Gasfitter Journeyman (� APPROVED (OFFicE USE ONLY) License Number Date.. ... . �..i/....... c NpRTM TOWN OF NORTH ANDOVER 0 ' � `p PERMIT FOR GAS INSTALLATION SgACHUSE 1. • C •r This certifies that . . ? . . . . . . f . . . .!. ��c: . . . . . . . . . has permission for gas installation . . . !. . . . . r. in the buildings of . ; ` � ,�.!. �._ . .. .�. ..•/ .z.,. . . .�. :. . .J. . . . at . . . '� ,?.. !.r ? North Andover, Mass. Fee. . ? . Lica No:? . /. /. . . . . . . . . . . . . . . . . . . . . . . . . . . GASINSPECTOR �If/_ f/i3 j W:39 25.00 RAID WHITE:Applicant ----CANARY: Building Dept. PINK:Treasurer GOLD:File MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO 00 CASFITTING (Print or Type) --- NORTH ANDOVER Mass. Dat ' 14uilding Location /S D Permit # Owners Name &1,41 6 c�r-1 c, Ll G� • Y New Renovation D Replacement p Plans Submitted D `� FIXTUP_5 N N W N N l77 U a F � S E- W Wcc W Z0 m H f' W lrJ a Q W W > d N G W Z V W 07 y`� 4 Ct �0. p � LU 03J Q = Q a W W ~ W F- 2 W W O ? 1 W H 0 O Z O N 2 Q u y C W O Z 4 G 4 C O O W O V = W O 3 A O .s U s y a a h- O SUa—+3SNIT, t I BASEMENT -ISTFLOOR i 2ND FLOOR 1 3RD FLOOR 4TH FLOOR I 5TH FLOOR I 6TH FLOOR I 7TH FLOOR ` STH FLOOR (Print or Type) Check one: Certificate Installing Company Name p3{ A rL &t7o 52 Q Corp. Address k 3LJ - 64 Sa I T 60 = Partner. ~� LJ Firm/Co. Business Telephones 7 / 7` q-)6 Name of Licensed Plumbe or Gas Fitter ,16jel;?l x J Insurance Coverace: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy ® Other type of indemnity u Bond �( Insurance Waiver: I , the undersigned, have been made aware that the licensee of this appiication does not have any one of the above three insurance coverages. Signature of owneriagent of property Owner U Agent F7 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 tlat at1 plumbing .uric and Installations petfomted under Permit issued for this apptitation will be in compliance with all p=ttacnt provisions of the Massachusetts State Gar Code and chapter 141 of the General Laws. By TYPE LICENSE: Plumber Title Gl tuber r ig ature of Licensed Master Plumber or Gasfi.tter City/Town: 936 Journevman APPROVED (OFFICE USE ONLY1 License NUMber I 3 2 0 J Date. ..�.-j.. l l..... A H6 G ,ORTN TOWN OF NORTH ANDOVER 0 op PERMIT FOR GAS INSTALLATION g s ; a ,SSACMUSEt r.,. O This certifies that . . . . . -x: c �`., �- : :K.�-�. . . . . . . . . . . . has permission for gas installation in the building. '/f,--- -� . . f-z a -: ... . . . . . . . . . at .!�? .7 . . -::. • . . . • •, North Andover, Mass. Fee� . . . . Lic. No.. . . . . . �._::....:` GAS INSPECTOR WHITE:Applicant CANARY:Building Dept. PINK:Treasurer r MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) No. AncJcyrr - ,MA Date uN 19-5-!�- Receipt# Permit# � Building Location 117 41 b f'kU a�5�" . OwneesNamel—a-r) . Map: Lot: Zone: Type of Occupancy f✓ES e� Y1CLC New ❑ Renovation Replacement❑ Plans Submitted: Yes 13No Ll Fee: CF) CC Y cc f!1 U) N N0 z H ¢ W ¢ N ¢ O ¢ N x !•- W ¢ O V x W Z J W W ~ > m = F ¢ V a o W C a ¢ z O z W ¢ m N w O a w N ¢ �} U W 2 N Z a m Q C > W _ ¢CC LUf- r- x W CC H Z '� Z a W W O O > U- H U J H W Z a W J a ¢ F- i- > N ® z o z ¢ O y x Q W > ¢ W M z a ¢ 4 a O O W O W 1,- ¢ x 0 la x W n o t7 J v ¢ > o a H o r SUB-BSMT. BASEMENT 1ST FLOOR M 2ND FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing Company Name ) 1AS6rn r QTCA-nE C-�r145=, -�-h� Checkone: Certificate Address 'IAI- L04 kF-r C3 , ahyFt ' 1'Y1► i 4 Corporation Estimate Valueof Work: ❑ Partnership Business Telephone ) rl act 3. -(.y y ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter H r t%.i t V-1 —a"©Y1 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 9 No ❑ If you have checked lag please indicate the type coverage by checking the appropriate box. A liability insurance policy I5il' 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. Checkone: Owner❑ Agent❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the I Laws: 6C By 7 Type of License: Plumber Signature of Licensed Plumber or Gas Fitter i Title Gasfitter Master License Number Q City/Town Journeyman APPROVED (OFFICE USE ONLY), E BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES PROGRESS INSPECTION FEE 4 NO. APPLICATION FOR PERMIT TO DO GASFITTING NAME& TYPE OF BUILDING LOCATION OF BUILDING PLUMBER OR GASFITTER LIC. NO. PERMIT GRANTED I, r DATE 19 GASINSPECTOR Commonwealth of Massachusetts City/Town of NORTH ANDOVER, MASSACHUSETTS System Pumping Record N , o Form 4 M DEP has provided this form for use by local Boards of Health. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information r-' Important: When filling out 1. System Location: JAN 10 2008 forms on the computer,use J, I TNAhv 01 NORTH ANDOVER only the tab key Address HEALTH DEPARTM_ to move your – - - cursor-do not use the return City/Town State Zip Code key. 2. System Owner: 10 Name — Address(if different from location) City/Town State Zip Code - 9 (D Telephone Number B. Pumping Record 1. Date of PumpingD Date _ r6 2. Quantity Pumped: _1500 Gallons 3. Type of system: ❑ Cesspool(s) T, Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes M No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: -- d` 6. System Pumped By: Npa�me \` � Vehicle License Number W(f\C v � CAyirotiM nlTC, Company 7. Location where contents were disp ed: Signature of Hauler Date http://www.mass.gov/dep/water/app.rovals/t5forms.htm#inspect t5form4.doc•06/03 System Pumping Record•Page 1 of 1