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HomeMy WebLinkAboutMiscellaneous - 258 REA STREET 4/30/2018 (3)No Date ..... 4h..1Y TOWN OF NORTH ANDOVER PERMIT FOR WIRING '­Z.-.,!�- -, � This certifies that .../)/ ......- .....r .... e� ................ /Zaaeo ...... C ..................... has permission to perform ................ j, .................................... ... ... ............ wiring in the building of ..... /..� . )r .................. at ....... .......................................................... �K .......... ,,North Andover, Mass..' .................... .................. ........ . .............. . Fee—, Lic. No. ELECTRICAL INSPECTOR Check # WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Elie (dammanuliettftli of filttssoeliusetts Office Use On Department of Public Safety Permit No.� BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Occupancy &Fee Checked 3/90 (leave blank) 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) City or Town of _yA )e9lV-Dd The undersigned applies fora permit 6 perform the eh Location (Street & Owner or Tenant described below. Date / To the Inspector of Wires: Owner's Address Z=D H6!'Y Is this permit in conjunction with a building permit: Purpose of Building Existing Service New Service Yes LJ No I_ Amps / o2 D Volts C_CLAmps / ;2 2/g4LVolts I (Check Appropriate Box) Utility Authorization No./ -O-14 if Overhead�L,'�J Undgrd 1:1 No. of Meters } Overhead LJ .Undgrd ❑ No. of Meters Number of Feeders and Ampacity 'n Ile J p I - • Location and Nature of Proposed Electrical Work Y^7 ✓ (die ►'1���� � ���,� y N*o. of Lighting Outlets No. of Hot Tubs TOTAL No. of Transformers KVA A oveIn- ❑ ❑ o'No. of Lighting Fixtures SwimmingPool rnd. gmd. Generators KVA M No. of Emergency Lighting No. of Receptacle Outlets No. of Oil Burners Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Total No. of Ranges No. of Air Conditioners Tons Initiating Devices No. of Sounding Devices. Heat Total Total No. of Disposals No. of Pumps Tons KW No. of Self Contained Detection/Sounding Devices Municipal 11,❑Other No. of Dishwashers Space/Area Heating KW No. of Dryers HeatingDevices KW Local Connection No. of No. of Low Voltage No. of Water Heaters KW Signs Ballasts Wiring No. Hydro Massage Tubs No. of Motors Total HP 4'OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusttes General Laws `�� 1 have a current Liability Insur nce Policy including Completed Operations Coverage or its substantial equivalent. YES UYNO ❑ 1 have submitted valid proof of same to this office. YES NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE LJ BOND ❑ OTHER❑ (Please Specify) (Expiration Date) Estimated Value of Electrical Work $ Work to Start C "' -'� 0' 01 Inspection Date Requested: Signed under the penalties of perjury: , FIRM NAME Licensee Address Signature Rough — — Final .. LIC. NO. �+ C> LIC. NO. Q CL Bus. Tel. No. L Alt. Tel. No. .OWNER'S INSURANCE WAIVER: I am aware that the Licensee 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) Telephone No. PERMIT FEE $ Lv ''v (Signature of Owner or Agent) Locations No. Date Mo�TM TOWN OF NORTH ANDOVER n a � + _ • , Certificate of Occupancy $ s4NU5 C Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check #� r, o Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPI)ICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING M wx., xI[A�If� � BUILDING PERMIT NUMBER: DATE ISSUED:_ SIGNATURE: Map Number Building Commissioner/1for of Buildings Date SECTION 1- SITE INFORMATION I I.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided R red Provided fD0t- 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record ; K A i 2 0 114 LE Z/. Name (Print) Address for Service v -6/-L Signa re Te ne 2.2 Owlier of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Cnstruction Supervisor: Not Applicable ❑ Licensed ConsTction Supervisor: O s � w C S License Number Address —� Expirati n Da e Sign re Telephone 335 r---- 3. Re ' tered Home Improvement Contractor Not Applicable ❑ Company Name / ,0 A Registration Number Address' v / E Pira on DateE Pira on Date O / Si at Telephone au M X z z M 90 mn ro 0 z G) SECTION 4 - WORKERS COMPENSATION (M.G.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 ....... 0 SECTION 5 Descri tion 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: 4 �. SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant �; , ` , �96 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) p� I I 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 O Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, �. L� as Owner/Authorized Agent of subject property Hereby authorize._ ��/�,/*x/` Cl? to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNERJAUTHORIZED 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 - e A3;Z Si tore of Owner A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINMERS 1 2 3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DINIENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS S17 -E OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE FORM - U - LOT RELEASE FORM . INSTRUCTIONS: This form is used to verify that allnecessary approval /permits from Boards ,and Departments having jurisdiction have been obtained. This does not relieve the ` applicant and or landowner from compliance with any applicable requirements. names APPLICANT v G r /j/1 A1�-l2 PHONE -vD ASSESSORS MAP NUMBER LOTNUMBER SUBDIVISION LOT NUMBER STREa MasonET ��on W-00-4 None&=sowsmom SswoonTREET NUMBER S OFFICIAL USE ONLY COMMENDATIONS OF TOWN AGENTS G c ■ ■n.,k■aas ■■.■.■■.■...■,..■■.■.....a■.....■....r.......■.s■..■.a■.■■.■ ` �•. DATE APPROVED CONS RVATION ADMINISTRATOR- ( DATE REJECTED COMMENTS t (\ Vg/ DATE APPROVED TOWN PLANNER DATE REJECTED COMMENTS DATE APPROVED ;FOOD INSPECTOHEALTH DATE REJECTED DATE APPROVED SPE -HEALTH DATE REJECTED / . COM81ENTS G PUBLIC WORKS - SEWER / WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPARTMENT DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR DATE RXE C E V E FEB 1; 2001 BUILDING DCPT. 0 J72- frioonm,,n&xwA1 of BOARD OF BUILDING REGULATIONS _ cense: CONSTRUCTION SUPERVISOR Number: CS 057186 Birthdate: 08101/1958 Expires: 08/01/2001 Tr. no: 1002 Restricted To: 1G BRUCE K FERRARO�!� 1257 WORCESTER RD FRAMINGHAM. MA 01701 Administrator ►01 -- HOME IMPROVEMENT CONTRACTOR _ _ = �y Registrttioa� 111540 c51 Expintior 11/30/2001 Type: DBA SIGNATURE DECKS BRUCE FERRARO G�•`oe 1257 NORCEST£R RD ADMUSTRATOR FRAMINGHAM MA 01101 I I AR WCIP ISSUING OFFICE 354 INFORMATION PAGE _ ACCOUNT NO.1 SUB ACCT NO LIBERTY MUTUALN�" Liberty Mutual Insurance Grcu.F/Boston I LIBERTY MUTUAL INSURANCE GO. 15028 Workers Compensation and Employers Liability Policy POLICY NO. rD/CD�SALES OFFICE CODE ",ALES REPRESENTATIVE COD N/R ST YEAR WCI-31S-321663-010 XXXSTWOOD 101 ASSIGNED 3000 1 2000 Item 1. Name of BRUCE FERRARO Insured DBA SIGNATURE DECKS FEIN 01-8503052 Address 1257 WORCESTER RD RISK ID FRAMINGHAM, MA 01701 Status 01 Otherworkplaces not.shown above: SEE ITEM 4 Mo. Day Year Mo. Day Year Item 2. Policy Period: From 04-27-00 to 04-21-01 12:01 AM standard tine at the address of the insured as stated herein. Item 3. Coverage A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: PSA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3A. The limits of our liability under Part Two are: Bodily Injury by Accident 100,000 each accident Bodily Injury by Disease 500,000 policy limit Bodily Injury by Disease 100,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: SEE END WC 20 03 06A D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE Item 4. Premium - The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Minimum Premium $ 500 ( MA) Total Estimated Annual Premium $ 516 Interim adjustment of premium shall be made: ANNUAL This policy, including all endorsements issued therewith, is hereby countersigned by SEE ATTACHED FORM 1710 Authorized Representative Date 05-22-00 l.oc. Code . I Terra.r. Audit Basis Periodic Payment Rating Basis Pol. H.G. liome State Dividend � 05.22-00 NR MA NEW GPO 4030 R1 Copyright 1987 National Council on Compensation Insurance wC00 0001 A INSURED COPY Premium Basis Rates LINE 110 Fstimated Per$100 Estimated Code Total Annual of Re- Annual Classifications No. Remuneration muneration Premiums SEE EXTENSION OF INFORMATION PAGE Minimum Premium $ 500 ( MA) Total Estimated Annual Premium $ 516 Interim adjustment of premium shall be made: ANNUAL This policy, including all endorsements issued therewith, is hereby countersigned by SEE ATTACHED FORM 1710 Authorized Representative Date 05-22-00 l.oc. Code . I Terra.r. Audit Basis Periodic Payment Rating Basis Pol. H.G. liome State Dividend � 05.22-00 NR MA NEW GPO 4030 R1 Copyright 1987 National Council on Compensation Insurance wC00 0001 A INSURED COPY Town of North Andover ' Building Department 27 Charles Street North Andover, Massachusetts 01845 (978) 688-9545 Fax (978) 688-9542 DEBRIS DISPOSAL FORM IAORTH 40 0 ~ i �4 '�. COCMKWMK• 1' In accordance with the provisions of MGL c 40 s 54, and a condition of Building permit. # the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL cl 1, s150a. The debris will be disposed of in /at: Facility location Signature of Applicant Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. orrice OT invesrigarions Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print Name: Location: Ci Phone am a homeowner performing all work myself. �I am a sole proprietor and have no one working in any capacity v ► am an employer providing workers' compensation for my employees working on this job. ComPany Address! City' Phone # P-06 Insurance Co .? Com n name: Address Ci Phone#: Insurance Co Policy # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage ver cation. ! do herby certify under the pains and !ties of perjury that the information provided above is true and correct S N Print name `> C� . �`'� U Phone # E00. Official use only do not write in this area to be completed by city or town official' E]Check if immediate response is required Building Dept Contact person:_ Phone #: FORM WORKMAN'S COMPENSATION 0 Building Dept p Licensing Board Q Selectman's Office Ei Health Department 11 Other Commonwealth Engineering Associates, Inc. MORTGAGE SURVEY This certification on this plan is made for mortgage purposes only. The undersigned will not be responsible if this plan is used for boundaries, fences, plantings, special permits or. variances. WF ,1 8 d REALTY TRUST 146.71 � 0 \ LOT 5 P/o X05 �1 \ p �i CA, - A = 258029 SJ'.-- l/. � LOT 6 � �NO. 238 l STY. WOOD LOT 4 0 �. m • ,o `-\ 125.00' REA . STREET .10 CF Location NORTH ANDOVER, MA_ cm _ ��( Date . 2- 1966 Scale: t inch - 40 feet + No, 33343 �o,�a Ro�wEoot Deed and Plan Reference: Dead Book12= 5 Page 6 9 2 Plan Book 7 243 Page — //I// Commonwealth Engineering Associates, Inc. MORTGAGE SURVEY This certification on this plan is made for mortgage purposes only. The undersigned will not be responsible if this plan is used for boundaries, fences, plantings, special permits or variances. i N/F J a V REALTY TRUST 146.71 _ r 0 LOT 5 i A= 25,023 s.f. 1 2 LOT 6 N0. 238 I STY. WOOD LOT 4 c� v m 'o OF No. 31342 _ L uwo� (7) - X 125.00 REA STREET Location NORTH ANDOVER, MA. Date 7-2-1966 Scale: I inch . 40 feet Deed and Plan Reference: Deed Book 12__ Page 6_ Plan Book 7 2 4 Page — rarrifirntinn in herebv made to: REQUIREMENTS FOR FORM U SIGNOFFS BY BOARD OF HEALTH To be filled out by the applicant and submitted with the Form U 1. What is the proposed project? oDecipool addition new house other 2. Are plans attached? Yes No (For additions and new houses on septic systems, complete floor plans of proposed construction and any existing house must be submitted. For pools and decks, a site plan with location of pool or deck is required. Dimensions of deck are needed.) 3. Is municipal sewer available at this location? Yes 6:D 4. If sewer is available and a house already exists, is it tied in to the sewer? Yes cl�o) 5. Is the location served by private well? Yes 6. If this project is an addition and the house is served by a septic system, has there been a Title 5 inspection done recently on the septic system? 5 ��s �56,7. Nes No If, yes, is the inspection report on file at the BOH? No Cl) M M M Cl) 0 -v, 'v o CD Z y CD O 'D CL n• e C Q =' CO) O n o p o co o CL Cr CD Cc) o 00 00 � C O Cn� CD Q O y co co p CA O i� Ej O —• VH c Q IN CLCDO CO) m-1:mcc,m C4 C.) CL c) m C N y O o f m W CD2 N co G O G LO). -OCD �o �a CL o =r r CD cc, y CD nco � C O. °3 ) :w d yN Q O . h d C O co �•W CD =r � 3Ey o S ,: N y Vb :1 � 3 )zo- CD . CD ca �CD::� dd• ate. y O : C O moo: CD 0 rip n p rn 7 d tTj ?t; w O b w �' A Cr1 t hn n w x "ti O O � n � aha r o r-' a g � ^ N o �. x 0 d O z 0 NG rA H 0 0 c t n � W C all x 6 o n �I � o J`7 b �N 'f> w � r 73 cn o Z Go A or -M �f OD c��nv �'- mol N mn Ul C UlnN m z nv U) xv D m 0 m �� m c -1 m 5 z v p ^ w < v { 41 G �a�, D D o x m m �) \� a c n le Location No. Cf off• Date TOWN OF NORTH ANDOVER s i Certificate of Occupancy $ C MUS Building/Frame Permit Fee $ SA Foundation Permit Fee $ Other Permit Fee TOTAL Check #-3Gd6 17143 `"Building Inspector . 4 TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: _a�� y SIGNATURE: CLQ Building Commissioder/12t22tor of Buildings Date SECTION I- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number AAAN 1.3 Zoning Information: Zoning Dish c_t Proposed Use 1.4 Property Dimensions: Lot Area (sf) Frontage, (ft) 1.6 BUILDING SETBACKS (ft) Front Yard Side Yard Rear Yard Reqyired Provide Required Provided Re aired Provided 1.7 Water Supply M.G.L.C.40 54) 1.5. Flood Zone Information: Public 0 Private D Zone Outside Flood Zone 0 1.1Sewerage Disposal System: Municipal 0 On Site Disposal System D SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT er of Record '.I M 4 Z I . '�� SALE P- 1A L amen( 'nt) Address for Service 7Z 'Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1"Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Not Applicable 0 License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable 0 Company Name Registration Number Address Expiration Date Signature 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 all appUcable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory.Bidg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: - Dv + y D 9- X 'K [-:-1 oo S ��J I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I Item Estimated Cost(Dollar) to be ( Dollar Completed by permit applicant a OFFICfAL 17SE ONLY 1. Building OM (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) 36 4 Mechanical HVAC 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 I, , as Owner/Authorized Agent of subject property Hereby authoriz to act on My behalf, in a matters relative to work authorized by this building permit application. Signature of qhvner 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 Signature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIlvMERS 1 2 ND 3 PD SPAN DIN (ENSIONS OF SILLS DINIENSIONS OF POSTS DR,AENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CH VINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE FORM - U - LOT RELEASE FORM 31 INSTRUCTIONS_ This form is used to verify that all -necessary approval/ permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. 10 ...............■r...■............................r.......................■ APPLICANT_ l� 2 j ��J i � 21 /lis PHONE q?e 7 %z/.2 S7t/, ASSESSORS MAP NUMBER LOT NUMBER 1 SUBDIVISION LOT NUMBER i STREET C4 J r STREET NUMBER —2S� N.....r•r.memo ....•...r....................■...�..........................■ / OFFICIAL USE ONLY �I,.................................................................................0 ' RECOWENDATIONS OF TOWN AGENTS t.... ................■.................................................. 1 DATE APPROVED �S CONSERVATION ADMINISTRATO DATE RESECTED COMMENTS DATE APPROVED TOWN PLANNER DATE RESECTED COMMENTS DATE APPROVED FOOD INSPECTOR - HEALTH. DATE REJECTED t2 -.>l 11-1� 5 DATE APPROVED SEPTIC INSPECTOR - HEALTH DATE REJECTED COIvR-NTS PUBLIC WORDS - SEWER ! WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPARTMENT DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR 1 'f 4y Lot #5 Rea Street North Andover, Mass. Scale: 1" = 40' July 2, 1976 �oT�y I hereby certify that the `building on this property is located as shown on plan and complies with the Building and Zoning Laws of the Town of North Andover. CHARLES E. CYR CIVIL ENGINEER LAWRENCE.,_MASS. .4107'. a Town of North Andover Building Department 27 Charles Street North Andover, MA. 01845 D. Robert Nicetta Building Commissioner (978) 688-9545 (978) 688-9542 Fax HOMEOWNER LICENSE EXEMPTION Please print. I DATE JOB LOCATION Number Street Address Map / lot ! "HOMEOWNER / " \i-\ 2 K EAT a (A LE ( -7 Tq-2 32 Name Home Phone Work Phone PRESENT MAILING ADDRESS Sct nA-a_. 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 home 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 understands the Town of No. Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. If HOMEOWNER'S SIGNATU APPROVAL OF BUILDING OFFIC 00 00 417 y .0 C � CO) CD a Z Nf CD O 'v O. � t7 _ = O CZ a. CA c CD CDCL cr o ww++ = CD CD o CD C O y. Q CO),O O I CO CD F v CO) O .0 CD o CD O CCD 4 O C H o o d = aO �.m .'M y CL O y 0dCmo 0 �Y m Zca a) _CIO N = .-► m =ra..a m N O y Z W mm a ® 7 C, m C! C =r N CL (V/^�I J2 0 V) m m y m n CD d m :� . 0 � o H .�• H y d � Q cn cc a� `►p��7J Nca C IC cn ,CD m Q� o CD Itj: ® _oo m 0 1 :46 cn cn �_C A CD W : C' n o bE CA � y o = y o co Cn Cn a1 d b ?1 ,b bH '�r1 07ud Com" ?1 p0 T tz ro C 0 CQQl 7 Q � y 0 9 O C CD Location No f t Date �� F 0f~O*TM TOWN OF NORTH ANDOVER �.an ,a,ti0 � • OL p Certificate of Occupancy $ sACN Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ ` Check # Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING , BUILDING PERMIT NUMBER: DATE ISSUED: A SIGNATURE Building Commissioned) for of Buildings Date SECTION I- SITE INFORMATION 1.1 Property Addres pp s� <\—` 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: Zoninp, District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage(ft) 1.6 BUILDING SETBACKS (ft) Front Yard Side Yard Rear Yard Required Provide Required Provided �red Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. . Flood Zone Information: Public 0 Private 0 Zone Outside Flood Zone 0 1.9 Sewerage Disposal System: Municipal 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT r 2.1 Owner of Record V�c� Name (Print) Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service' Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Not Applicable 0 VC) \I License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable 0 Company Name Registration Number Address Expiration Date Signature Telephone ou M X Z 0 SECTION 4 - WORKERS COMPENSATION (M-G.L C 152 & 2506) 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 ❑ Repair(s) ❑ [Alterations(s) ddition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brie scription of Proposed Work: \ f SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Comleted b ermit a licant- �(iFFiCIAL >�7SE (?1SLY ; ; 1. Building i (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (8) X (b) 4 Mechanical (HVAC) 5 Fire Protections 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 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 O)xmer Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 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 ,�1��� Sr ature of Owner/A en Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2 ND3 RD SPAN DINIENSIONS OF SILLS DIN ENSIGNS OF POSTS DM ENSIONS 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 I c� C stricone Roofing & Siding REPAIRS FREE ESTIMATES j(c) �` . - • _� �7-) Telephone (978) 682-4266 MARIO CASTRICONE a 31 Court Street, North Andover, Mass. 01845 I/we, the owner (s) of the premises mentioned below, hereby contract with and authorize you as contractor, to furnish all necessary materials, labor and workmanship, to install, construct and place the improvements according to the following specifications, terms and conditions, on premises below deseri ed: Owner's Name... �5, ................. t�rtu............................................................... Job Address..... ....4 �..... ..................................... City.>t�:..... State.. .. Ci1.1��` 1. ................ SPECIFICATIONS `.....`............. * ................................................................................... ........... .................. A. ....................................... ............................ � :,..... ...................................................................................................... ..... . .... .......................... ....... r......................... .. ... ............ ...........i C.-*--* ......... .... --- ... ­* fijJ�.......� ,,U*.....**-"**& ­.****** 1 �JJ`,( ............... :�:-::.:.:.,:::::.::::.....� ......................................................................... ...........................................4\•.........i ............ (.............................................................................. ..... .............. 7" ....................................................... ........... ........................ 4-I'Ac........... J4K�iMaterials and labor to cost $ .... ............................. Payable�r�.��y............................and balance in............ monthly installments of $ .........................................each, payable on ..........................................day of each and every month thereafter until paid in full (..............% charge per year is to be added to above cost of labor and materials and is included in monthly payments.) Contractor will do all of said work in a good workmanlike manner. Upon completion of above work, all undersigned agree to execute and deliver to contractor, their joint note in accordance with his (their) above obligation and a completion as requested by the contractor. Upon refusal to do so, contractor may at its option declare the entire contract price or so much as then remains unpaid immediately due and payable. It is agreed that if permitted by law contractor shall be paid by the owner(s), all reasonable costs, attorney fees and expenses, in addition to the amount due and unpaid, that shall be incurred in enforcing the terms and conditions of this contract and/or any lien in connection therewith. It is further agreed that this contract may be assigned by contractor; and also that the obligations hereof shall bind and apply to their heirs, successors or estates -of the parties. The undersigned warrant(s) that he is (they are) the owner(s) of the above mentioned premises and that legal title thereto stands of record in his (their) name(s). PROVISO: This contract shall be void and of no effort if credit approved of owner(s) is refused. There are no representations, guaranties or warranties, except such as may be herein incorporated, if any, nor any agreements collateral hereto, nor is this contract dependent upon or subject to any conditions not herein stated. Any subsequent agreement in reference hereto shall be binding only if in writing and signed by all parties. Cover attic storage cleaning not included. Receipt of a copy of this contract is hereby acknowledged, and it is further acknowledged by the undersigned that the foregoing provisions have been read and the contents thereof understood and that no representation or agreement not herein contained shall be binding upon the parties and that all of the agreements and understandings of said parties are contained herein. Owner or Owners are not responsible for Property Damage or Liability while job is ' operation. IN WITNESS WHEREOF, the parties have hereunto signed their names this day of...... ..........., Tj.��.L;Y,:� Accepted: Signed..... .... ................. ` ........ Owner (OWNER HAS 3 DAYS IN WHICH TO CANCEL CONTRACT) 4 SI - Pt......... - z. '.= Owner ..: . Signed. f..................................................................................... Representative '``-- The Commonwealth ofMassachusetts Departntenl of Industrial Accidents _= r Office offtestlgatlnn. 600 JVashitrntall Street Boston, Mass. 02111 Workers' Compensation Insurance Affidavit a� City ��/—�---t � � _ phone # 0 1 am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity E] I am an employer providing workers' compensation for my employees working on this job. Comp an risme.'Ea .. ;,� LAmse :.(�patg k� _..� addre§' 7775 .::;>:.......j.:� �:..:�. : r':�:��'..tR�::�.:,"•t'..' .Z�. :�>>''`:.\�.` � ::��e'�'. ,.r..�....rt...Y1....... .i'7..: .: ...::.��. ..:Z:'c:�i'/0''::`l'i`'a��� .".:1.n..:�v°''#4'`ii:"w<:'� � .isti�G"'.':'R...:Y. . 0 I am a sole proprietor, general contractor, or homeowner the following workers' compensation polices: Failure to secure coverage as required tinder Section 25A of MCL 152 can lead to the imposition of criminal penalties of a fine tip to 51,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER anil a fine of 5100.00 it day against me. I understand that a copy or this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and{toldes ojperjury that the information provided above is true and c rrect. Signature Date Print name # official use only do not write in this area to be completed by city or town official city or town: permit/license # OBuilding Department 01-leensing Board 0 check irimmediate response is rtquired (]Selectmen's Office C]Ilealth Department contact person: phone #; 00thcr 0"ised 7105 PIA) 0 0 r Z 0 00 = rn o o F > U o $ Q H H- O Z�_ C:, (7 H d it ai E W S O >- O +o Q O oW i C D m � �_ O N � Wj Q ro CD V o m l0 �_ CO o r z ;c�- Z U 4 Z 0 00 rn o F > $ H d it ai E O O i Q I Z O i C D m � �_ O N � U. CO CD V m l0 �_ CO o m w E. 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O h � C O cm I O 'D O G r... co) O O m m Cl CD CL O CD L _O O d CL cmQ O }� ca .EL C3C Cl CL V y O C — C— _c d LU U) Cn w W LU U) 90 � N° 2 " a Date..`.... `:.:'7 .................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that...l.'.:� -G -....... has permission to perform.:-/..................................................... wiring in the building of ........................................ .North Andover, Mass. Fee --.0................ Lic. No. ?v. .....................A:z...:... %:- `...,.................... ELECTRICAL INSPECTOR C7) WHITE: Applicant CANARY: Building Dept. PINK: Treasurer i 0 Office use only The Commonwealth of Massachusetts - Department of Public Safety Permit No. BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Occupancy & Pee Cheekedj_�— 3= (leave blank) 1 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to to pertomwd in axordancs wdh V* Massachusetts ElsanW Code. 527 CMR 1200 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION f _ ! City or Town o - e 1-?IV.D © -The undersigned applies for a permit to perform the elect Location (Street & Number) IL or Tenant -20/-2 P / work described below. Date_ .�"'c,13"o�d© 0 To the Inspector of Wires: Owner's Addresse" Is this permit in conjunction with %a building permit yes Er no ❑ (Ch -;k Appropriate Box) Purpose of. Buildin 9yV�%f-� ©w�i'Ll%�� Utility Authorization No. Existing Service Amps_ / Volts Overhead ❑ Undgrd- ❑ No. of Meters New Service -Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Am Location and Nat -+e of Proposed Electrical Work Wzel o t 4 -9 avile tri 1 � O Lam. + No. of lightingTOTAL Outlets No. of Hot Tubs No. of Transformers KVq No. of Lighting Fixtures Above n Swimming Pool crud. 1Fgrnd ❑ Generators KVq No. of Receptacle Outlets Nc. of Oil Burners No. of Emergency Lighting 113attery Units No. of Switch Outlets INo. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Initiating Devices No. of Sounding Devices No. of Self Contained Detection/Sounding Devices Municipal Local ❑ Connection ❑ Other No. of Ranges TOTAL No. of Air Conditioners TONS No. of Disposals HEAT TOTAL TOTAL No. of Pumas TONS KW No. of Dishwashers SoacelArea Heating KW No. of Dryers Heatina Devices KW No. of Water Heaters KW No. of No. of Signs Ballasts Low Voltage Wiring No. of Hydro Massage Tubs No. of Motors ITotal HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liability Insurance Policy}}'pciuding Completed Operations Coverage or its substantial equivalent. YES 00N0 ❑ I haave submitted valid proof of same to this office. YES YNO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box. ke INSURANCE 1 -9 BOND ❑ OTHER ❑ (Please Specifyl (Expiration Date) Estimated Value of Electrical Work S Work to Start 0 2-.�piDo Inspection Date Requested: Rough Final /yf) �/g,4 L Signed under the penalties of perjury: FIRM NAME --V)' /Y6'0 r✓ iL2 9 C. NO Jr Licensee IF% ",ev _ UC. "NO r? tel. Alt. Tel. No OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its .substantial equivalent .as required by Massachusetts General Laws, and that my .signature on this application waives this requirement. Owner Agent (Please check one) - E , (Signature of Owner or Agent) Telephone No p� FE C 11 � C k -;N2 � i , �- /.... '7 Date.. � ....... ;5-1 ....... ��.... TOWN OF NORTH ANDOVER PERMIT FOR WIRING A This certifies that: — .......................................................................................... has permission to perform 84 ................... ...... ................. wiring in the building of ... ...................................... ............. North Andover, Mass. Feb ..................... Lic. Nofil�.9- 0-� ELECTRICAL INSPECTOR C 4 WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Z ti 10 I _ 04P CrommonWralo of 4.flttoottrl�uo>,:i�o +40epartment of Public i4ttfetg r BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Office Use Only Permit No. /G % i Occupancy & Fee Checked 3/90 (leave blank) 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) Date �' j,:C—' / City or Town of &_I�L�' >� R To the Inspector of Wires: The udersigned applies for a permit to perform the electrical work described below. Location (Street & Number) Owner or Tenant G *$ -7 9AIL :�:2 3,7 Owner's Address Is this permit in conjunction with a b ilding /permit: Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building J l J N Utility Authorization No. Existing Service Amps —J Volts Overhead ❑ Undgrnd ❑ New Service Amps —J Volts Overhead ❑ Undgrnd ❑ No. of Meters No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work OTHER INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws I have a current Liability Insurance Policy including Comple d Operations Coverage or its substantial equivalent. YES - NO G I have submitted valid proof of same to the Office. YES NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE BOND ❑ OTHER ❑ (Please Specify) Estimated Value of Elect al r $ Work to Start �� Signed under theli PenaV of perj r) _ FIRM NAME C - Licensee r Inspection Date Requested: Rough 61-T /i' i (Expiration Date) Final _ 57 LIC. NO. -� /l yN� Bus. Tel. No.�Ji La Q G�.� 6`7 Address / / �����0W_�� /7, Alt. Tel. NO. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as re- quired by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner / Agent . (Please check one) (�(7 Telephone No. PERMIT FEE $ (Signature of Owner or Agent) x-6565 No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total K VA No. No. of Lighting Fixtures Swimming Pool Above ❑ In - grnd. ❑ Generators KVA No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Initiating Devices No. of Sounding Devices No. of Self Contained Detection/Sounding Devices Local -Municipal ❑ Other Connection No. of Ranges No. of Air Cond. Total tons No. of Disposals No.of Heat Total Total Pumps Tons KW No. of Dishwashers Space/Area Heating KW No. of Dryers Heating Devices KW No. of Water Heaters KW No. of No. of Signs Ballasts Low Voltage Wiring No. Hydro Massage Tubs No. of Motors Total HP OTHER INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws I have a current Liability Insurance Policy including Comple d Operations Coverage or its substantial equivalent. YES - NO G I have submitted valid proof of same to the Office. YES NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE BOND ❑ OTHER ❑ (Please Specify) Estimated Value of Elect al r $ Work to Start �� Signed under theli PenaV of perj r) _ FIRM NAME C - Licensee r Inspection Date Requested: Rough 61-T /i' i (Expiration Date) Final _ 57 LIC. NO. -� /l yN� Bus. Tel. No.�Ji La Q G�.� 6`7 Address / / �����0W_�� /7, Alt. Tel. NO. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as re- quired by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner / Agent . (Please check one) (�(7 Telephone No. PERMIT FEE $ (Signature of Owner or Agent) x-6565 Location `s 3 No.r° Date NaRTM TOWN OF NORTH ANDOVER Certificate Occupancy $ • 1 ; , of cMuSE< Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # �y Building Igspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUNIBER, DATE ISSUED: SIGNATURE: Building Commissioner/InSL=tor of Buildings Date SECTION I- SITE INFORMATION LI Property Address: as- 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage (11) 1.6 BUILDING SETBACKS (ft) Front Yard Side Yard Rear Yard Required Provide R'red Provided RecIttired Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public 0 Private 0 Zone Outside Flood Zone 0 1.8 Sewerage Disposal System: Municipal 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record \P, Name (Print) Address for Service Signature Telephone Z2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Not Applicable 0 License Number Expiration Date 3.2 Registered Home Improvement Contractor 0-.S�Q— Not Applicable 0 Company Name Registration Number -- Expiration Date Addr`8ss z2o -11�1 Sigifalure Telephone SECTION 4 - WORKERS COMPENSATION (M.G.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 Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) 11Alterations(s)l Addition Elns. Accessory Bldg. ❑ Demolition _❑ Other ❑ Specify , 1., h ,. Brief Description of Proposed Work: I SECTION 6 - F.STIMATF.D CONSTRUCTION COSTS I Item Estimated Cost (Dollar) to be Completed by permit applicant ",,"FFIC]fAL.USEONLY ` 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) 4 Mechanical HVAC 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 BUH DING PERMIT 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 §ig2 tore of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR T MBERS in 2ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHRVINEY IS BUH DING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE j ... The Commonwealth of Massachusetts IT) Department Of Industrial Accidents IS mce fl11flYeSffff2jjffflS 600 Washington Street Boston, Mass. 02111 Workers' Compensation Insurance Affidavit =9 name* :.: *.:, N., Failure to secure coverage as required under Section 25A of MGL 152 can lend to the Imposition, of criminal penalties of fine tip to 51.500.00 and/or— one years' Imprisonment as well as civil penalties in the form of sTop WORK ORDER and a fine of 5100.00 2 day against me. I understand that a copy of this statement may be forwarded to the Office Of Investigations of the DIA for coverage verification. I do hereby certify under ifte pains and peer ties ofperjury that the ii!formation provided abo've is true an7 cone - Signature -nate Print name C -n kf e Phone it OMC1121 use only do not write In this area to be completed by city or town official city or (own: permittlicense N --__OBuilding Department CjLicensing Board 0 check if immediate response is required oSelectmen's Office offe2fth Department contact person: phone #; —other ' (rM3ed 3/95 PIA) Jb 1: W o av�i a a OO O Z \ (a Cn CD V O Cff O � v n z o ti w W Cd i•r O w a O� cA o v u aG w C/)Q cn 0 GO z z oo G w w > a U x 0 GO GO z a °' w � iz. a u U w w u: v cn w a H a' C w z w w � W ° z b cn -� O cn O F=4 c c W as c �t .1 Qu W o �01 "F O F=4 E a N O N C A cm CD cm C m 0 cm C •C PQ CD s O Z O a fil O O E CD O Z O 0 CO2 y .9 O z C O co CL CO2 0 O .y C O L.7 R C _R CL CO) S.: O Q co CL CO2 C CM C O .� cp m CO O � Lft G3 o o a Q J O .O O CO Z 43 CL. CO) C 0 U) VJ CC W W w c c as c o C CO O C � O C.2 V CC m m 03 Cc O L N EcoQ - -. _O • = V CD O C •+ N o m o� 0 . C.2 o c N R mm CD Z m 3 N cm O 'O m CO) R N ECD b.: � O ICM CD I cco 3� W C O=�t 'a=OC y •m +� N =cm V p V� a O CDCA m = tm N •O r 0 nom E a N O N C A cm CD cm C m 0 cm C •C PQ CD s O Z O a fil O O E CD O Z O 0 CO2 y .9 O z C O co CL CO2 0 O .y C O L.7 R C _R CL CO) S.: O Q co CL CO2 C CM C O .� cp m CO O � Lft G3 o o a Q J O .O O CO Z 43 CL. CO) C 0 U) VJ CC W W w Commonwealth of Massachusetts C ity/Torn ofQ (�h � dove j/ System Pumping Record Facilii� Inf®rnation: Systern, Locatiow Address City/ --'J Town Systern. Owner- ame: 0Z 58 S+ r 6 a4 e ria I e- dress cif diFerent from location of pump) City/Town- Zip ity/Tom State RECEIVED JUN - 8 2009 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Zip Code State Zip Code q-)� - -�qq-,2 3-1 (4 Telephone Number Pumping Re(--®>r°d Fate ofpump] ng Aho //t, Quantity Pumped 149��U alions hype of System Septic Tank Grease Trap qq p p other (what) Systema Pumped by: Company: ROOTER MAN 12 East Dracut Rd., Methuen, MA 01844 Location where c jets were di osed: Signature of Hauler - Hate 's