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Home My WebLink AboutMiscellaneous - 26 EASY STREET 4/30/2018Xv 0 0 w w. Q 0 rn Y' 0 0 0 0 0 0 10797 Date ....t. u �.r�....1.1.9.... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING Mn " A be This certifies that.(f �- ,.��!............... - .��( .................. has permission to perform ..Q1W ..... .....�.!:-Jv........................................... plumbing in the buildings of .............................................................. at..........t:..c......................... North Andover, Mass, '�� Fee ...�A..: ":....... Lic. No. SAO ...................................................................... PLUMBING INSPECTOR Check # . Mql MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM —PLUMBING WORK CITY[_ . . � I . .1 PERMIT# MA DATE . . ....... ... .. JOBSITE ADDRESS LOWNER'S NAME OWNER ADDRESS .!!�4tM e__ __ — P ............ . .... . .. . . . ....................... TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIALI EDUCATIONAL RESIDENTIAL PRINT t CLEARLY NEW:0 RENOVATION: 1�1 REPLACEMENT: El PLANS SUBMITTED: YESE] NOT.... FIXTURES -1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 1 13 14 BATHTUB ... . ...... . ... ... . ..... . .... CROSS CONNECTION DEVICE ..... . ............ M ----------- . . . . . ........ .............. DEDICATED SPECIAL WASTE SYSTE Ji . .......... I it DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM .... . .......... . . . ......... ...... . .......... . . DEDICATED GRAY WATER SYSTEM 7 DEDICATED WATER RECYCLE SYSTEM - y ....... ----- --- .. ... .......... DISHWASHER ... . ... ...... ... .. ......... .......... ...... DRINKING FOUNTAIN ill' ...... . ...... . ...... . . . ::..:..~I I .... . ... . ... ...... . . ..... .... . ..... . . .... FOOD DISPOSER FLOOR /AREA DRAIN . . ......... . .... ....... ...... INTERCEPTOR (INTERIOR) ... . ........ ... . .. . ......... ..... .... .. ... ...... ......... . . ... ..... .... . .. KITCHEN SINK L. LAVATORY ...... . ..... . . . . ..... .. ...... . ... .......... . .... .. .......... . . ...... ....... ...... . ... ..... . .. ..... .......... .. — .......... . ....... ... . ......... ROOF DRAIN J . .......... ........... T SHOWER STALL ....... .. .. J --7 . .. . . ....... . ............ . .... SERVICE MOP SINK TOILET URINAL I ................... . .... ........ ......... .... . . . .. .......... ...... ......... . ..... . ... ... ... WASHING MACHINE CONNECTION ..... . ........ . ............ .......... ... .. ... ........ ............... .. . . WATER HEATER ALL TYPES .......... ............. ... .... ..... ....... .......... . . ......... . WATER PIPING . . ... . . . . . . . ........ ... OTHER F77: ...... .......... . . . ........... .. ... ...... - -- ----- . . . ... ....... I . . .. . ...... .. ...... ........... ............. . .. . . . . - - -------- - - . . . .......... ....... . .. . ...... . . . .... . ............ ........ ...i r. ... . ............. ...................................... . . . .... ............. ............ .. . . .. . ................ __j i . . .... . ..... J .... ............. I ..... . . . ......... . ...... . .... . ...... . . ... . ................ INSURANCE COVERAGE: A I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YE'* NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY* OTHER TYPE OF INDEMNITY E] BOND F— OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER El AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are u a accurate to he best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in c i e with 'lip pr ision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. V PLUMBER'S NAME J..G1 P- ki 0 <-7�� P7, LICENSE IJ SIGNATURE MPV JP CO RP 0 RAT 10 N Ej #1... PARTN ERSH I P LLCZ#FTO�Ae, COMPANY NAME eA ADDRESS CITY --i STATE ZIP FAX CELLI EMAIL AMIN 11 mac. a 'I'll The Commonwealth of Massachusetts Department of Industt iql Accidents Office oflnvestigations V . 600 Washington. Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Buil.dens/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organi'zation/iudividual): Address: ME e P P,6 PN 7-e,4 Phone #• '-� �� Q Are you an employer? Check the appropriate box: - 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors listed on the attached sheet. t 2.4 I am a sole proprietor or partner- ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner -doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] employees. [No workers' comp. insurance required] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions IQ] Plumbing repairs or additions 12.❑ Roofrepairs 13.❑ Other *Any applicant that checks box41 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicatingthey tie doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that checkthis box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. A' am an employer that is providing workers' compensation insurance for my employees.. Below is the,policy and joh site information. Insurance Company Policy # or Self --ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well.as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. Xdo hereby cert d aiepai",P/' ena/l//tii%es ofpertury thatfine tnj-ormartonprovcuea ttvuvetaA/ Nom-- Phone #: Official use only. Do not write in this area, to he completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Information and Instrudions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or. written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners; are not required to carry workers' compensation insurance. If an LL C or LLP does have employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date*the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town officials Please be sure that the affidavit is complete and printed legibly, The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill. in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current Policy information (ifnecessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i, e. a dog license or permit to burn leaves etc) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, Please do not hesitate to give us a call. The Department's address, telephone anal fax number: The CQwmawalth of M-a:.ssa r,,hv is Depaftelit Offadusidal Accidents OfAce ofIuvestigatiom 600 Wasbbgtoa Street Boston, .02111 TQL # 617-7274900 ext 406or-1;-g77.,MASSAFE Revised 5-26-05 Fay, # 617-727-7749 41 ,� IAI-2 C--� /t;, i Date ....... 1p-Z-1�/ ............................ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............... V& �- ........... has permission to perform ..........k..1. 7 / ........................................................ wiring in the building of .................... A�lIZ-777 at ........................................... ............. (�7 . .......... . ..... ...................... North Andover, Mass. Fe No Ze ,e .............................. .................... . ........ ELECTRICAL INSPEC 'R I f Check # '2 12 7 ID 4. Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 10 I—l q City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant a,,,ck Telephone No. y7�r a�3-31 �S Owner's Address -L6 C - a 5..1 S� Is this permit in conjunction with a Purpose of Building At permit? Yes RR No ❑ (Check Appropriate Box) 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 Ampacity Location and Nature of Proposed Electrical Work: Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- 1:1 rnd. rnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump I Number I Tons KW No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water Kms, No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work Lt ttbU (When required by municipal policy.) Work to Start: - Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such c verage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and completes FIRM NAME: i f C , LIC. NO.: OA Licensee: `u. S �• Signature ° LIC. NO.: (If applicable, enter "exempt" in the lic ise number ling.) Bus. Tel. No.: 97 Pr 0'7 l ( 30 Address: 1`.. - a tl'&4 bL 61g3� Alt. Tel. No.: 21 L- 376- 1 I/ 1 *Per M.G.L c. 147, s. 57-01, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's a ent. Owner/Agent Signature Telephone No. PERMIT FEE: $ P4rg I -e go-�- /U ru-4,j N v S D YS P..m • 0 . a. vim u-- ZZ mcn.C-) �_ •c Z D r C3 :rO n CAO�� trW z .0 • U1 L7 '7[ l.: 00 a .= N a m 1Il) ` m � +, Date.A�.I.q ......... TOWN OF NORTH ANDOVER RMIT FOR WIRING This certifiesat that V has permission to perform . . ...... .... jo je , � Ail ... ............................... wiring in the building of Prth Andover, at .... ........ .................. . ...................... rth Andover, Mass. 6511D Fee .............................. Lic. No. .......... ....... ... .... ......... . . .. ... .. ...... sp ELECTRICAL INSPECTOR Check # 12!- �' V-, Commonwealth of Massachusetts Official Use Only lug Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) (poSe� S Owner or Tenant c.^J (1,49-r �v\e- � Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No j. (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service-kpc) Amps acs / a Volts Overhead ❑ Undgrd New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: S, G �e ay.� 12% ID SA CA f, I 4 V} 1rPCt✓l�+cc Icj Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- El rnd. rnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump I Number I Tons I KW No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: `j 0 (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such co erage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: u y I4. atc_y Y.c L .4 LIC. NO.: DotwA Licensee: Signature _ LIC. NO.: (If'applicable, enter "exempt" in the license number line. Bus. Tel. No.: 57°x- D�ik -1 [ 0 Address: J\ iA'4 W4 A19P. (j. J-1- t� 1A Alt. Tel. No.: C'Q5-174- %16— *Per M.G.L c.-147, s. 7-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's a ent. Owner/Agent Signature Telephone No. PERMIT FEE: $ / ! �//'� �( / �^_ / Y r-r--s.-�-- 's :3�vni+��s�sNa�n .. E :� HU This certifies that Date ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING ...................... :; ....... I ........................... .................................... 0 .......... has permission to perform wiring in the building of .................. .................................... A............... Si'``...... .... . . ........ North Andover, Mass. e 01 Lic. No. ................. ... t &�MCAL INSPECTORS Check # 117217 SCIIN Commonwealth of Massachusetts Official Use Only —7 Department of Fire Services PernutNo.i ! L o BOARD OF FIRE PREVENTION REGULATIONS [Rev. Occupancy 7(leand Fee la Checked d w(leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (ME71;11 7, ' 12.00 (PLEASE PRINT IN)NK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspe or o ices: By this application the undersigned gives notic,,.gf his or her !r %t n to perform the electrical work described below. Location (Street & Number) L to " Owner or Tenant (j� Owner's Address 7A. Is this permit in conjunction with a building permit? Purpose of Building - Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Telephone No. Yes ❑ No YK (Check AppropriiaateB x) Utility Authorization No. Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Cell: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑A rnd. grnd. o. of Emergency ig ting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number "' Tons ' "' " " "' KW """""". "" No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal El Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KWNo. of No. of Data Wiring: Heaters Signs - Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications quival: No. of Devices or E uiva ent OTHER: , 0 tJ Attach adlitional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: �� Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability ins rance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such Covera is in force, and has exhibited proof o ame to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I� certify, under the pa II penal ' s f p 'ury; that tl in ation on this applicatton is true and complete. FIRM NAME: LTC. NO.: Licensee: �� c/ Signature LTC. NO.: (If applicable, enter+ "exe " in the icense number I' Bus. Tel. No. Address: (S Cd Alt. Tel. No.: *Per M.G.L c. 147, —s5 -7---6f,- security work quires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. I ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the ' permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass F?1 Failed [N Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass n Failed M ` Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: L Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations 600 Washington Street Boston, MA 02111 UT www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/lElectricians/Plumbers Applicant Information Please Print LeLyibly Name (Business/OrganizatiorAndividual): <7(__) Address: (31n ackt2V4 City/State/Zip:aone #:. &Lrq Are y u an employer? Check the appropriate box: 1. I am a employer with &"' 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12. ❑ Roof repa' 13 E1 Other !Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. „t Homeowners who submit this affidavit indicating they a're doing all work and then hire outside contractors must submit anew affidavit indicating such. $Contractors that cheek this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. A i m _ Insurance Compa Policy # or Self -n Job Site Address: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well .as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify under /t�hjepJjain d p alties of perjury that the information provided abs a is ue anti correct eit'm�firra• //1'1/// ��si��j'` r�a{'A• �� Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - 11 Contact Person: Phone #: II N Information and instructions - Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or' -permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial .Accidents Office of Investigatitons 600 Washington Street Boston, MA 02111 Tel, # 617-727-4900 ext 406 or 1-877.7MASS.AFF, Revised 5-26-05 Fax # 617-727-7749 wWVV-Mass,govldia This certifies that Date. A-.4-.04%.. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING has permission to perform .................. plumbing in the buildings of -4 a 4 ........... atr ?e� . .-- ....... , North Andover, Mass. �- ,. Few.sl..... Lic. No.. l �.. ............ ' PLUMBIN INSPECTOR Check # 411" G 2- 7169 71b9 t_15 ,MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) , 1 Q %t Mass. Dat16—A)..T 0 —id Permit # 4 Vj Building Locaum&a-,t��_/__c2taOwners Namef I'L J�4,2141idd,4.4 141d. Oiteype of Occupancy_ZQCA4j t & 0 'New QRenovatlon�D' Repia anent S �mitted Y 0 No IN Installing Company Name CHMATE ZONE He. Address 38 MILILILESEX S BRADFORD, MA 01835 Business Telephone q79-- 379.- ;�;2-23 Z m, Name of Licensed Plumber Check one:. Certificate 011'lrporation 0 Partnership I] hrm/Co. INSURANCE COes rGE: I have aY current ' @ity No O policy or Its substantia! equivalent which meets the requirements of MGL Ch. 142. If you have checked Vis, please Icate the type coverage by checking the appropriate box A liability insurance policy Other type of indemnity 0 Bond O OWNER'S INSURANCE WAfVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner D Agent 0 1 hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit isvred for this application -will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code vpd Chapter 142 of lldeGqral taws. Title gnature of Used mtxr Type of License: Master ®� Journeyman D (O 1 NL license Number % 1'� NONSENSE mossommosommusono Installing Company Name CHMATE ZONE He. Address 38 MILILILESEX S BRADFORD, MA 01835 Business Telephone q79-- 379.- ;�;2-23 Z m, Name of Licensed Plumber Check one:. Certificate 011'lrporation 0 Partnership I] hrm/Co. INSURANCE COes rGE: I have aY current ' @ity No O policy or Its substantia! equivalent which meets the requirements of MGL Ch. 142. If you have checked Vis, please Icate the type coverage by checking the appropriate box A liability insurance policy Other type of indemnity 0 Bond O OWNER'S INSURANCE WAfVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner D Agent 0 1 hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit isvred for this application -will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code vpd Chapter 142 of lldeGqral taws. Title gnature of Used mtxr Type of License: Master ®� Journeyman D (O 1 NL license Number % 1'� i 0 v W ' a• N Z N N W m .'O • i`.�, .'•1^b'M ' S•.:%f# ti Y _�•''l?`?�..•! ^F•'dt?tn.^[R +r}i _ �::.wY. �T[hy.'Y%a�`•✓"•y>'.i .%�I. M1'tMHM R ri+1+Sf"� � . ... . 6 W LL r Date ...... TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION This certifies that ................. has permission for gas installation\:.. in the building of ................... atc-.-.., North Andover, Mass. Fee .�O-.—... Lic�No.. .7!1,3.. ......... . ......... GASINS ECTOR Check# 5:782 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT IU iiu UA.'toral111IINU (Print or Type) G ass. Date 1t) --d Permit # Building Location Owner's Name P(' �o jL0-azUZ s'r�1pe of Occupancy a C New r! Renovation ❑ Replacements Plans Submitted: Yes n No FIXTURES Installing Company Name Address t^I I^�� ZDDtF tr 38 MIDDLESEX ST. Business Telephone Name of Licensed Plumber or Gas Fitter��`� Check one: Certificate L�Corporation - = Partnership Firm/Co. INSURANCE COVERAGE: 1 have a currp liability insurance policy or its substantial equivalent which meets the requirements of :NGL Ch. 1 2. Yes _ No if you have checked yes, please indicate the type coverage by checking the appropriate box. •A liability insurance polio; Other type of indemnity = Bond -- OWN ER'S OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 14= of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner r Agent Signature or Owner or Owner's Agent I hereby cerrdv chat all or the oerads and niormation I have submined for entered) in the above application are true and accurate to the best or my knowledge and that all plumbing -Mork and msrallations nenormed unaer the permit Issued ror ;his aoohcanon will !x !n comoi,ance •v ahall aemnent Provisions of the Massachusetts :tate Gas Code and Chanter lag or the General Law+. or License: vpeum av Plber uli CJ hd 2&- / j2snrter Signature t Licensed Plumber or Gas Fitter • LD aster Title - Journeyman License Number Gry/Town .APPROVED !OFFICE USE ONLY) in • • CL• • U Un un un z • z• • z CC • •• • QQQQQQQQQSEEN QQQQQQOMEN QQQQ�QQ�QQQQQQQQQQQQQQQQ QOMEN QQQQsoon list FLOORNONE QQSENSE MEN .• • QNEESE QQQQQQQMISEEN . E. QQQQnQQQQQQQnQQQQQQQQQQ'' EEmo- QQQQ - • . QQQSEEM 0 soQQQQQQQQQ®Q • . QQQQQQQMIS .. QQQQQQQQQQQ�®QQQQQQQn QQQIS so . • � QQQQQQQQQ�ISEESIZE Q ! .. ■QQQQQQQQ�®QQE0001S1S=E Installing Company Name Address t^I I^�� ZDDtF tr 38 MIDDLESEX ST. Business Telephone Name of Licensed Plumber or Gas Fitter��`� Check one: Certificate L�Corporation - = Partnership Firm/Co. INSURANCE COVERAGE: 1 have a currp liability insurance policy or its substantial equivalent which meets the requirements of :NGL Ch. 1 2. Yes _ No if you have checked yes, please indicate the type coverage by checking the appropriate box. •A liability insurance polio; Other type of indemnity = Bond -- OWN ER'S OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 14= of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner r Agent Signature or Owner or Owner's Agent I hereby cerrdv chat all or the oerads and niormation I have submined for entered) in the above application are true and accurate to the best or my knowledge and that all plumbing -Mork and msrallations nenormed unaer the permit Issued ror ;his aoohcanon will !x !n comoi,ance •v ahall aemnent Provisions of the Massachusetts :tate Gas Code and Chanter lag or the General Law+. or License: vpeum av Plber uli CJ hd 2&- / j2snrter Signature t Licensed Plumber or Gas Fitter • LD aster Title - Journeyman License Number Gry/Town .APPROVED !OFFICE USE ONLY) O Ln 71 m --i r) rn 'n F1 In 0 X C C: Ln rn Z i 0 > Ln 71 m --i r) rn 'n F1 In 0 X C C: Ln rn Date ... -z.?.. TOWN OF NORTH ANDOVER PERMIT FOR WIRING 114914'0< P1441L This certifies that .......................................................................... has permission to perform .... wiring in the building of ........... 5.4 ..................................................... at ....... 6P!.0. .....5�'*- ............................... . North Andover, Mass. ............. /,26& —;0? ............... lee'3570'��. Lic.No ........ ....... ELECTRICAL INSPECTOR Check # 5651 11W l,tltrllMUly "riftu n yr lntsariL"VLU" i u DEPARI11 WOFPIIB ESAFEIY BOARDOFFREPREVE APPLICATIONFOR PERMIT AIL WORK TO BE PERFORMED IN ACCORDANCE WITH (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Town of North Andover The undersigned applies for a permit to perform the electrical Location (Street & Owner or Tenant Owner's Address REGU MONSSl7091280 Permit No. Occupancy & Fees Checked PERFORM ELECTRICAL WORK % MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00Date / I % I d To the Inspector of Wires: described below. Is this permit in conjunction with a building permit: Purpose of Building 'pCA P P w 0iQ, Yes " No (Check Appropriate Box) Utility Authorization No. Existing Service Amps Volts Overhead Underground No. of Meters New Service I Amps olts Overhead Underground 1:3 No. of Meters �! Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work N 14 to d 00 P4 .Pur al?0 No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool* Above El Below ri Generators. KVA ground ground No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlet No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposal No. of Heat Total Total Pumps . Tons KW Initiating Devices No. of Sounding Devices No. of Dishwasher Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local r7 Municipal Other No. of Dryer Heating Devices KW Connections No. of Water Heater KW No. of No. of Signs Bailed No. Hydro Massage Tubs No. of Motor Total HP =C..W Rz=11DdrmpwnftdMa 1ftMG=SdLaws IhmaawtLidtl'tylnvarc>rR yi ciidngCanpim scmworitssl egtavalai YFS a NO Ihmesubmdedva6dptoafofsMZ10 t 0fl1 a Y$S r)whr&chedadYMple=atdraleQtetypedanaa�by bcoL INSURAI �E BCM OMER a city) F n*dVatledEb2WWak$ WodcbSlat kWecfimrD leReq x9ed Rottgft FsW Stgnedunda Pbrtaldesafpecjtiy. FIRMNAME LimwNa t ffit� S>l��e LioereeNo Bttsttes TeL Na AlL Td No. OWNER'SMJRANCEWAM3kIarnamdntftLioernedDmnotharetheirm><ato aNaWcrgsatbtraq ivWnasm4fmdbyM=d>t>. oC nWLam ardthetmy rnihispemiappkaoionwai�esdistec}irerttett (Please one) / Owne Agent G. (�( ` Telephone No. PERMrr FEE tgnaof Owner 11W l.tlJMVjVLV "r AjU n yr 117tLX t L," v.u.i A u DF.PARl MW 0FPUB[1C&MY B0ARD 0FF1REPRFV F fMNRDGiIlAT i0N5S17a21ZW Permit No.� Occupancy & Fees Checked -5,T t IS APPUC47IONFOR PERMUTO PERFORMELECMCU WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) w Date h 7 a :s - Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) y Owner or Tenant �/�rw / f C -P -Ti l �A J o I L A V Owner's Address f y X7 Is this permit in conjunction with a building permit: Yes® No Ej Purpose of Building ��c (Check Appropriate Box) Utility Authorization No. Existing Service Amps �Volts Overhead Underground � No. of Meters New Service Amps olts Overhead Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work 0 /4w7Udt- 4 e.7.777 77, 71 No. of Liphtin No. of Liahtin No. of Recept No. of Switch No. of Ranges No. of Dispos No. of Dishws Dryers No. of Water No. of Hot Tubs Pool No. of Transformers Generators. Battery Units Tow No. of Air Cond. Total 1 FIRE ALARMS No. of Zones No. of Haat Pumps Space Area Healing Heating Devices No. of rotal Totes Tons KW No. of Detection and Initiating Devices No. of Sounding Devices KW No. of Self Contained Detection/Sounding Devices Local Municipal KW Connections No. of Massage Tubs I No. of Motors Total HP vaWptoafafwwlDftCflkoe Y¢ got . YES a NO a r)out,a`ectzdWYE%pk=1 idcz I drgecfw=Vby BCND OHM 0 � D F ataavaluec(ElecilicalWade$ D&Rmz*d Rao aw LiaaneNo. Bt>S=TdNa 1A.. AkTdNa OWN�S]NSURANMWAM-Iamawaed9ftLio wd=rothateteizinwcnWarisae 1YWa1asm4imdbyNhmmhB tyGernWLm ° arddestmy comp-aritappicatippwai�esdistaquerna�e (Please on) Own Agentri Telephone No. PERNff FEES Sagnature or Owner or Agent - .41oL d ilou�ti. _ o fC 0 Date.... TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING S,qC14US ....................... This certifies that hr— has permission to ..... ..... ................................ wiring in the building ..... . ...%............... at 2&.C5 ............. Fee ..4 5../V .... Li.x . ... P-� Check # 13191 Sb57 .......... . North Andover, Mass. ELECTRICAL INSPE&OR 11M t.UMV11VLV VYLSfiLdn Ur tnr>ta7tt>►� ntv.as�s i �••• �• •, DEPARlMWOFPUBl1rC'SAMYPermit No. 7 BOAMOFFMPREMMONRBgJLMOASS27a2,aW Occupancy & Fees Checked ` APPUCA77ON FOR PERMIT TO PERFO. ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSST� (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) 7 Town of North Andover The undersigned applies for a permit to perform the electrical work descri below. Location (Street & Number) Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: Purpose of Building Z7r Y,,�i e= ELECTRICAL WORK IICALCODE, 527 CMR 12:00 Date To the Inspector of Wires: No (Check Appropriate Box) Utility Authorization No. Existing Service Amps Volts Overhead Underground a No. of Meters New Service Arnps....�.V olts Overhead Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work f2. Wt&44 X, No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of lighting Fixtures Swimming Pool Above Below rl Generators KVA ground ground 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 Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps . Tons KW Initialing Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipal Other No. of Dryers Heating Devices KW Connections No. of Water Heaters KW No. of No. of Signs. Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER, lrrtratoeCoraage: ArtatartbdterequitartealsGaraalLaws Iha►eaamaitLiatki aa=RfgiriftCanp� Cj—��`Y ,oritssubsl<riba q i%a YES a NO E lharesu1vi0dva5dpwdofWWlo r0l� W 1 1fyouhmdz&dYES,ple=naic* t Wcfaowrageby OWNWSMJRANCEWAIVER.lammwaedildiet donnot demm=ww*crgsakgndqpaimtasmglmedbyMwxbrmCandLan anddratmyagnamcndispwnk wamdlistagtiawert (Please check one) Owner [:3 Agent L j 1 Telephone No. PERMIT FEE S J iSignature of Owner • • JIM LU1MV1U1V"VAA J n yr AL3 DERUM TOFPU W34 Permit No. BOARDOFFMPREVF1MNRBOULAT M517adRl2i Occupancy LL & Fees Checked APPLICAHONFOR PERMIT TO PERFO ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSST ICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perforin the electrical work descri led below. Location (Street tit Number) Owner or Tenant ' V A7. Owner's Address Is this permit in conjunction with a building permit: es No [� (Check Appropriate Box) Purpose of Building �j f f�,C;) I�/'s��f i t� I Utility Authorization No. Existing Service Amps olts Overhead M Underground a No. of Meters New Service Amps...L.V olts Overhead Q Underground C3 No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work ( ,� psi 2 V.1 i (�-lei' ?U' /�-j No. of Ughdng Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pooh Above Below Generator KVA ground 0 around 171 No. of Receptacle Outlets No. of Oil Bumen No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Bomar FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Tout Tons No. of Detection and No. of Disposals No. of Haat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwasher Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipal Other_ No. of Dryer Heating Devices KW 0 Connections No. of Water Heater KW No. of No. of signs Ballads No. Hydro Massage Tubs No. of Motor Total HP ftE a t ia' w Zf)kqvcdmD*Rao aflimbi YE, M NO 1F)euhmdnJWY1Kpl=irldrI dze pecfaovaVby E+gi�oBD�ate Estiiria�dVatleafIIrirel Wadc $ Ra* Anel J Liomm 9 5 yGD 11� Bt zxTdNa 576 Y -t �2Q;ti cC' /f� �� t� ALTdNo. — f7Y G� f Sri y chxk one) Owner � Agent a Telephone No. PERMIT FEES �-) POE$ gr`p*�-2 ok FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. APPLICANT FILLS OUT THIS SECTION APPLICANT (p u t- J0, at l oA HONE jT 7 3 01 oZ LOCATION: Assessors Map Number PARCEL SUBDIVISION LOT (S) Snag STREET a'Z "i "4S % / y ST. NUMBER � 6 OFFICIAL USE ONL `" -- -- - DATE REJECTED TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD TH TH DATE APPROVED DATE REJECTED_ DATE APPROVED DATE REJECTED_ COMMENTS %v�l/w �cL `� i<1 PUBLIC WORKS - SEWER/WATER CONNECTIONS _ DRIVEWAY PERMIT FIRE DEPARTMENT, RECEIVED BY BUILDING INSPECTOR DATE_ Revised 9197 Jm a