The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 205 FOREST STREET 4/30/2018 (2)i.� Date. % /.;h f,�(.,.<..... TOWN OF NORTH DOVER PERMIT FOR GA64NSTALLATION This certifies that .. ? «: .« has permission for gas installation ... . p' ................ in the buildings of .. !! . l? . �. o.'� ........................ . at ... n r. ?L .. North_Andoyer, Mass. j v Fee.14). Lic. No.. .2 l .? .. ..--�, 9A; -'R.. PECT f Check # 2 1 7 SSU6 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) NORTH ANDOVER Building Location 205 FOREST ST Date 11/27 2006 Permit # Owner's Name WILLIAM TARBOX Owner Tel# 978 681 1837 Type of Occupancy New Fv—(] Renovation[] Replacement Plan Submitted: Yet No❑ FIXTURES Installing Company Name Eastern Propane & Oil, Inc Address 131 Water Street Danvers, MA 01923 Business Telephone # 800-322-6628 Check one: Certificate Corporation Partnership �� Firm/Co. Name of Licensed Plumber or Gas Fitter ,�'O�-'We/L/L / L (, INSURANCE COVERAGE: I have a cu liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes ✓ No ❑ If you have c ecked ys, please indicate the type coverage by checking the appropriate box. A liability insurance policy ❑✓ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner 11 Agent 11Signature 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 ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. By Type of License: h2 lumber Signature of License umber or Gas Fitter Title &�S A,as fitter l 7 • -Master License Number 102 1 J Cityrrown • -Journeyman APPROVED (OFFICE USE ONLY) Date....Vii° 3 ,. f NORTH , TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING �,SSACNUS� This certifies that ........................... t-� ............. ............... ................ ;as permission to perform A................../r1.. ' wiring in the building of .......... ..I ......I.....`................................................. �t.................................. ..................... -............�torthh Andover; Mass. Fee. �. �..:L�!l.. Lic. No/. ..%�>> ..�.7 � ........... �........ ELECTRICAL INSPECTOR Check # WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 11/01/2001 21;51 1-978-372-5640 MEADOWL'IEW COPrSTR PAGE 01 A o&w Use QNy `. P9mtt Na. — 2�v d ft6ksafsiy & Fes C C , __. BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12.00 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK " wont to be pertained in smadw= with dw UAnwzhusofta EWctdw Cada 527 1 (PWm Print In We or type sit tnfoew MM) eat. to the h psetar of unrea' Tow„ of North Anflover The undera}g W applies for s Pw t to 0WmR the alhcMcel work daealtsd babes. ter, (saw a oyster or Tow, wLl l Ot_fdt ct_, I r�tr c� - c7as,er'sAddrss+s is this peM* It eu _wih s WON yc'vxo: No p (check Awmprislti 00 1 Pulpmo i %7i umy AuWffb Ian No. Existing t3arvice �Mw voles OrorMresd p UnVM p No. of Meters - New Bw as Artws - Yaks ovart,aed Q Lkxdmd p No. of Mtetels Number of PoKk s and LocOm end Neh ad of Proposed EIsabI r l No. of Liol m FiAurea WHO: Pod Above p tr KW KVA of EfANOMW FIREALARM Nn. d2ona No. of DaWSM ant hrNistlrg Dwtaes NO. or so ut alnp nervosa No./ d Salt Conwnsd Dewdovswwft DrAm Q Mwtcivol 0 O*w MSU C -5001M. Rnut" to ta (rqulromev>aa of mn"dwseda Bonino" Laws I haw s au"Wo Lab" bisurwm Poicy h,GWdhq Comet W Operstlons Corarne or its subatar W ogwwkWd YES - NO ha west Proal of same to MG 0" Yea . NO - M you have dmdtea YES PIDW faaloffia ft type of WAVApe by Dnp the appropriate WX Llfa)RANCOBOND - OTHER - (Plssse SPadHJ �Eapinlbn Deb} EdbasM d Yarw at 9MCt toot tMork! - wwom to >ntanr _ tnspat4len Drte Rss�Yadsd lioeph Fk,N _ FSigmW undsrtae f4nallks pas}retr: �iZ s4 /G LIC. NO I.tce■.s. _ s�nas+re _ p'/` _Lte. / TN No. rI rF� OMumsPARwA1Wl�tt- I -art swm Mnt ft Llanap dos no4 have 1hr tnserana ravrraga o► Id sutastantlN sautvaiMet es eagvMwl by tM..arshusiter Ge sf e�,j a this psnfrk rPPft� waMea Ws rfqutMO M Ol~ Apert (glossa Ctwk onal l / : Telephone No. , PEMT FEE i , .— (Slpn*Am of *~at AV" Date .//-,'��/,?,-)/ ........... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ......... has permission to perform ................. plumbing in the buildings of —%�� .......-....... at. - . . . d—� ........ North Andover, Mass. Fee Lic. No/�-V. . . . �'T' P L U N' Pf") �CC;R Check # 611" 50339 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS ' Date 1 l - 2-1 -G Building Location 205 Fc2>cSi Owners Name =PCRTs-e'-)e Permit # 0-3 Amount /» i Type of Occupancy l�t_nNt New Renovation Replacement Plans Submitted Yes No ❑ F-KY11RES i ilk -------------------------- 17D TO 0 MMMM0MMMMMMM0MMMKiMM (Print or type) Installing Company Name Address in r %L'i M ► I I �� - � Check one: ❑ Corp. F1Partner. ® Firm/Co. Name of Licensed Plumber: NAIVE AAA.L Q /R6 Insurance Coverage: Indicate the type of insurance coverage by checking theappropriate box: Liability insurance policy ® Other type of indemnity E] Bond ❑ Certificate Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature IOwner ❑ Agent 11 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 Massachusetts in ode and C pter 142 Rrf the General Laws. By:Signature oficeens�e Pum er Title Type of Plumbing License City/Town icense TN um er Master Journeyman ❑ APPROVED (OFFICE USE ONLY ation A. Date . • I MaRTM TOWN OF NORTH ANDOVER 16 ` Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ ,2 i Check # r y v 9 l/ Building Inspeytrgf N • TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING 44 A BUILDING PERMIT NUMBER: DATE ISSUED: ass 10 -�� C) SIGNATURE: Building Commissionerfigs 2EELor of Buildings Date 1 SECTION 1- SITE INFORMATION I -r' U 1.1 Property Address: 1.2 Assessors Map and Marcel Map Number Number: Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft s Front Yard Side Yard Rear Yard Required Provide Required Provided ReqWred Provided 154) 1.7 Water Supply M.G.L.C.40. Public ❑ Private ❑ 1.5. Flood Zone Information: Zone Outside Flood Zone ❑ 1.8 Municipal Sewerage Disposal System: ❑ On Site Disposal System ❑ NES U17Vf'4L - rKVrKKl Y OWINFHStUr/AU'1'riUKlZE-D AUEf4-l- 1 2.1 OwnerofRecord r ` 1 \ £ LZ r i �Q ✓ ��i� �� T (� 1� S i Name (Print) < Address for Service: Signature 2.2 Owner of Record: Name Print SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: 1GI U •yea,t— LicenseddConstruction Supervisor: Ct ?�p Addre Signature Telephone 3.2 Registered Home Improvvement Contractor LL`I � ( �ya1Q�e Company Name Addres Address for Service: Not Applicable ❑ C, S C)5q gC) 3 License Number ffb) ,-)' d Expiration Date Not Applicable ❑ >(:,-2os&o Registration Number l/3o, ,;)-170�— Expiration Date H L r r I L. 1 SECTION 4 - WORKERS COMPENSATION (NML. 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 rmit. Signed affidavit Attached Yes .......0 No ....... 0 SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: OnRl ani r_e la- B -N'8 Ja►' zePIC -Q e)(44 (k � .y�u. 44d, /N Cvn,Mp/aeve -,-_ SECTION 6 - F,STIMAT-M r6NCTwirTTnN rncTc Item Estimated Cost (Dollar) to beGIAL$E Completed by t applicant -4 ;M� (a) Building Permit Fee Multiplier �} 1. Building Do 2 Electrical (b) Estimated Total Cost of Construction 000r 3 Plumbing Building Permit fee (a) x (b) 7 n , - / 4 Mechanical (HVAC)/ 5 Fire Protection 6 Total 1+2+3+4+5 Check Number .M 1. - L evil i s V v11\L' JM FkU l K1%Jn GPUL IL 1174 1 V 19E %-V1gYLE I ED W t1EiV OWNERS AGENT OR UQ APPLIES FOR BUILDING PERMIT I, -D", i S 0, W e s -� , as O / My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I zed Agent of s bject property to act on mw_—�WA� 1, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Signature of Owner/Agent Date r r FORM U -LOT RELEASE FORM u,cw i=1 w 12 ooua . �s INSTRUCTIONS: This form is used to verify that all necessary approval4ermits from 1 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 1�Gt,I � a 6, I/ e5, t PHONE h W— / �39 LOCATION: Assessor's Map Number PARCEL SUBDIVISION LOT (S) STREET 6S f 'D & y f` �` 'T: ST. NUMBER&O I*****************************************OFFICIAL USE ONLY*********************************** RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER COMMENTS DATE APPROVED DATE REJECTED ECCTOR-HEALTH / DATE APPROVED DATE REJECTED i 6 u SEPTIC INSPECTOR -HEALTH DATE APPROVED 1272 d DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIO DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTO Revised 9\97 jm TE COMPANY y 771-;7 c COMPANY - THIS IS TO HE POLICIES OF INSURANCE LISTED -- INDICATED. NOTWITHSTANDING ANY REQUI INDIC CERTIFY THAT T 7777-7'7�� 'ERTiFICA TEMAy BE ISSUED 0 BELOW HAVE BEEN ISSUED TO THE I S RE EXCLUSIONS REMENT, TERM 7777777777777r7� AND CON ED OR MAY PERTAIN, THE INSU OR CONDITION OF ANY CONTRACT T AMED ABOVE FOR T CO 'ttPOLiCIES. RANCE AFFORDED THE LICIE LIMENT WITH HE POLICY F 0 z V IN ---_"H DR I t S IC T L U r I F S T SC T E 0 A TOC T N E PE SHOWN M y AVE N E UC ES Ri E EREIN is DC SU LTR I YPE OF INSUFtANCe ------ A H H RESPECT TO WHIC ED In I N L SUBJECT TO ALL THE 1. POLICY A i�GENERALL LIABILITY NUMBER POLICY L --------- 'A ABILITY EFFECTIVE iPOLIC y DATE (MM,DD EXPIRATIO CO E.qC 'Do/VV) DATE (MMjDD/yy) -90AL N -�OMME GENERAL LABILITYF. LIMI,rs AIMS 1CLAIMS MADE f .0.. NERAL .. ... OCCUF, 3 'k 03. ovv'V[-:9 S a CON7 031("91 RACTOR,S PROT 020 UCTS- CcIvpiop AGG I 000, RSONAL & ADV iNJUR A�TOMOBILE LIABILITY -Ct'.00CURRENCE '--- ---- I a, 00(j, ANYAUTO E DA,1'14AC�E�An, one re, ALL OWNED AUTOS D EXp n one perscn) SCHEDULED AUTOS Mf3INED SINGLE LIk4I-.l $ HiREDAUTOS NON-OWNEDD*LY INJURY AUTOS er person) is DLY INJURY er accident; GARAGE L�IASILITy ANY,,,(; I -Y DAMA OPERI GE IA N t Y L'AB 'TY '0 ONLY EA NT E ---- HER THAN-T— SS Llf - ry I EXCESS i ABILITY AUTC 0141-1 -�7 L I ACV��CCCIDEA4+1.$ UMBRELLA FORM f C ",E_R T _AGGREGATE J.s UM OTHER TH_ANUV3REL-LAFC8M OCCURRE CE jrGREG Fmp'0YER -)MPE-NSAT!ON AND I GRE GATE ----------------- THE FE R ----------- 'Op"'FTO $ -N /EXEC T 0':' E �S RC AiLjTo�;Y 'CR -A OTHER_PH ACCIDENT - DESCRIPTION OF op'FA"ONS'LOCATIONSNE-41CLES/sPkCIAL ITEMS 3EASE---POUCY LIMIT 4— _EASE - EACH �YE E; '11BED POLICIES BE CA.,ELLED BE ;SUING COMPANY WILL ENDEAVOR E CERTIFICATE HOLDER NAMED TO SHALL IMPOSE NO OBLIGATION OR 'My, IT8 AGEN-rS OR ..—. TH a a a SEP. -E6' O1 (THU)14:21 AC PRDb 1�1`60*, �46zin BARROW GROUP, LLC 110 EAST CROGA N LA STREET W'REPICEVILLE, ICA 30046 INSURED TEL:770 348 54 - 40 P. 0(j] ONLY CERTIFICATte owiv ANO CO NF 18 ISSUEL) ASA HOLDER, TNja ERS NO ArTER ALTIII CERTIFICATE RIGHTS UpON OFINFORMATION COVERAGE A ')OE E- CERTIFICATE FO NOT AiW a COMPANIES By TkE I RESOURCECOMPANY '; - PANI S A. I a C SSND L R MANAGEMENT A FRONTIER AFF Ve. 261 MAIN STREET, INS FITCHBURG, MA SUITE 5 EI -tJRANCE COMPANY 420 COMPANY (508) 343-0048 COMPANY c ry.a7117, COMPANY L —7m," 1— COL�W EG[v 15SUED NS AND TO TORE jN.5Ujj 0 ED NAIVE AS VE L.ISIOTERIRAMEEAF n tk.- R Th q NY CONTRACTOR OTtigR rJOCUME E 'THE PI )r -SCR -7 WT,4 RCS LTq TYPE OF INSURANCE S SfiOWN MAY HAVE EFN REDU IfIED HEREIN F cPOLICY PERM0 CIE 11 GENERAL fLITY P CeDsaor, PAID I is SusjECT T I T IS LI1y6FqcrfvE,P T" *HE — 0 . A - L __- C S, 01 NUMBER PC QLAIAJ& T L I Cy k4p, RA TIO N -Y _91`141FRciAt GENERAL LIAOILITy DATE lAIMrDGryyl I CLAIMS MIOC Ne .ADEGA 1,; ; JOCLR LIMITS CONTRACTOR 8 PRbT 1 AGORE-OAT, PRODUCES • CojMp -.lop AGO I s AUT000a -LE�SON4. I ACV,N , y.EACH OCCujReNCeIANYAUTO ..FIRE C ALI- jjWjjrj) AUTOS AMAcj (A,, E)(P IAny one pareon ScHI., DULED AUTOS HIREP AUTOS ICOMshro SINGLE OMIT NON-OWNEDAUTOS par pa, an) eODllvINJU GARAGEBOOItY INJURYLIABILITY Wel accia'I') ANY,kU !PROPERTY CAMAC3e AUTO EXCESS Y * -IIA4CC� DEII THAAIAUTO oNty. �,i UMIMELLA FORM I EACH ACC!J)CtqT 1HA W EM�KPR'S COMFICNZ ;EACH QCCURREN om N UMORELLA FOR4 AOOREOA1Z OYEgB' LIABILITY 110 AND Ire PPe79 iGa4TF AGof PA 4Ttql:R y: Irly A 103 Q 03-01-02 1 Y .: wc vrATU OTHER i6XCLJ r'311YLIII T3 cy EL "CHACCiOENT ER I EL C-" AGE "CLICY LIMIT 1, POP, 000 EL 0111 EAPLOYL-;E "IF 178%,Efrommr "I — 1. pOD COVERA8E ISE r'ONI/L. MFA'0c)w V, = EXT'VI TI" I'Tjf PECIA I 'WCONSTRUC I EASE MPLOyEES OF ALTERNATEE TMINI— MPLOYER: ICONS V, FA DOW A Tr- DAVI VlVIEWTRLJCTION [) WEST 9:? LA,MOILLE AVE. BRAC)FOIII MA 07835 SH u . ..... LO ANYOF TqL, .4 1I OESC EXPIRATION 0 Rifito P ATE rfeREO Cl 30 F. CANCELLED DAYS Issul C NY BEFORE 1-4, WRITTEN NOTICE To I`�- ENDeAVOR OWT FAILVR6 TO AI THF CEP CATTO AI OF ANY KING LCH NOTiCB NAL.L 1UP BE HOLDER NAMED TO THLI LErr, PON Tije No ONLIGATII ON LIABILITY WGFI SE COMPANY ITE AGENTS _11III . OR RIEPREsemr,""E'. ��e ai�eirea�curaa�ir- ol, llawackjeffi BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 059803 Birthdate: 08/22/1970 Expires: 08/22/2002 Tr. no: 1688 Restricted To: 00 DAVID O WEST 92 LAMOILLE AVE BRADFORD, MA 01835 Administrator :Te �i%o�nononuie¢�,/� � "`raimr./(u.elC,t NOME IMPROVEMENT CONTRACTOR Registration: Expiration: 010/300/2002 Type: DBA MEADONVIEN CONSTRUCTION kV B NEST ADMINISTRATOR 2 LAMOILLE AVE BRADFORD MA 01835 North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: 0 - (Location orF 'ty) Signature of Permit Applicant lo Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector own of North Andover Office of the Health De CO � NOR7h mmDevelopment unity Develo partment og...,. ,.. 27 Charles Street Services Division North Andover " z ,Massachusetts 01845 � Sandra Starr � < •�-::.. Health Director �SS'QCHUS t Telephone (978) 688-9540 Fax (978) 688_9542 October 1, 2001 William and Gail Tarbox 205 Forest Street North Andover, MA 01845 Re: Application for an Addition Dear Mr. and Mrs. Tarbox: The Health Department has reviewed application was denied on October 1, your application for an addition at 205 Forest Street 2001 for the following reason: The current septic eet. The The p c system was upgraded regulations was granted for m 1998 and a variance from the current Title V be constructed 3 the separation to ' above the seasonal high ro groundwater. The variance allowed new construction is allowed to take g $ undwater. table. Under the Title V re the system to subsurface sewerage disposals stem lace which Re utilizes a system that has dations, no Regulations for any nem, constructern.must be upgraded to comply this variance. The p y with current Title V Please feel free to call the Health Office at 978-688_9540 with any questions you may have. Sincerely, an J. LaGrasse Health Inspector Cc: David O. West 92 Lamoille Ave., Bradford, MA 01835 Building Department File BOARD OF APPEALS 688-9541 BUIL DING 688-9545 CONSER VATION 688-9530 88 9530 NURSE 688-9543 PLANNING 688-9535 Cl) m m m 0 C) 10 C cm CO) Cl) 10 0 CD C) Z CO) MM a. r �• � O C1 =• y 12 o v CD CDCL o crd CD 0 CD wW C CD y. CD GL O CO) CD i � v y O CD n a o CD O C CD C C y O O O S d OEP&M CO2 An m H Z y' O 0=. .+ CD O m y O N C;, imm�y D CD > o� o V nj n O N COitD C = y � I n 0 :• =r m 3 3 1 � `mom,.• cn r< N G1 O C/) GHQ o m m -� o � t p O ?a.��1 � CD D o '� •► r. 1 C M n O n� CD 7d : C51:r: cn Y n, o ?i �' ,�' n' P�j-x O M :71 CL O x 0 0 0 c = N° 3 S. i Date... Vii ......::......... ......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....j.. �' ..........................�.....�.................................... has permission to perform.............................................................................. j wiring in the building of :....� .!..` f ........................................... at ................................................::.. f.................... , North Andover, Mass. Fee -;7 ................ Lic. No........................................................:.................. ELECTRICAL MpEcwlk Check # 64-0"" WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Official Use Only Permit No. t:U t �� Occupancy & Fee Check BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00 (Please Print in ink or type all information) Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number `D_7 Fc> ' `1�'�"�� • Owner or Tenant—Lk) �p d Owner's Address Date ��` — _ d / To the Inspector of Wires: Is this permit in conjunction with a building permit Yes ❑ N (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Voits Overhead ❑ Undgmd ❑ No. of Meters New Service Amps Voits Overhead ❑ Undgmd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy includin ompleted Operations Coverage or its substantial equivalent ftS = NO = valid proof of same to the OfficNO = If you have checked YES pleas§ indicate the type rage by checking the appropriate box FF� BOND = OTHER = (Please Specify) —7/ Z (Expiration Date) Estimated Valof EI ctric 1}{�ofiC$ Work to Stag ue -7 v / Inspection Date Resquested Rough Final Signed under P ies o path] / FIRM NAAMME� —� wI L—rT i G LIC. NO. /S Liensee> I kH �J V w v Signa re LIC . NO. ?cS6f BA/Tel No.� `�Addre4L�wiv/G� AR Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) ,-5- Telephone -./Telephone No. PERMITTEE $ _ (Signature of Owner or Agent) Total No. of Lighting Outlets No. of Hot fuse No. of Transformers KVA Above ❑ In ❑ No. of Lighting Fixtures Swimming Pool grnd ❑ grnd ❑ Generators KVA No. of Emergency Lighting No. of Receptacles Outlets No. of Oil Burners Battery Units No. of Switch Outlets No of Gas Burners FIRE ALARMS No. of Zone No. of Detection and Total No. of Ranges No of Air Cond Tons Initiating Devices Heat Total Total No. of Di osal No. Pumps Tons KW No. of Sounding Devices No./ of Self Contained No. of Dishwashers Space/Area Heating KW Detection/Sounding Devices ❑ Municipal ❑ Other No. of Dryers Heating Devices KW Local Connection No. of No. of Low Voltage No. of Water Heaters KW Signs Bailases Wiring No. Hydro Massage Tuds No. of Motors Total HP OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy includin ompleted Operations Coverage or its substantial equivalent ftS = NO = valid proof of same to the OfficNO = If you have checked YES pleas§ indicate the type rage by checking the appropriate box FF� BOND = OTHER = (Please Specify) —7/ Z (Expiration Date) Estimated Valof EI ctric 1}{�ofiC$ Work to Stag ue -7 v / Inspection Date Resquested Rough Final Signed under P ies o path] / FIRM NAAMME� —� wI L—rT i G LIC. NO. /S Liensee> I kH �J V w v Signa re LIC . NO. ?cS6f BA/Tel No.� `�Addre4L�wiv/G� AR Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) ,-5- Telephone -./Telephone No. PERMITTEE $ _ (Signature of Owner or Agent) -5�N, Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 �y DEP has provided this form for use by local Boards of Health be submitted to the local Board of -Health or other approving A. Facility Information Important: When filling out 1. System Location: forms on the ; f\ - I ^ -- computer, use only the tab key ` to move your cursor - do not use the return key. 2. System Owner: RECEIVED JUN 5 2006 iJ ,Xsote Pumping ReRc� rd must IFRKTH DEPARTMENT http://www t5form4.doc• 06/03 Mate / Zip Code rvame - Address (if different from location) City/Town State _ —Zip�Cotle Telephone Number B. Pumping Rlecord ]0 1. .Date. of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) [otic Tank ❑ Tight.Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes U -N If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: O'c C t 6. System Pu ped By , Vehicle License Number Compan t 7. Loca!!i9rMhere con.0 r we--Aisposed:: A17VIu�C� Date water approvals/t5forms.htm#inspect system Pumping Record • Page 1 of 1 Cityfrown B. Pumping Record 1. Date of Pumping 3. Type of system: 8 Other (describe): State r ZtC e Telephone Number 62 Date L Quantity Pumped: Gallons Cesspool(s) is Tank Tight Tank 4. Effluent Tee Filter present? F1 Yes G --vu 5. Condition of System: 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Locati here contents were disposed: .L.S. Lowell Waste Water of If yes, was it cleaned? [ Yes [j No �& �- "zzN , ( � F 5821 Vehicle License Number 6 --� �S� Date t5form4.doc• 06/03 System Pumping Recons • Page 1 of 1 Commonwealth of Massachusetts _. RECEIVED of RECEIVED - System Pumping Record JUN 2 2 2009 La, Form 4 --" TOWN OF NORTH ANDOVER NT DEP has provided this form for use by local Boards of Health., ut the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location: Left front, left rear, left side of house. Right front, right tea , right sid of house. forms on the computer, use only the tab key to move your Address cursor - do not use the return City/Town State Zip Code key. 2. System Owner: Name Address (if different from location) Cityfrown B. Pumping Record 1. Date of Pumping 3. Type of system: 8 Other (describe): State r ZtC e Telephone Number 62 Date L Quantity Pumped: Gallons Cesspool(s) is Tank Tight Tank 4. Effluent Tee Filter present? F1 Yes G --vu 5. Condition of System: 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Locati here contents were disposed: .L.S. Lowell Waste Water of If yes, was it cleaned? [ Yes [j No �& �- "zzN , ( � F 5821 Vehicle License Number 6 --� �S� Date t5form4.doc• 06/03 System Pumping Recons • Page 1 of 1