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160OOsgood Street
Building 20, 2035
North Andover MA 0 1845
Tel: 978-688-9545
Fax: 978-688-9542
COMPLAINT FOR INVESTIGATION
f7lDATE: Tel #:
FROM L�6 -his, n-�A I �-j
ADDRESS: 2�� znc(
Complaint Against
ELECTRICAL:
PLUMBING:
GAS:
BUILDING CONTRACTOR:
PROPERTY OWNER: Q�3 svee-�
Signed:
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41
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North Andover Board of Assessors Public Access
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Summary
Residence
Detached Structure
Condo
Commercial
Page I of I
North Andover Board of Assessors
17-�Property Record Card
Farcei r Y:.zuil uornmunity: iNortn Anaover
SKETCH PHOTO
Click on Sketch to Enlarge -�Click on Photo to Enlarge
Location: 19-25 SECOND STREET
Owner Name: THORNTON, JUNE G
Owner Address: 22 SCHOOL STREET
City: NORTH ANDOVER State: MA
Zip: 01845
Neighborhood: 5 - 5 Land Area:
0.19 acres
Use Code: 111 -4 -8 -UNIT -APT Total Finished Area:
5436 sqft
ASSESSMENTS CURRENTYEAR. PREVIOUS YEAR
Total Value: 476,500 473,000
Building Value: 317,000 317,000
Land Value: 159,500 156,000
Market Land Value: 159,500
Chapter Land Value:
http://csc-ma.us/PROPAPP/display.do?linkld=2616439&town=NandoverPubAcc 4/7/2015
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Date............
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ....... A. A. 1. �� ..... ..............................
has permission to perform .... ...................
wiring in the building of ... 5.�rAod ............ I ................................
...... y ........ .......................... Nortli,44dover, Mass.
at ..... ......... C— - t
.................
A Fee -:5S ............. Lic. No. ELEcmicAL INA�45
Check #
7187
P
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Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. 7/c�- 7
Occupancy and Fee Checiwd-,
[Rev. 9/051 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECT ICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 7 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: h
City or Town of. NORTH ANDOVER To the In4ect4r of Wires:
By this application the undersigned gives notice of his or her intentiop to form the electrical work described below.
per_
Location (Street & Number)
e -
Owner or Tenant
Owner's Address
Is this permit in conjunction with a building permit?
Purpose of Building
Existing Service Amps
New Service . Amps
Volts
Volts
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Telephone No.
Yes 5�� No F-1 (Check Appropriate Box)
Utility Authorization No.
OverheadEl Undgrd 0
Overhead [] Undgrd []
No. of Meters
No. of Meters
I 'Comptetion of the followinz table may be wai4dybv the l5spector 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 Ei In-
0. Of Lmergency Lighting
grnd. grnd.
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
FNo. of Zones
No. of Switches
S
No. of Gas Burners
No. oTDetection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerti ng Devices
No. of Waste Disposers
Heat Pump
Number
I
I Tons
KW
I I I-- . .
No. of Self -Contained
I
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local EJ Municippi El 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 Evivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
IOTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value o9EIe9tricaI Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with M EC Rule 10, and upon completion.
INSURANCE COVEIRAGE: 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 coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE F] 13OND [:1 OTHER 0 (Specify:)
I certify, under thepains andpenalties of perjury, that the information on this application is true and complete.
FIRM NAME: LIC. NO.:
Licensee:
Signature
LIC. NO.:
(If applicable, enter "exempt" in the license number line.) Bus. Tel. No.:
Address: Alt. Tel. No.:
*Security System Contractor License required for this work; if applicable, enter the license number here:
OWNER'S INSURANCE AI.E I am aware that the Licensee does not have the liability insu
WAI Xce coverage normally
required by law.. m ow, I hereby waive this requirement. I am the (check one) Yowner 0 owner's agent.
W
Owner/Agent ,
Signature �o- Telephone No. -7P11056CE61PERMIT FEE. $
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.govIdia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le2ibly
Name (Business/Organization/individual): &=c�
AJ_ , or\. n
Address: TT'%��ns
City/State/Zip:
Phone#: 72 91 q0S_6Cb(0
Are you an employer? Check the appropriate box:
1.0 1 am a employer with
4. El I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2.0 1 am a sole proprietor or partner-
listed on the attached sheet. I
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. El We are a corporation and its
Kr uired.]
uil
officers have exercised their
3.M ama 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. F-1 New construction
7. 0 Remodeling
8. E] Demolition
9. E] Building addition
10 . bjKlectrical repairs or additions
11.0 Plumbing repairs or additions
12.E] Roof repairs
13.R Other
*Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
I
+Contractors that check 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 insurancefor my employees. Below is the policy andjob site
information.
Insurance Company Name:
Policy # or Self -ins. Lie. #:
Job Site
Expiration Date:
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 required under 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 U!AfQr insurance coverage verification.
I do hereby
z
ofperjury that the information provided abvve isirue and correct.
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
Contact Person: Phone #:
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Date /- .. . ......
.. ........... .. ...
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
Thiscertifies that ..............................................................................................
has permission to perform .... �7� ....................... :�� .........................................
00
........................
wiring in the building of ............ ............................. . .
at ..... ...... \ Ngh Andover, Mass.
........ ...... .. .... ...... ................
Fee Lic. No . ........... . .....
................ .... I ..................... .......
ELECTRICAL INSPEC'fOR
Check #
7185
12
14
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
'7
Permit No.
Occupancy and Fee Checked 16Z
,[Rev. 9/051 (lea,e 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 INFORAL4 TION) Date: L— 0'�q, 07
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) 97 --2 9 /1.., -e6 _!�:'rle 41<,f �
Owner or Tenant Telephone No.
Owner'sAddress
Is this permit in conjunction with a building permit? Yes No (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps /� Ac Volts Overhead Eg' Undgrd El No. of Meters c7_
New Service Amps Volts Overhead El Undgrd El No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: )g7L-
Completion of thefollowing able may be waived by the In ector 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
Above In
Swimming Pool 1:1
No. of Emergency Lighting
grnd. girrid.
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
INo. of Zones
No. of Switches
No. of Gas Burners
No. of Detect-lon and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
in
Heat Pu p
Number
I Tons..
I KW
No. of Self -Contained
—Totals:
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
LocalE] Municippi El 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: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with M EC 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 coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE F] BOND 0 OTHER [—] (Specify:)
I certify, under the pains and p F enalties qfpqJuty, that the information on this application is true and complete.
FIRM NAME: I;VIK44oll,�7 LIC. NO.:tf_97--�'
Licensee: Signature_�_____� LIC. NO.:—
(If applicable, enter "exempt" in the license number line) Bus. Tel. No.:
Address: Alt. Tel. No.:
*Security System Contractor License required for this work; if applicable, enter the license number here:
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) El owner E] owner's agent.
Owner/Agent I PERMIT FEE. —
Signature Telephone No. $1�37
A <11,69 2
Date/. / ......
0" TOWN OF NORTH ANDOVER
PERMIT FOR -PLUMBING
This certifies that .....
has permission to perform .... A-7-41� P.L�- A4
plumbing in the buildings of ............
at. ..................... North Andover, Mass.
<77
PLUMBING INSPECTC(R
Check #
7254
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
/ /7 -7 /—,
Building Location / . Date
20 Owners Name 401001 -2%c ol-l_ Permit # 7.2)T
Type of Occupancy 9,C J--viCe Amount
New Renovation 0__� Replacement 0 Plans Submitted Yes El No 0
FIXTURES
(Print or type) Check one: Certificate
Installing Company Name 0 Corp.
Address 114 6)1��a' �Q) Partner.
1) yj" e. 11
Business Telephone Firm/Co.
Name of Licensed Plumber i�__Ico J,
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity El Bond
insurance Waiver. 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature I Owner 11 Agent 11
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massac�" State Plumbing Code and Chapter 142 of the General Laws.
By:
Title
City/Town
-APPROVED (OFFICE USE ONLY
Type of Plumbing License
License NumbeF- Master 0-1-1ourneyrrian
Date .......
,40RTH
AIR TOWN OF NORTH AND6'VER
0
PERMIT FOR OAS INSTALLATION
This certifies that f. ."7 t . . . . . . . . . . . . . . . . . . . . . . . . . . .
has permission for gas installation .... � '14. ?1 ;5. :-�c ..............
in the buildings of ..... P -(., -
.........................
at .............. North Andover, Mass.
Fee. . k —. Lic. No. .....
INSPECTOR "'
Check # / e- ( 121
5773
SUB—BSMT.
BASEMENT
1ST FLOOR
2ND FLoon
3RD FLOOR
TH FLOOR
STH FLOOR
6TH FLOOR
7TH FLOOR
GTH FLOOR
6stalling Company Name, b I
i-// LAI _ I X , Check one: Certificate
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Corpomation
Partnership
lusiness Telephone Firm/Co.
Name of Ucensed Plumber or. Gas Filter It le—
NSURANCE COVERAGE:
Ihave 8 current liability insurance polic'y or its Substantial equivalent which m'
Ye -s W No 0 LetS the requirements of MGL Ch.
IfYou have. checked yes, please indicate the type coverage by checking the appropriate box.
Aliabiltty insurance policy 0
father type of indemnity ED Bond [I
142.
OWNER'S INSURANCE WAJVER: I am aware that the licensee does not have the Insurance coverage required I by
Chapter 142 of the Mass. General Laws, and that my signature On this �PerW21DPlication waives this requirement.
Check one:
-1 —ner or Owner s Agent Ownero Agent D
1 hereby certifY that all of the details and info
mialion I have submitted (Or entered) in above apPfir-ation are true and accurate to the best of my
knwAedge,and that all Plumbing work and installabons Perlormed under the permit issued for this application will be in compliance with -all
Pertinent p Ovisions of the M—rhusetts State.Gas Code and ChapteT 142 of the General Laws.
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911 -tuff! 01 ucensed Pl—un
Dty/Town License Number
A�-1—DFF1—CE—U—Sr0NLW— Journeyman
(Plini oi lype)
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Date
Fermft 4f
Buildlirig Locatior,
? iln�od
YL.
Owner's Namejz�C4
Type of Occupancy --&—e5
New D
Renovati6ng
Repiacement 0
Plans Submitted: yes[D NO
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SUB—BSMT.
BASEMENT
1ST FLOOR
2ND FLoon
3RD FLOOR
TH FLOOR
STH FLOOR
6TH FLOOR
7TH FLOOR
GTH FLOOR
6stalling Company Name, b I
i-// LAI _ I X , Check one: Certificate
_21t
rr
kddres�-
Corpomation
Partnership
lusiness Telephone Firm/Co.
Name of Ucensed Plumber or. Gas Filter It le—
NSURANCE COVERAGE:
Ihave 8 current liability insurance polic'y or its Substantial equivalent which m'
Ye -s W No 0 LetS the requirements of MGL Ch.
IfYou have. checked yes, please indicate the type coverage by checking the appropriate box.
Aliabiltty insurance policy 0
father type of indemnity ED Bond [I
142.
OWNER'S INSURANCE WAJVER: I am aware that the licensee does not have the Insurance coverage required I by
Chapter 142 of the Mass. General Laws, and that my signature On this �PerW21DPlication waives this requirement.
Check one:
-1 —ner or Owner s Agent Ownero Agent D
1 hereby certifY that all of the details and info
mialion I have submitted (Or entered) in above apPfir-ation are true and accurate to the best of my
knwAedge,and that all Plumbing work and installabons Perlormed under the permit issued for this application will be in compliance with -all
Pertinent p Ovisions of the M—rhusetts State.Gas Code and ChapteT 142 of the General Laws.
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911 -tuff! 01 ucensed Pl—un
Dty/Town License Number
A�-1—DFF1—CE—U—Sr0NLW— Journeyman
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01 D VER
TOWN OF NORTH ANr
PERMIT FOR PLUMBING
This certifies that ... b. e. �� i . �� . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
has permission to perform .... I ...........................
plumbing in the buildings of . . .................
at ... )
........... North Andover, Mass.
Fee. . ... Lic. No..2Zi.)0E- 2 .......... VAD
PIUMBING INSPECTOR
Check # 10
7161
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ev., 7j hvrimraux,
OWNER'S INSMAJ4CE VLAr%sp,: I cm lawme V -W tjt� e:
jiensL 012�--Z-ve Ithe- insuranm COVEraot- required by
noi fu-�
-40Ptel 142 of the iitasx. GiencrX Laws. an:1 ffat my zignature on this pernth appli=tlon walv=
Check one: this requirernmrtt
6 -1 -of Or L-ner , Apent avmw Agent ,
ftify ffizi all Of the details and iniommuon I have sub,11fted j -------
I tell a!,' Plumbing %W: anc; instaltations Pertormed under the Permit df - is
en, -4-%,;� 0 - Or entered) in &bOve ADDlication we tnp- an to th6 WS! 01, my
Pariinent provis, ns Of Um wa=chusett, Sute p, i=ue C� th aD41. Will 4��`a
ng CDdc- and mad LAWS. be m compliance vAth all
41 — ��42 Of V* Gen
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Tjjx of Ljcen�--- Master
tPPR:y _--burneyman 7
(Dr I— t DNL J
License Number 26 3
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0 F-Artnership,
NIMC Of UCensed PlUmber
0 FIMVCO;
LANUE CMIEFLAGE.
I have a current i lifty insu
Y= rance Por1cy Or ft rubst1lintial
yes:
eQUK%Ient wtlich meets
the
No 0
recluire.171ML,
of MGL Ch. 142.
i it You h av,
t YOU haVe CheCJ�ed.K-'—S. PIMSL'
indicate th-_ ty;>- CDVLMge ty CheCpjrlg %e appropriate box
A 1,6r4 "'ur
in'Suranr-e
Other bl>-, Of inCIMMnIty
Bond n
OWNER'S INSMAJ4CE VLAr%sp,: I cm lawme V -W tjt� e:
jiensL 012�--Z-ve Ithe- insuranm COVEraot- required by
noi fu-�
-40Ptel 142 of the iitasx. GiencrX Laws. an:1 ffat my zignature on this pernth appli=tlon walv=
Check one: this requirernmrtt
6 -1 -of Or L-ner , Apent avmw Agent ,
ftify ffizi all Of the details and iniommuon I have sub,11fted j -------
I tell a!,' Plumbing %W: anc; instaltations Pertormed under the Permit df - is
en, -4-%,;� 0 - Or entered) in &bOve ADDlication we tnp- an to th6 WS! 01, my
Pariinent provis, ns Of Um wa=chusett, Sute p, i=ue C� th aD41. Will 4��`a
ng CDdc- and mad LAWS. be m compliance vAth all
41 — ��42 Of V* Gen
- -----------
01 —15cu Muml>er
Tjjx of Ljcen�--- Master
tPPR:y _--burneyman 7
(Dr I— t DNL J
License Number 26 3
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Location
No. ,-� -/ 2, Date &.n �,-
TOWN OF NORTH ANDOVER
Certificate of Occupancy
$
41
Building/Frame Permit Fee
$
CHU
Foundation Permit Fee
$
Other Permit Fee 1el
$
Sewer Connection Fee
$
Water Connection Fee
$
TOTAL
$
Building Inspector
Div.
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Castricone Roofing & Siding
REPAIRS FREE ESTIMATES
Telephone (978) 682-4266
MARIO CASTRICONE,
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, o,)nremises be described:
B I
1 4 .... ..
Owner's Name ... .......... ......................................................
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... . ..... V"' ........................................................... Cil State...
Job Address .... .. /--1EDNC ".' A -Z
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SPECIFICATIONS
...... ............................................... .......... ......... ...... I ................... 11IL ...... ............
.. ............. .................... v
........................
........... . ....
. . ......... ...... ................
........... ....... .......................... ................ .. .............................. .......... ..
............
.. .......... . I ............................. 4� .... .. .... ..... C� .....................
........................ ............................ ...... ................................................. * ... ...... . ................................ . .......................................................................
. . . . .... ........................ ... . ............... .. .. .............. .... ......................................................................
....................... . ..... ..........................
....... .... ..
. ................................ . . ...... .......... . ... .... .... ...................... ................................
....... . ................. ........ .. ..... ...................... . ...... ..................
............ ..................... A .......... ..... ............... ........................ ...........
. ......... . . ..... ..................................................... .. ........ .. 74 ..................................
..........
Materials and labor to cost $ ...................... Payable ......................................... on ........... ............... 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 in oper piior�li
IN WITNESS WHEREOF, the parties have hereunto signed their names this ....... . .
....... d a y (0 .... 19...
Accepted:
Signed..,. . ; ...... ... . .......... J
Owner
(OWNER HAS 3 DAYS IN WHICH TO CANCEL CONTRACT)
Per... . . ... .......... .. ........ ...............................................
Representative
Signed......................................................................................
Owner
Signed......................................................................................
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTI N*G L
(Print or Type)
< NORTH ANDOVER Mass.
Date
buildina Location o1Z SE:caA---12 Permit #
Owners Name�DAfA-"'
New -7 Renovation Replacement F -J, -"Plans Submitted
FIX7UD!HS
(Print or Type)
Check one: Certificate
Installing Company Name (:�;dvorecQ-tv Corp.
Address— C-fy C--5 TL--rz- Partner.
Firm/Co.
Business Telephone: 6�22-73
Name of Licensed Plumber or Gas Fitter Orc-(,(^e:�'? 0 voiz
Insuranc(- Coverage. Indicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy &��Other
Insurance Waiver: 1, the undersigned
this application does not have any one
Signature of owner/agent of property
type of indemnity F--� Bond D
have been made aware that the licensee of
of the above three insurance coverages.
Owner Agent El
I hereby certify that ail of the dc(AUs and information I have submitted (or entered) in above application ore tzue and accurate to the best o( my
knowledge and that &U p(umbing work and WCAUations performed under* Permit issued to,- this appLjc;L6,pd`w-2Nbc in compliance with all p=tInent
provisions or Lho Ma'sachusetts State Cas Cude and Chapter 142 of the Central Laws. z . . E;n —
By
Title
City/Town:
APPROVED (OFFICE USE ONLY)
TYPE LICEN
Plumber
Gasfitter
Master
Journeyman
Signature of Licensed
Plumber or Gasfitter
License N(=ber
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PI ST FLOOR
-:S:T-
2ND FLOOR
3RD FLOOR
4TRFLOOR
5TH FLOOR
6TH FLOOR
7TK FLOOR
ST HFLOOR
(Print or Type)
Check one: Certificate
Installing Company Name (:�;dvorecQ-tv Corp.
Address— C-fy C--5 TL--rz- Partner.
Firm/Co.
Business Telephone: 6�22-73
Name of Licensed Plumber or Gas Fitter Orc-(,(^e:�'? 0 voiz
Insuranc(- Coverage. Indicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy &��Other
Insurance Waiver: 1, the undersigned
this application does not have any one
Signature of owner/agent of property
type of indemnity F--� Bond D
have been made aware that the licensee of
of the above three insurance coverages.
Owner Agent El
I hereby certify that ail of the dc(AUs and information I have submitted (or entered) in above application ore tzue and accurate to the best o( my
knowledge and that &U p(umbing work and WCAUations performed under* Permit issued to,- this appLjc;L6,pd`w-2Nbc in compliance with all p=tInent
provisions or Lho Ma'sachusetts State Cas Cude and Chapter 142 of the Central Laws. z . . E;n —
By
Title
City/Town:
APPROVED (OFFICE USE ONLY)
TYPE LICEN
Plumber
Gasfitter
Master
Journeyman
Signature of Licensed
Plumber or Gasfitter
License N(=ber
Date.....................
"O"T" 4, TOWN OF NORTH ANDOVER
0
PERMIT FOR GAS INSTALLATION
-- This certifies that ...........................................
has permission for gas installation ............................
in the buildings of ..........................................
at ................................... I North Andover, Mass.
Fee ........ Lic o
. . ........... ..........................
GASINSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File