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HomeMy WebLinkAboutMiscellaneous - 18 WEST WOODBRIDGE ROAD 4/30/2018 (2)N To The Town of North Andover COSTR UCTION WORKS AFFIDAVIT To The Building Commissioner, I certify that I have checked the proposed construction works that are being performed and associated with the permit to build at locus 18 West Woodbridge Street. And that to the best of my knowledge, information, and beliefthe works are designed and planned and are being carried out in conformance with the plans approved by the Town Inspectional Services Depamnent; with the provisions of the Massachusetts State Building Code, current engineeringards, and all pertinent la ws and ordinances. Marcos A Devers 33848 Engineer Mass. Reg. No. Address 35 Howard Street, Lawrence Massachusetts OI84I Location No. U Date a NORTH TOWN OF NORTH ANDOVER i • OL 9 Certificate of Occupancy $ HUS Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # �— 1757 8 �f wilding Inspe(iff TON" OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Contnif6sioner/Inspector of Buildings x Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: z; - f•J� % W o©1� )i /ri O� E- • � illi � � Map Number Parcel Number _ a 1.3 Zoning Information: '1.4 Property Dimensions: S/v(xCE= �iyM/CY �E=1, Z�� 12 U Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide R red Provided Provided 391 41? -,So 15' —Required 1 ¢2, TO 30' 404, 1.7 WaterS ly M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Zone Public Private ❑ Outside Flood Zone Municipal 'k On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT HiStoric,DiStriCt: Yes NO 2.1 Owner of Record Dll'/3LYog c.�C—ST (,VV00130Wi�1,4c /Zo, Name (Print) Address for Service: . 1AZ 5! 6 8 2 - zi 5,9 Signature Telephone 2,2 Own of Record: S�l�-ORS D IJA4v ®iQr wc—.rl— Name Print Address for Service: Si nature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable Licensed Construction Supervisor: License Number ' Address Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable Company Name Registration Number Address Expiration Date Si nature Telephone 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 .......❑ No....... SECTION 5 Description of Proposed Work check au applicable) New Construction ❑ Existing Building j Repair(s) ❑ Alterations(s) X Addition Accessory Bldg. ❑ Demolition ' Other ❑ Specify Brief Description of Proposed Work: C --'h' O 6,4 e r9 D 9 N Ew A- 'J'P "Po 0 -P, "r Parte H �cCoa-.7 rcnd`z 9 $Y.7 �e�z J",; 4/ - /2te-/Sr ,n vbP47 r -r 0104 PC Ile 11 Y3 SECTION 6 - ESTIMATED CONSTRUCTION COSTS ;;�0 tlo Item Estimated Cost (Dollar) to be Completed by permit a licant bF>F'ICLiiUSEONLY I . Building /00,000 (a) Building Permit Fee Multiplier 2 Electrical /'0'000 (b) Estimated Total Cost of Construction l C,' �� 3 3 Plumbing Building Permit fee (a) X (b) i�® l 6 4 Mechanical HVAC -- 5 Fire Protection 6 Total 1+2+3+4+5 1 2-0z 0 0 0 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUELDING PERMIT I, NN '►-�- 15-AGV o as Owner/Authorized Agent of subject property U-0kJ^� 0 Seo L 4),0 to act on My behatters relative to work authorized by this building permit application. Hereby /:/I Si a e of Owner Date S TION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, 4 PC ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief M^- s4<Y o Print N SignaWe of Owner/A Ient Date OF STORIES SIZE 3 ale a BASEMENT OR SLAB SIZE OF FLOOR TITVMERS I zxz 0 2 N13 -Z, z 3 RD SPAN DI1vIENSIONS OF SILLS 2 - Z x 6 DIN ENSIONS OF POSTS %t 4,4 c c y DM ENSIONS OF GIRDERS i - HEIGHT OF FOUNDATION 87, THICKNESS SIZE OF FOOTING 7-0 X i e -X MATERIAL OF CHIMNEY /3a�ek IS BUILDING ON SOLID OR FILLED LAND S' o r-, o IS BUILDING CONNECTED TO NATURAL GAS LINE Y Lf ($q !a 0% -two fc. Jqg (' t` Lpi F� �q y�Q Cottr. p. #I' 1c/E,S T �t/DOO�R/OG E— " 1 HEREBY CRRTIFY TO THE TITLE INSUROR AND TO THE BANK THAT THE DWELLING IS LOCATED ON THE LOT AS SHOWN AND THAT IT DORS CONFORM WITH ZONING RRCULATIONS REGARDING SETBACKS FROM STREETS k LOT LINES.' " I FURTHER C TIFY THAT THIS DWELLING IS NOT LOCATED IN TH 'FEDE FLOOD HAZARD AREA AS SHOIIN ON FE ITY PANEL �2sao9e 0003c STEPH 3 ` }I S. DATE THIS PLAN FQc jl0;{iURPOSRS - NOT FOR BOUNDARY BOUNDARY INFORMATION TAKEN FROM RECORDS. PLOT PLAN IN DRAWN FOR �i,s,gGva � ' 5'D DCT 2oD0 HERRIVACX ENGINEERING SERVICES sB PARK STREET ANDOVER, MASSACHUSETTS 0810 �/ODO��2/OG E 1 HEREBY CERTIFY TO TUR TITLE INSUROR AND TO THE BANK THAT THE DUELLING IS LOCATED ON THE LOT AS SHOWN AND THAT IT DOES CONFORM WITH THE � a � ✓OF.� � oo - � 2 ZONING JUGULAVIONS REGARDING SETBACKS FROM STREETS k LOT LINES.' 1 FURTHER C TIFY THAT THIS DUELLING IS NOT LOCATED IN T ! FEDE FLOOD HAZARD AREA AS SHO UN ON FE IrY PANEL �!2Sao9B 0003G ld I SrEPHir ,. S. DA VE THIS PLAN FQ -t URPOSES - NOT FOR BOUNDARY DEk�[ajp ' BOUNDARY INFORMATION TAKEN FROM RZISTIAiG RECORDS. e-40�1-q -0 PLOT PLAN IN A/D. DRAIPN FOR Oi�.q c v,o � = 5'D aGT 20D0 MEMMACK ENGINEERING SERVICES sB PARK STREET ANDOVER, MASSACHUSETTS 0 ! 810 `.N U1,e,�S FORM U - LOT RELEASE FORM -7-30-5T 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 or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT �Dl�l ti S� LV d LOCATION: Assessor's Map Number. SUBDIVISION 3z STREET W Ej % Gayo O 13 1"A C R 19 PHONE C7� �i 6 t' Z-- Z 7�1 ffb^ E S. 6 6 8S` 'I- i w u2A PARCEL 4-1 LOT (S) /Z ST. NUMBER / S *****************************************OFFICIAL USE ONLY*********************************** RECOAWENDATIONS OF TOWN AGENTS: �1„NSERVATION ADMI STRATOR DATE APPROVED !/ DATE REJECTED COMMENTS TOWN PLANNER COMMENTS DATE APPROVED DATE REJECTED FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR -HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm D. Robert Nicetta Building Commissioner (978) 688-9545 (978) 688-9542. Fax Please print. DATE —7 0 � JOB LOCA Town of North Andover Building Department 27 Charles Street North Andover, MA. 01845 HOMEOWNER LICENSE EXEMPTION /9 G.,C-ST Gv Number Street Address /Zn 32- 141 / lot "HOMEOWNER 5'7O 6 SZ -2 355___ 578 6 84 =2,0 3 i Name Home Phone Work Phone PRESENT MAILING ADDRESS g (i✓ EST W ou �RiPi�G, fs /V 0, M iy 00 u (F^ - City Town State 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 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 in a two-year period shall not be considered a homeowner. 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 unders s/the Town. of No. Andover Building Department minimum inspection procedures an uirements and that he/she will comply with said procedures and requirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFI %Y Commonwealth of Massachusetts Department of Fire Services I Per,tlit°•`��' l Occupancy and Fee Checked (99/ ,z� r BOARD OF FIRE PREVENTION REGULATIONS ;[Rev. 9.05 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All �ork to he pertornied in accordance with the \k1SSaCIIIISCttS LlC06Ca1 Code t\IF.C'). �'_(AIR 12.00 iPLEASE PRL\T LN INK OR TYPE ALL LNFOR.1I,)TIO,�-) Date: City or Town of: ci l ir/tJcG'i'/`( To ljlc' lltsj,eClor of i�'ires: By this application the undersigned gives notice of his or her intention to pel,rornl the electrical work described below. Location (Street & Number) )%j/.? -f �C `' 7 � Owner or Tenant 7 �iP �� �' .���.� Telephone VoflL.� ;l'f Owner's AddressJrl&-4'S %"- C -e Is this permit in conjunction with a building permit? Yes 0" No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Und rd g ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ilolllvIelion of /he /fl//rill ins, rNhlp m"l) 1 1. "i". -,l Al; rh,, lnc;?.,, •f, v• ;'(kir. No. of Recessed Luminaires �'Cv� No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA ,No. of Luminaires Swimmino Pool Above (-1 In- ❑o. rnd. rnd. of Emergency Lighting Battery Units 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 No. of Ranges No. of Air Cond. Tonal No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number Tons KW 'No. of Self -Contained yDetection/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 Water Heaters KW No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of :Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: . 111m h oddirrr;lurl ,irlod 11 fit'st ed, or yrs reyuirrd li} lire 11,a'1;C rur ,;; 11 li : E-,,tinlated Value of Electrical Work: (\Vhen required by municipal policy.) lbork to Start; :; -d 6' In:,pections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COV ERAGE: Unless waived by the owner, no permit for the performance of electrical work play issue unleSe the IiCC1hC(: ProvideS Proof of liability insurancC inClUding "ComPleted operation" covuarc or its substantial equivalent. The nndersk-Aied certifies that such co\,..aoc i" in Iilrcc• ;Ind has u.'.hibitcd proof of sacu. to the Permit i.,:.uin- office. (11F..CKONE: lNS1.'R,\NCl_. ❑ M-)\[) ❑ (,)flll:R 1­1(Spccily:) 1 tertitr, lander the- pains :rnd penalties ofli rjnrp, 3tul the hi * rntution wt ,chis vpplicettlim i,% Ire ultll rcrllplefe. ~;r !F'!R1I V;\i\IE:—Y'c - Licensee: / r:-1/ils l' r l,lrlLh ar1 c. �nrl , n l/;r r r ur/r rlilt"/ _ dBills. Bills.•rel. '�o.i';>l �c'"l✓S�'�:_ Address: ` L�1�i .�%'�'� %%1�'%�c'F�°l/�/it z� ;kit. lfel.Vn.1p`'= Security System Contractor L,icunsc requu cd for this .vurk; if applicable. utter the IiCCI1Se number here: 0W (.;P2 a 90!9_ - OW,NER'S INSURANCE bNA1VER: ' I and aw;urc that the Licen::ee dn(t.c 1701 herr(, the liability insurrtnce ,;u ,,.r.u_.e ill anally required by law. By my :.i,11naturC below, Ihereby waive this re ui a1111. nt. I an ❑ d t le (Check one) owner ❑ owner':; ;ioent., Owner/;(gent ��2g �j O �- % a-"i� 6 % / /Z/�� G-- �Z Zomp, c9h- GC,7 0 . 2 7,0 Cv o am 6 Z w 0 LL Ell 0 E E ai 3 — c M c m al in 3 3 `10 m —u 2 ai w u ma� 2 CD EL aj c aj 0 c 0 - 0) Z -A 0 m 7E c 0 3 N 0 LL ai as cl m 0 Z 0 o aj u 0 10 .0 3 F. =aj F. m m H co) Oki�.� .64 13 Coori IL Aw Q go S. A. � Al � 9j ro=: C a) 0 1.0 0 o � m 00 > "0 ra; 0 w ac 0 CIO) �g Cc 0 .v U) m L6 uj U .c .20 o 0 E E ai 3 — c M c m al in 3 3 `10 m —u 2 ai w u ma� 2 CD EL aj c aj 0 c 0 - 0) Z -A 0 m 7E c 0 3 N 0 LL ai as cl m 0 Z 0 o aj u 0 10 .0 3 F. =aj F. m m :u A Q 0 E E ai 3 — c M c m al in 3 3 `10 m —u 2 ai w u ma� 2 CD EL aj c aj 0 c 0 - 0) Z -A 0 m 7E c 0 3 N 0 LL ai as cl m 0 Z 0 o aj u 0 10 .0 3 F. =aj F. m m A o Phi v �2 w° � a cn a a A a � � ° G U w x o4 � `� W � W W • a, � p A � z° cn o cn WhH co C=2 ` O C A , v C3 O; O A O c cl ON .. o E¢ w D c •• 0 : y .0. ts OE ti R� U: M CD m3 z _ CO zip h • y C=G O CD 0 co aC m cc cm CwQ KI c y:mo� m V N O O A o z :o `0 O d C m :yC �C = m mr=m ...p N Z W .y A car O H y dtZ M E 3,0 . y o CM ND a 40'9 o �- t sawm S y O caL c O CD C3 cc M CO2 0 C3 H c cc 0 .0 _cc �. CO) "r ev � 3� CD L Ls a ca ccc O O Z s Cos C LU LU U) W W CC W LLIN Date..................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... ......... .............. has permission for gas - 'installation. ........ I in the buildings of ... ................. at hy)-... Z44f4-v—ie-! - Fee../ —'— Lic. No. //x& Check # 1(:P41;� 4851 tqoNorth Andover, Mass. 0�AS ........... ' Pr MASSACHUSEIIS UNH ORMAPPUCA (Type or print) . NORTH ANDOVER, MASSACHUSETTS Building Locations /v ' /7/7�Srti`•�/' NFOR PERM TO DO GAS MING Date a s Name New ❑ Renovation I Replacement ❑ Permit # XQ4�lAmount $ Plans Submitted • (Print or type), i Name w Address eC� J Name of Licensed Plumber or Gas Fitter Check one: Certificate Installing Company ElCorp. ElPartner. Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. YesEzy No 0 If you have checked Les, please to the type coverage by checking the appropriate box. in Liability insurance policy Other type of indemnity 0 Bond D Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 13 Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations -performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massach Gas andtor4A f th ,neral Laws. Title City/Town APPROVED (OFFICE USE ONLY) .I- Signature of Licensed 0 Plumber Gas,. Fitter aster Journeyman 'J i3RD. FLOOR • (Print or type), i Name w Address eC� J Name of Licensed Plumber or Gas Fitter Check one: Certificate Installing Company ElCorp. ElPartner. Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. YesEzy No 0 If you have checked Les, please to the type coverage by checking the appropriate box. in Liability insurance policy Other type of indemnity 0 Bond D Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 13 Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations -performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massach Gas andtor4A f th ,neral Laws. Title City/Town APPROVED (OFFICE USE ONLY) .I- Signature of Licensed 0 Plumber Gas,. Fitter aster Journeyman 'J Date .!� 3 -ege" ........................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .... - ...... . .... ......... ) ............................. bas permission to perfo ....... - .... ....... ... ................................................... wiring in the building o P, ......................................... at /?North t h A n d o v e r, Mass. FeC.,�. ..... Lic. Nhl,�14-3 .. .. ........ ;ZiN**A T-2— ELEcTR?, Check # 6432 i minonwealth of Massachusetts r w� Department of Fire Services 7 BOARD OF FIRE PREVENTION REGULATIONS N t K icial I isc Onk -- Permit Na Occupancy and Fee Checked t991 [Rev. 9,05] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK SII work to he pertornled in accordance with the %lassachusetts Hcorical Cudatktfi.C�; 5'2=7{"SIR 12.00 WLE.I.S'E PRLIT LV L W OR TYPE, ILL I.VFOR1II TION)—Datiei rt� :� •--�� City or Town of: To /he In peclor of Wires: By this application the undersigned gives notice of llis: 1_Q Location Nb; t Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ `y � TOTAL $ o� 5-' W s Building Inspector 25 ,- 4a PAID Div. Public Works Location No. ? f Date �/ f t{ ij TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $��' Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL Building Inspector 4f9�'`©8:48 25. PAID '�' Div. Public Works Q N ¢ Y z N V) u z ¢ V z :t n N N W C :1 l- X CAz C ~ =' I G L- CC W ��• D 4 Z ` L N r+ G 1 C- y V1 ` w C < ¢ 6 uj W C n N z G W :� ¢ Z d W x t z 3 Vzz, z C u C C Z uj N z W. Z } W ? ^ = W G W Z W V W Z .1 J W Z Z Z Z Z U W ry N Z ^, 9 t%t N N Z Z Z t N LLJ ! N N N — N A r N O Z L. Q' U _ Z r W Q UJ W � Q N Z W } C N �z z Z C w C v a? F z C ¢.n N W N Z C z 3 .�. 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G) cmy0 //�� C m V Cf) L L d In y Z _p p a L "t y A p O •..a Q�Q co Em m W U C CC �' p C �'�'y='ot V J� 9 a+� mac-• y Z co cL m O d 4!vo L V CO) =0 c O p CL o m: c N C .y az"c Z CO) oc E 0� V all m p m C N a 2� o.6 S to 0 y �� o �-- L �0.. CL..-. m V` CN x cz � A o CE v u v ' � o CO c OU z z A .a c w° m 02 U m w O t a �°° C2 w 04 O F W ~ w �°° 2 vi w O a �°° a�' cz w ua w Q w c CO cn o cn 0 U6 0 0 m O CD z O G .d, ' � o CO c o o= cc, H . C .) C.3 V V CL C m C• L ..r w. cQ O m �E 3 o Q� E 3 :om o 0 d J« :mac a N p € Q! m m O. o C. m 1: N cm m N N E N m m 5 CoQ 32 CC5, C.3 > Z p �+c�o a c_ m ,A L4 H O C •C :d N .eyv r C" S_S N C O Z O V m m p -5e C C**i d 2pa 0C4) F- t Z. G..=. m _O 0 U6 0 0 m O CD z O G .d, WU11AM J. SCOTT Director Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES 146 Main Street North Andover, Massachusetts 01845 In accordance with the provisions of MGL c 40 S 54, a condition of Building Permit Number —Vk� is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by, MGL c 1 11, S 150A. The debris will be disposed of in: ---)dll '. 4L cation of cility) ture of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 /-/Date ...'��...... N° 4402 ",ORTH . °4, TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that it '�^ ' ... ....:........... has permission to perform . ..... ............... plumbing in the buildings of .-'................. . at .. 11�............ Noqh Andover, Mass. G' Fee X/. � i� ir� ........ �PLUMBINGANS ECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMITjTO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS ,, r c 9 L. Date Building Location �S' �" ° �D�%r1 �2 d Owners Name GYL24q-x�Permit#_A_/6- N Amount Type of Occupancy New ❑ Renovations Replacement ❑ Plans Submitted Yes ❑ No ❑ TiT4TTTv F C (i?riat or type) \ Check one: Certificate ffistalling Company Name 1� `-b E'% 1 ❑Corp. ❑ Partner. Firm/Co. Name ofLicensed Plumber: Insurance Coverage: Indicate the insurance coverage by checking the appropriate boat Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver•. L, the undersigned, have been made aware that the licensee of this application does not have any one of the above three *insurance 'ySignature Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations per rimed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By; bignature 01 L1CenSCQQSUME)Cr Type of Plumbing License Title City/Town Lice` nssee Num er Master Journeyman ❑ APPROVED (OFFICE USE ONLY NORTH to Date. . 4� /.`� 0. /. P. r TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that I ................... has permission for gas installation ........... nr.. in the buildings of ... .. ................................... 0C)CI w ................... .... I North Andover, Mass. D -2 (C�" Fee ... L... Lic. No. i�( �- -2.1. 1 . .......... .4 2 GAS INSPECTOR Check #I 563 r �\` IVIp66ALi- USSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) 1 = - tV , No r — -- Mass. Date a 5 20 Qs Permit # tt Building Location �' L.r6o1 6r,:die Owner's Name Jin t i .4 I U a tiV TyPe of Occupancy_ I<23t dev ),-Al— New p Renovation ❑ ReplacementV Plans Submitted: Yes❑ NOK. Installing Company Name S:C, r - _– V- - -Check -Check one:..... -Certificate AddressIN A- ❑ Corporation 0. Partnership . Business Telephone Firm/Co Name of Licensed Piumber or Gas Fitter 1 �� q�/ 1� �Q� S; INSURANCE COVERAGE`. I have a currqgpfiabilfty insurance policy or its substantial equivalent which meets the requirements of MGL Ch: 142. Yes No ❑ If you have checked yes, please indicate the , type• coverage by checking the app PProPriate box.`• -A liability insurance policy? Other type of indemnity dy Bond OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in abo knowledge and that all plumbing work and installations performed under the pPlication are true and accurate to the best of my. pertinent provisions of the Massachusetts State.Gas Code and Chapter 142 of the Permit etc I H S �s application will be in compliance with all BY T of License: title _ Plumber Sgnat of Licensed Plumber or Gas Fitter r Gasfitter a ler License , Ci fy/Town Ms se Number lu�yPfaOVF� ourne (O IC US NL Jan . + MEE mom mom son mom mom ME mom ME H 6TH FLOOR mom Installing Company Name S:C, r - _– V- - -Check -Check one:..... -Certificate AddressIN A- ❑ Corporation 0. Partnership . Business Telephone Firm/Co Name of Licensed Piumber or Gas Fitter 1 �� q�/ 1� �Q� S; INSURANCE COVERAGE`. I have a currqgpfiabilfty insurance policy or its substantial equivalent which meets the requirements of MGL Ch: 142. Yes No ❑ If you have checked yes, please indicate the , type• coverage by checking the app PProPriate box.`• -A liability insurance policy? Other type of indemnity dy Bond OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in abo knowledge and that all plumbing work and installations performed under the pPlication are true and accurate to the best of my. pertinent provisions of the Massachusetts State.Gas Code and Chapter 142 of the Permit etc I H S �s application will be in compliance with all BY T of License: title _ Plumber Sgnat of Licensed Plumber or Gas Fitter r Gasfitter a ler License , Ci fy/Town Ms se Number lu�yPfaOVF� ourne (O IC US NL Jan . + Z } O w r W a N x O W Q C7 , O a a Cl O Cl I W z o. F- N � p Z N - - N 4 J Z p O p Q W O W 1- U. W 2 ¢ LL ¢ J z h ul CLL m <O - G. ', O LL W < d O O m V r ¢ J ~ O W .. LL uj YC , O LU- a - N ; r F. v