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HomeMy WebLinkAboutMiscellaneous - 22 CLARENDON STREET 4/30/2018O N. 'r, Location r10 v No. Date Check # -_,274 I — U TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ z Foundation Permit Fee $ Other Permit Fee $ TOTAL $ /Buildiing Inspector 0 �I Z c 3 0 E J Z LL O Q m v Y \ O LL In Q VI O tLLJaif Z Z m C: O 'a 7 LL L O.' C U LL O H Z Z m J a -C 7 W N z J u V W L M 0 N U In !6 C LL O U W N Z Q Q t. j O w f0 C LL W GC Q W W LL i m z U y, CU N (% N N O. N V c1. U) J o = L N o> — = ai CD .moo= > 0 w V: a c O L: :foo m z �•�U� tm 0 c.2 ; ` amzmtoo��,a a �r�Qelta Office of Consumer Affairs & Business Regulation ME IMPROVEMENT CONTRACTOR f egistration: .15381'1 Type: xpiration: 14/2015. Priviite Corporafir! R.S. HEBERT CO & REMODEL&.& INC. RONALD HEBERT ` 102 ADAMS AVE. NO ANDOVER, MA 01845 ' Uuderseoretat�f Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS -058241 ``\.r: i. N o,. RONALD S HEBEJkT 102 ADAMS AVE: ' s N ANDOVER MA 0184 Expiration Commissioner 01/08/2016 AC- "PC" CERTIFICATE OF LIABILITY INSURANCE 08/08/14 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Phone: 978 688 8829 Michaud, Rowe And Ruscak Ins.Fax: 978 557 2130 2.0. Box 188 Vorth Andover, MA 01845 -awrence R. Michaud, CIC NAME: AHI Ne E,� : V No): E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE MAIC # INSURER A: NorGuard INSURED R S Hebert Const & Remod, Inc. INSURER B: Commerce Insurance Company 34754 INSURER C : 102 Adams Avenue N Andover, MA 01845 INSURER D: INSURER E: X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE Fx ] OCCUR INSURER F: ......�... w+-c� f-00TICIRATC hll UP9:r?• REVISION NUMBER: V V V GIRliV G�7 vr......�r.. .. �...��. .. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE POLICY NUMBER MM/UDD EFF MND EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 DAMAGE TO RENTE07- PREMISES Ea occurrence $ 50,00 A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE Fx ] OCCUR RSBP404812 05!11/14 05/11/15 MED EXP (Any one person) $ 5,00 PERSONAL & ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,00 $ IEMacidentSINGLE LIMIT 1,000,00 7X POLICY JECTPRO LOC AUTOMOBILE LIABILITY BODILY INJURY (Per person) $ B ANY AUTO ALL AUTOS OWNED X SCHEDULED NUTOS ED X HIRED AUTOS X AUTOS BBCM08 12/19/13 12119/14 BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR CLAIMS -MADE DED I I RETENTION WORKERS COMPENSATION $ X WC 3TATU- OTH- A AND EMPLOYERS' LIABILITY YIN(RSWC588683 ANY PROPRIETOR/PARTNER/EXECUTIVE r ---1N OFFICER/MEMBER EXCLUDED? (Mandatory in NH) Ifes, describe under DESCRIPTION OF OPERATIONS below I A 01/01/14 01/01/15 E.L. EACH ACCIDENT $ 100,00 E.L. DISEASE - EA EMPLOYEEI $ 100,00 E.L. DISEASE -POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) Augustine McDonald 26 Clarendon Street North Andover, MA 01845 ACORD 26 (2010/05) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD V R R.S. HEBERT Construction & Remodeling Inc. 102 Adams Ave. No. Andover Mass. 01845 (978) 686-0786 Phone / Fax Lic. #:058241 DATE 7/22/14 Reg. #:153811 Job: Augustine & Anne Marie Mcdonald 29 Clarendon St. North Andover Ma. 01845 Phone # 603-544-7257 PROJECT: Repair storm damage I. PARTIES This contract (hereinafter referred to as "Agreement") is made and entered into on this 22 day of July.2014 by and between Mr. Mcdonald (hereinafter referred to as "Owner"); and R.S.Hebert Construction & Remodeling Inc., (hereinafter referred to as "Contractor"). In consideration of the mutual promises contained herein, Contractor agrees to perform the following work, subject to the terms and conditions below: II. GENERAL SCOPE OF WORK DESCRIPTION Supply all material and labor required to build the following. 1. Supply building permit. 2. Supply dumster. 3. MAIN HOUSE ROOF TRIM 4. Remove remaining damaged gable end soffit, fascia and crown moulding. 5. Cut roof sheathing back appox. 6 ft.on roof to a rafter and replace with 1x8 rough spuce along 12 ft.of roof edge. 6. Install gable end rafter and 2x4 look outs. � f Contractor Owner Owner of 7. Install new 1x6 primed pine fascia board , 16 ft. 8. Install new 1x10 & 1x6 primed pine soffit, 16 ft. 9. Install new 1x5 custom milled crown moulding. 16 ft. 10. Paint gable end roof trim, 2 coats. 10.Remove damaged fascia, soffit & crown mould from left side of house at bottom of roof line. 12 ft. 11.Install new 1x6 primed pine fascia. 12.Install new 1x6 & 1x10 primed pine soffit. 13.Install new custom milled crown mould. 14.Paint roof trim left side of house two coats. FRONT PORCH ROOF 1. Remove right side gable roof trim, sheathing and broken rafters 7x7ft. 2. Install new 2x6 rafters. 3. Install new 1x8 rough spruce roof sheathing. 4. Install 1x6 primed pine fascia board. 5. Install 1x4 primed pine soffit. 6. Install 3-5/8" crown moulding. 7. Paint porch roof trim two coats. 8. Cut out broken roof sheathing. 9. Install 1x8 rough spruce to damaged area 2x2ft. ROOFING 1. Remove roof shingles from house and porch ( 2 layers) 2. Install new three tab shingles , drip edge and 151b. felt. 22 squares. SIDING 1.Remove damaged siding from front of main house bottom and top,32 sq ft. 2.Install new cement siding where removed. 3 -Paint front gable end wall of main house two coats, to match. z� Contractor Owner Owner FRONT 15t. FLOOR WINDOWS 1.Remove damaged sash , interior trim and exterior trim. 2.Install new exterior band mould and under sill mould on two windows. 3.Reinstall repaired and reglazed sash. 4.Install interior side bands. 5.Paint Two windows complete interior and exterior. 6.Install one new triple track storm window. FRONT PORCH INTERIOR 1.Remove water damaged bead board ceiling, 108 sq. ft. 2.Remove ceiling moulding. 3.Remove damaged 1x5 and 1x10 pine trim along ceiling and windows. 4.Install new primed pine bead board ceiling. 5.Install new ceiling moulding, 48 lin. ft. 6.Install new 1x5 and 1x10 primed pine trim, 48 lin. ft. 7.Paint interior of porch complete 2 coats. 8.Remove and reset porch furniture. 1ST FLOOR INTERIOR 1.Repair closet wall and ceiling and paint complete. 2.Remove and reset contents. HALL 1.Repair cracks in ceiling and wall inside corner. 2.Paint hall walls and ceiling complete. 2ND FLOOR INTERIOR 1.Repair wall and ceiling in closet. 2.Paint walls and ceiling of closet complete. 3.Remove and reset contents. A. LUMP SUM PRICE FOR ALL WORK ABOVE* $25,500.00 Twenty five thousand five hundred dollars 2. STANDARD EXCLUSIONS: Unless specifically included in the "General Scope of Work" section above, this Agreement does not include labor or materials for the following work: Plans, engineering fees, Contractor Owner Owner Testing, removal and disposal of any materials containing asbestos (or any other hazardous material as defined by the EPA). Custom milling of any wood for use in project. Moving Owner's property around the site. Labor or materials required to repair or replace any Owner -supplied materials. Final construction cleaning (Contractor will leave site in "broom swept" condition).,correction of existing out -of -plumb or out -of - level conditions in existing structure. Correction of concealed substandard framing. which may be discovered in the removal of walls or the cutting of openings in walls. Removal and replacement of existing rot or insect infestation. Failure of surrounding part of existing structure, despite Contractor's good faith efforts to minimize damage, such as plaster or drywall cracking and popped nails in adjacent rooms or blockage of pipes or plumbing fixtures caused by loosened rust within pipes. Exact matching of existing finishes. Cost of /testing/remediating mold/fungus/mildew and organic pathogens unless caused by the sole and active negligence of Contractor as a direct result of a construction defect that caused sudden and significant water infiltration into a part of the structure. B. DATE OF WORK COMMENCEMENT AND SUBSTANTIAL COMPLETION Commence work:7/30/14. Construction time through substantial completion: Approximately 4 weeks, not including delays and adjustments for delays caused by: holidays; inclement weather; accidents; shortage of materials; additional time required for Change Order and additional work; delays caused by Owner, Owner's design professionals, agents, and separate contractors; and other delays unavoidable or beyond the control of the Contractor. C. CHARGES FOR ADDITIONAL WORK: CONCEALED CONDITIONS, DEVIATION FROM SCOPE OF WORK, AND CHANGES IN THE WORK 1. CONCEALED CONDITIONS: This Agreement is based solely on the observations Contractor was able to make with the project in its condition at the time the work of this Agreement was bid. If additional concealed conditions are discovered once work has commenced or after this Agreement is executed which were not visible at the time this Agreement was bid, Contractor will point out these concealed conditions to Owner, and these concealed conditions will be treated as Additional Work under this Agreement. Contractor and Owner may execute a Change Order for this Additional Work. Contractor is released, held harmless, and indemnified by Owner from all pre-existing mold, fungus, mildew, and organic pathogen problems and is not responsible for costs or damages associated with correcting, containing, testing, or remediating the same. i F1r# - Contractor Owner Owner a D. PAYMENT SCHEDULE AND PAYMENT TERMS 1. PAYMENT SCHEDULE: * First Payment: Deposit $ 10,000.00 Second Payment When roof is complete. $ 9,500.00 • Final Payment: Balance of contract amount due upon Substantial Completion of all work under contract: $ 6,000.00 2. PAYMENT OF CHANGE ORDERS/ADDITIONAL WORK: Payment for Additional Work is due upon completion of either all or part of the Additional Work and submittal of invoice by Contractor. E. WARRANTY Thank you for choosing our company to perform this work for you. Your satisfaction with our work is a high priority for us, however, not all possible complaints are covered by our warranty. Contractor does provides a limited warranty against material defects on all Contractor- and subcontractor -supplied labor and materials used in this project for a period of one year following substantial completion of all work. This warranty covers normal usage only. You must contact the Contractor upon discovering an item in need of warranty service. Additionally, Owner's hiring of others or direct actions by Owner or Owner's separate contractors to repair a warranty item are not covered by this warranty and will not be reimbursed by Contractor. No warranty is provided by Contractor on any materials furnished by the Owner for installation. No warranty is provided on any existing materials that are moved and/or reinstalled by the Contractor within the dwelling or the property (including any warranty that existing/used materials will not be damaged during the removal and reinstallation process). One year after substantial completion of the project, the Owner's sole remedy (for materials and labor) on all materials that are covered by a manufacturer's warranty is strictly with the manufacturer, not with the Contractor. Repair of the following items and related damages of every kind Contractor Owner Owner .} are specifically excluded from Contractor's warranty: problems caused by lack of Owner maintenance; problems caused by Owner abuse, Owner misuse, vandalism, Owner modification, or alteration; and ordinary wear and tear. Damages resulting from mold, fungus, and other organic pathogens are excluded from this warranty unless caused by the sole and active negligence of contractor as a direct result of a construction defect which caused sudden and significant amounts of water infiltration into a part of the structure. Deviations that arise such as the minor cracking of concrete, stucco, and plaster; minor stress fractures in drywall due to the curing of lumber; warping and deflection of wood; shrinking/cracking of grouts and caulking; fading of paints and finishes exposed to sunlight are all typical (not material) defects in construction, and are strictly excluded from Contractor's warranty. I have read and understood, and I agree to, all the terms and conditions contained in the Agreement above. V5� DATE CONTRACTOR'S SIGNATURE VON 61�ld DATE f OWNER'S SIGNATURE The Customer has three days from date of signing to void this contract. Aon , Contractor Owner Owner Location C ta T'e Q 40 N S> No. Date '7-/ ,40RTN TOWN OF NORTH ANDOVER j 0 v Check # 157'18 Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 30 - ,30 -- ,/X,m (ce-c-, Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: 02 DATE ISSUED: SIGNATURE: 1 Building Commissioner/Inspector of Bjuildings Date SECTION 1- SITE INFORMATION 1.1 Property ddress: f-- s� 1.2 Assessors Map and Parcel Number: Map Number Parcel Number / 1.3 Zoning Information: Zoning District ProposedVse 1.4 Property Dimensions: Lot Area Frontage (ft) 1 1.6 1sU1LU11NU SETBACKS (ft) Front Yard Side Yard Rear Yard Required Provide Re4Wred Provided .Re red Provided 1 F 1.7 Water Supply M_G.LC.40. 34) 40' LS. Flood Zone Infomntion: Public ❑ Private ❑ ZOIIe Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSIIIP/AUTHORIZED AGENT �. i owner of Kecora "i C' Irl G/�• G Name (Print Address for Service 'e Signature Telephone 2.2 Owner of Record. Name Print SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervis r: `7 t 4a c �• e Licensed Cc &uctio`n Supervisor: Address Telephone 1! 3.2 Registered Home Improvement Contractor Company Name Address for Service: hone y i � �C:•r y_ 6� :;�(0y Not Applicable ❑ —0 a o a> sat License Number 03 Expiration Date Not Applicable ❑ I Registration Number Address Expiration Date TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: a t� DATE ISSUED: 8 SIGNATURE: Building Commissioner/Inspector of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property ddress: 1.2 Assessors Map and Parcel Number: M NumberJ J Parcel Number � SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 1.3 Zoning Information: Zoning District ProposedUse 1.4 Property Dimensions: Lot Area Fronta ft 1.6 BUILDING SETBACKS (ft) Front Yard Side Yard Rear Yard Required Provide Recl uired Provided Required Provided t 1.7 Water Supply M.G.LC.40. 54) i ' 1.5. Flood Zone Information: Public 0 Private ❑ Zone Outside Flood Zone 0 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal system o SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT z. r owner or xecora Name (Print Address for Servicee,: / //,I- /,V C/ -e Signature Telephone 2.2 Owner of Record. Name Print SECTION 3 - CONSTRUCTION 3.1 Licensed Construction Supervises �`� i 4, s1 �• 1 Licensed Cc itruction Supervisor: Address /f i ! 3.2 Registered Home Improvement Contractor Company Name Address n 7L�V ter Telephone Address for Service: I Not Applicable 0 OaOCO8Ot License Number Expiration Date — d Not Applicable 0 Registration Number Expiration Date 4 SECTION 4 - WORKERS COMPENSATION (NLG.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......0 No ....... 0 SECTION 5 Description of Proposed Workchecks-_ applicable) New Construction 0 Existing Building 0 Repair(s) ❑ Alterations(s) 0 Addition 0 Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated .Cost (Dollar) to be Completed by pennit applicant 1. Building b (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) 3 4 Mechanical AC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number - SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 7 I, as Owner/Authorized Agent of subject property Hereby authorize to act on 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, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Si afore of Owner/A ent Date ' NO. OF STORIES z SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1ST2ND 3 RD SPAN DIMENSIONS OF SILLS j DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Date:-�— .4, TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . .1 A. 4/144. .................... has permission to perform ... P e. ^ P .............. plumbing in the buildings of (-.r. 7 ................. at ... 72. ........... \ ' North Andover, Mass. Fee (740 Lic. N o. 5�� —f ........ ....... F�LUMBI . N G INSPe�TOR Check # 6 3 55 Print A am a homeowner performing all work r`►"�`e myself. �1 am a -sole proprietor and have no on6 working in any capacity tam an employer providing workers' compensation ' for My ernDlovees vtimmnn nr, #I,:- :_L_ Clty. Phone #- FaFrUre to sese covetage as ► wider 25A or RAE. t 2 can fail. to tCf � understand tand/or one hat ' imprisp this as welt as civil penattl sin-the.Ib m of a STOP VVOW d Er�rw►atP�'! .oEaflne r� to $I;5pfj pp opy of tt1Fs staterr�ent may be forwarded to the Oiflte d. ar►d afs►e of tsyoa00) a day agalnst me_ f k� of the DIA for amwage veriftatiori. 1 do herby certify under the pal penafts of pio►Mded above is &roe arwCoffert Signature y✓;� _ Date__�___�/�/ Print name Phone # ficial use only do not write in this area to be completed by city or town oMCW ©.Check YIMMediate response is ragUWVd 6uildiitg Dept 0 BUYding 1Dog- Q LtcOnsing Bard intact person: 0 Sw'/ectnian`s oft& Phone # Q Health Department other RKMAWS COP 61 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: (Location of Facility) r G' Y Signatur of Pe it Applicant 62- ate NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector r I Board of Buildinq Regulations and Standards! r One Ashburton Place - Room 1301 Boston, Massachusetts 02108 Horne Improvement Contractor Registration f Registration: 103310 Expiration: 7/7/02 Type: Private Corporation T, �m.9H4„�lG gr^_ if„errs ` 67'& NOME IMPROVEMENT COOTRpCTOR JOHN JENNINGS CO. INC. _ Registration: 103310 Shawn Danahy = = Expiration: 717102 192 Tyler St. Type: private Corporatio Methuen MA 01844 JOHN JENNINGS CO. INC. Shaun Oanaby 142 Tyler St. AoWNISTRATOR Methuen MA 01844 ,fie �ammaxcr�eallii o�'✓!�t{aurrrlufGeld3 BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 020089 ' a! Birthdate: 07/2811956 Expires: 07128/2003 Tr. no: 12254 Restricted To: 00 SHAWN C DANAHY 192 TYLER ST C.i.«a �► ”' METHUEN, MA 01844 Administrator 171 ERS In W E �� o CQ v .4 Uu aG b•� o � C/) a a ►�„r� as r•' co c�9 U w a 0- w°' w x o w W a cii w o aG ro w W 4 rA cn a' o cn O EM49M IMM a ui 2 CLM I� �I O I y h i CL dD O O V O r.7 C#2 0 v .y O cc _ C _cc Q. Cos 0 IN O V CO CLh c O CM CD m m Lij 0 U) U) CCW W crW �o •m c �o • O y p W VV c ca o • Z; ' o L sa Ai � �.. � O ca o �� CM E E*= � CC o „� r: CM c Co ID O: c i fir: O O`er _ IL0 to O E CO3 m O cm L oa c d c�t = m ;•0 O CO3 •y O +-%C d O cm C =~ O � � y O O p •O y0 m a.=.. N m _ t r •h Go O C P uj dt =2 ; Z CM m� �. g y a �cc = 4-a�m� I� �I O I y h i CL dD O O V O r.7 C#2 0 v .y O cc _ C _cc Q. Cos 0 IN O V CO CLh c O CM CD m m Lij 0 U) U) CCW W crW MASSACHUSETTS UNIFORM APPLICATIOY FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building C L4te;'J09 f S'7 -Owners Name C, 4)L of New Renovation ( Replacement /n ry Date O Permit # Amount �Q J�--- Submitted Yes❑ No ❑ FLKT-.1RES .r .M • 'N • .r . i ilk -.�----------------------■ 11.' ------------�--.--------- (Print or type) Installing Company Name J2 /�. G✓�s�l '' " Address 36 fl -/64— Check one: Certificate ❑ Corp. ElPartner. Firm/Co. Name of Licensed Plumber: 0"1(a # J Insurance Coverage: Indicate the type o stir"ance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ 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 Signature IOwner ❑ 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 Massac s to Plu g Code and Chapter 142 of the General Laws. By: igna ure oT-Licen7eu FlumSer Title Type of Plumbing License Q City/Town is nse Numoer Master ❑ Journeyman APPROVED(OFFICE USE ONLY LLLJJJ