HomeMy WebLinkAboutMiscellaneous - 29 ANNE ROAD 4/30/20184 'a3
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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
X--I"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-decined bythe.Inspector-of Wires abandoned-and-invalidifhe—
or she has determined that the authorized work has not commenced or has riot 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 23 8 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 existen&� during the qualifying period beginning on August 15, 2008 and extendingthrough August 15, 2012.
8 — PermitA[)ate Closed:
Extension Act — Permit/Date Closed:
Note: pply for new permix
Date... P-�� ..........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that
has permission to ... ............................
wiring in the building of .........................................................
at . ............................... ............................... . North Andover, Mass.
Fee B;�� . . ..... Lic. No . ............. .(
................ i�i ...... i;r
CAL S
Check # --� & --
6 ) .'j
P -- 0
�p
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. �,- Fz_-C�,
Occupancy and Fee Checked
[Rev. 9/051 (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 PPJNT IN INK OR TYPE ALL INFORM -4 TION) Date: 72_�_
City or Town of- A I - u LT_ To the Inspector �f Wires—:
By this application the undersigfied gives norice of his or her intention to perform the electrical work described below.
Location (Street & Number)
OwnerorTenant
Owner's Address
Is this permit in conjunction with a building permit?
Purpose of Building
Existing Service _ Amps —Volts
New Service Amps I Volts
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Telephone No.
Yes CU/"_ No El (Check Appropriate Box)
Utility Authorization No.
Overhead 0 UndgrdEJ No. of Meters
Overhead [:] UndgrdE] No. of Meters
Completion of the followine table mav be waived bv the InSDector of Wires.
No. of Recessed Luminaires
No. of Ceil.-Susp. (Paddle) Fans
of Total
T
Transformers KVA
No. of Luminaire Outlets
4No.
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above
grnd. 0 1rnd
o. ot Emergency Lighting
Battery Units
No. of Receptacle Outlets C)
No. of Oil Burners
FIRE ALARMS
INo. 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
Number
Tons
I
KW
1 11 — I
No. of Self-Ci;-n--tained
Totals:
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
LocalEl Municipal F1 Other
Connection
No. of Dryers
Heating Appliances KW
Security Svstems:*
No. of bevices 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
Telecom m un i�ations Wiring.
No. of Devices or Equival . ent
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 MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the perfon-nance of electrical work may issue unless
the licensee provides proof of liability i rance including "completed operation" coverage or its substantial equivalent. The
ity i is i
ge
i�
undersigned certifies that such cove e is in force, and has exhibited proof of same to the permit issuing office.
.ov
CHECK ONE: INSURANCE '� BONED [-] OTHER El (Specify:)
I certify, under thepains andpenalties of perjury, that the information on this application is true and complete.
FIRMNAME: =C)CL- LIC. NO.:
Licensee: Signa LIC. NO.:
(If applicable enter "exempt " in the license number line.) Tel. No.: q 78:123- y707
Address: 4 AeVNOW '�>000 OfK , *TJQ.22 Tel. No..toD3- _76?
*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) 0 owner E] owner's agent.
Owner/Agent
Signature Telephone No. FPERMIT FEE. $
1% 97 1 8
/ 0, 2- �--
Date..................................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ......... Nit -C 4-Wq-7z"t (-- 5-
...................................................................................
jo
has permission to perform ......................................... ............
b i,,,, ..........................................
wiring in the building of .................................... ..
at .......... ............... -,-North Andover, M I S.
/A
Fee.?r�� Lic. No. .......... / ... �S
i�E** c**r*R-I'C' A**L* *1* N**S* P**E'C'*T* 0- R -
Check # 1 -?-
rm
services PennitNo._,97 /.LT
Department (of Fire
occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (leaveblank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be perfornied in accordance with the Massachusetts Electrical Code (I�IEC), 527 CD&:� 12.00
(PLEW SE PRTNT.VV INK OR TYPE ALL INFORMA NON) Date:
City or Townof. NORTH ABDOVER To the Inspector of Wires:
lectr" al work described below.
By this application the undersigned gives notice of his or her intention to perform the e ic;
Location (Street & Number)
Owner or Tenant
Owner's Address
Is this permit in conjunction with a building permit? Yes J�f
Pur'noseof Building' --L, 1.
volts overhead
Existing Service Amps —
New Service Amps -- volts overhead
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:'
No. of Recessed Luminaires
No. of Ceil.-Susp
No. of Luminaire Outlets
No. of Hot Tubs
No. of Luminaires
swimming P
No. of Receptacle O.utlets
No. of Oil Bu*rne
No. of Switches
No. of Gas Burn
No. of Ranges
No. of Air Cond,
No. of Waste Disposers
Heat Pump
10�
Totals:
..........
No. of Dishwashers
Space/Area Hea
No. of Dryers
Heating Appliar.
No. of Water KW
Heaters
No. of
Signs
No. Hydromassage Bathtubs
No. of Motors
Telephone No.
No [] (Check Appropriate Box)
Utility Authorization No.
U,ndgrdE] No. of Meters
UndgrdFJ No. of Meters
. (Paddle) Fans
Above E] In-
grnd._ grnd. El
�rs
ers
�Total
Tons
�ib--er I Ton KW
................ I ....... ... . ................. . ..
ting KW
LCCS KW
---7yo. —of
Ballasts
Total IIP
table mav, be waived 6y the
Transformers KVA
Generators KVA
ALARMS I No. of Zones
0.
No. of Alerting Devices
No. of Tel-f-C-o—nta—ined
Detection/Alerting Devices
-7--�r---,Municipal F] Other
Local F] i-n-nilpfinn
evices or
Data Wiring:
No. of Devices
No. of Devices or
.,4ttach additional detail ifdesired, or as required by thelnspector of Wires.
Estimated Value 0 ectrical, Work: 0 (When required by municipal policy.)
'If E�
Inspections to be requested in accordance with NEC Rule 10, and upon completion.
Workto Start: 16la--4 work may issue unless
INSURANCE Co ERAGE: Unless waived by the owner, no permit for the performance of electrical
the licensee provides proof of liability insurance including "completed operatioif' coverage or its stbstantial equivalent. The
undersigned certifies that such coverage is in*fQrce, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ET�BOND 0 OTBER 0 (Specify:)
n on this application is true and conz
I certify, under thepains andpenaldes ofperjury, that the informatio plete.
FIRM NAME: Cv- - LIC. NO.: J2 1 -Z-b-051,
Licensee: Signature! LIC. NO.: 24-9 --421Z-
(1fapplicable, enter lex Pt"in elicensenumb I'm) ��Bus�. Tel. No. -
Address: Alt. Tel. No.:
*Per M.G.L c. 1 7, s. 5f , 61, security work requires Department of Public Safety "S" License: Lie. No.
OWNER'S INSURANCE WAIEVER: 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 (che one) owner owner's
Owner/Agent Telephone No. �AERYIT FEE.- $
Signature
100-
<C�x The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www. mass-gov1dia
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name (Business/Organization/Individual): ZZ�1!1 a 44 4�t_— "gA
Address: --�' 37 en / ;= -
City/State/Zip: Phone
Are you an employer? Check the appropriate box:
1. L3,ram. a employer with
4. E] I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
listed the attached sheet.
2. F1 I am a sole proprietor or partner-
on
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comP. insurance.
5. [] We are a corporation and its
[No workers' comp. insurance
officers have exercised their
required.]
3. 1 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. E] Remodeling
8. E] Demolition
9. E] Building addition
10.0 Electrical repairs or additions
ll.E] Plumbing repairs or additions
12.E] Roof repairs
13.El other
*Any applicant that checks box# 1 must also fill out the section below showing their workers' compensation policy information.
f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
lContractors 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 andjoh, site
information. 1�
Insurance Company Name: CIXVVd
Policy # or Self -ins. Lic. #: R —r IJ L 9 Expiration Date:
Job Site Address: -2 `97 4�1 4-- z6�.... C1tY/State/Z1P:_4
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 DIA for insurance coverage verification.
I do hereby ce ains an�d�alt' �s ofperjury that the information provided above is true and correct
rli,7�d --I -n.f ,, 1-2 :o
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
Location 'C'z? Ao J04-1-1
No. 70 - .)a Date 3 /�//jy //
14OR #I TOWN OF NORTH ANDOVER
41
Certificate of Occupanc $ %
CHU Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL
Check # 6—�m-
2 3 94'- 8
Building InspKAr
CERTIFICATE OF USE & OCCUPANCY
I
Building Permit Number 270-2011 Date: March 3 2011
TMS CERTIFIES THAT
THE BUILDING LOCATED ON 29 Anfie Road, North Andover, MA 01845
Bob Duffy
MAY BE OCCUPIED AS remodeled sinp-le-family interior renovations only
IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING
CODE AND SUCH OTHER REGULATIONS AS MAY APPLy.
Certificate Issued to:
Fee: 100.00 P)
"Receipt: ,2 '-�> f 44
Bob Duffy
29 Anne Road
North Andover, MA 01845
Building Inspector
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Date /0. - . � a..
0 1.
TOWN OF NORTH ANDOVER
PERMIT FOR GASJNSTALLATION
Is SACH
A0 A 640 CQ -11 eie,# w
This certifies that ........................ P! ......... n ....
has permission for gas installaAn A ...............
of 0 JA
in the buildin s ...............
at . .................. Nofth 4nd -r,Pass.
'
Fee.k557. '�7 Lic. No. 14( �� * * *)' �** * * .7
GASINSPECTOR
Check# '0102
NMSSACHUSEITS LINUDEVI APPUC ATON FOR PERTNIrr TD DO GAS FMING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
BUildin- Locations C2-
0
Owner's Narne
Now Renovation El Replacement Plans Submitted
Date /OA�hp
Permit #
A mount
(Print or type) Checkone: Certificate Installing Company
Name—r--ka tl[-e -5- vle-ek-C-41) 41of Corp.
FlPartner..
DFirm/Co.-
Name of Licensed Plumber or Gas Fitter
hNSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 0 No
If you have checked yg�i, please indicate the type coverage by checking the appropriate box.
Liability insurance policy rV% Other type of indemnity Bond
16W I rl 0
Owner's Insurance Waiver: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of [tic
t2
Mass. General Laws, and that my signature on this permitapplication waives this requirement.
Check one: '
Signature of Owner or Owner's Agent Owner 0 A-ent
0 0
i nereoy corn ry mai ai i or Eno auLat is anu in iormanon i pave su t) mi itea (or entered) i n above appl ication are true and accurate to the -
best ofniN know1cd-t! and thatall. plumbing P n-fo -m 1-1 1 -1 y Pt--�rrnit TSSLIed for thisap fication will be in
work and i tal afipqns t: i I I s
Wptcr142oftheGen Laws.
compliance with all pertinent provisions of the Nfassa�b`uss, ate Qgqode an
B y:
Title
CityiTown
1APPROVED (OFFICF, USE ONLY)
Signature of Licensed Plumber Or Gas Q:tter
Plumber
Gas Fitter ME ense IN umber
Master
JOUrneyman
1�
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SUB -B A SEM ENT
BASEIVI ENT
JIST. F L 0 0 R
12N D. FLOOR
13R D. F L 0 0 R
4T 1-1 FLOOR
5 T H F L 0 0 R
6TH. FLOOR
7 T H FLOOR
8 T H FLOOR
L—L
I-
I
I
I
I
(Print or type) Checkone: Certificate Installing Company
Name—r--ka tl[-e -5- vle-ek-C-41) 41of Corp.
FlPartner..
DFirm/Co.-
Name of Licensed Plumber or Gas Fitter
hNSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 0 No
If you have checked yg�i, please indicate the type coverage by checking the appropriate box.
Liability insurance policy rV% Other type of indemnity Bond
16W I rl 0
Owner's Insurance Waiver: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of [tic
t2
Mass. General Laws, and that my signature on this permitapplication waives this requirement.
Check one: '
Signature of Owner or Owner's Agent Owner 0 A-ent
0 0
i nereoy corn ry mai ai i or Eno auLat is anu in iormanon i pave su t) mi itea (or entered) i n above appl ication are true and accurate to the -
best ofniN know1cd-t! and thatall. plumbing P n-fo -m 1-1 1 -1 y Pt--�rrnit TSSLIed for thisap fication will be in
work and i tal afipqns t: i I I s
Wptcr142oftheGen Laws.
compliance with all pertinent provisions of the Nfassa�b`uss, ate Qgqode an
B y:
Title
CityiTown
1APPROVED (OFFICF, USE ONLY)
Signature of Licensed Plumber Or Gas Q:tter
Plumber
Gas Fitter ME ense IN umber
Master
JOUrneyman
1�
87�7 Date la - /a
TOWN OF NORTH ANDOVER
PERMIT FOR PLUM13ING
"; �14U"' �
This certifies that Z�4947�t. .��:eellA?JPDX-
has permission to perform AM,6ie-f . ...... / .......
4
plumbing in the buildings of . .61? IJ- -7 ...........
a t 06 Ay)n -e--. . IV .............. North And er Mass.
Fee.S.57. . . . Lic. No./. .... . ... ... .. .....
PLUMBING INSPECTOR
Check # 1,203
-MASSACHUSETTS UNWORMAppLICATION FOR FERART TO DO PLUAOING
(bp e or print)
NOF,Ta AND UVER, MAS SACHUSEM ]Date
N.;B D u Permit
Amount
Building Locati&_2Z JW -
Me of Oc plans Submitted Yes No
�Tew Renovation Feplacemeiit
Chock Ono:
(Print-ortypel) Corp.
any 3�amq Lll� �14C_c El
Installing Comp
/I Partner.
Address
E21 Firm/Co.
------------
C -y-vew- k q) &--o
Name OfLicenscA Plumber:
typ e
Insurance Coverag Thdic-IdJ& of insurance coverage by checking the approp�iato box: Bond
Other typ a of indemnity
Liability insurance policy V -D th
licensee ofthis application does no! . hale any one of ciabovo
,,,,liran,
1, the undersigned, have been inade aware that the
three insurance
tgnature, Owner Agent
sand information I have submittO (or enf6red) in above application M-truo and accurate to the
I hereby certitr that all ofthe detail lations perfo under Permit Issued for this application will be in
best of MYIMOWledge and that all plumbing work an -ode and Chapt 42 ofthe Gen6ral Laws.
, witbL all pertinent provisions ofthe Mas a
compliance
CitylTomm
�APPROVED (oMCE USE ONLY
� ofPlumbing License
"rY, 0 —
qumber Master 0
lomueyman AP
The COm"10,zweidth ofAfassxhusats
DeP`ttnent qfrndusf7-ia1_4cdd,,t,
Office of bivesfigations
90 wa-Vizing-ton street
-B0-S`t0Yz, JVL4 02-11-7
QV )MM_Mass�govldia
WO-rkETs5 ColuPensation Insurance Affidaldt: BaUders/Contractorsy
jertXicuns/Plumbers
Name (B,,iness/organization&di-,�id,,I)
Addre�s-_�_�e XC4
City/State/Zip: Id -
Phone
A -re you an employer? Chieck the appropriate boxi
am a apployor �vith.
4. 1 am ageheral contractor and I
employees (fiM and/or part-time).*
I
hav6 hired the snb-contractors
am a sOle proprietor or partner-
rJ
-listed on, tbLc aftiched sheet
ship aad have no employees
These sub-coiatractors, ha:ve
Working for me mi any capacity.
[No workers' camp. insurance
workers' Comp. insuranc
5. El We are, a corporation 8'
and its
roquimdj
3.f:] I am a homeowner doing aU V� Ork
. C)fficers have exercised their
right of cxe�mption
Myself [No workers' camp.
per MCjL
c. 152, 6-1 (4), a -ad we have
'no
insurance required-] t
employ=s. [No *orkers,
P6MP- iast3rance. rermm-A I
Type of Project (required):
6. El Net constinction
7. Remodeling
8. Demolition
9. EJ Building addition
10. El Electrical repaim or additions
.11.0 Plumbing regairs or additions
12.0 Roof repairs
13.E] Other
A A-va-pp-Ticauttha- . I I . - —
boxt#,l M._-1 abO al 01-d Cat: _-=6an btlow shovvinag; -i��
is —=!!' W-rk COL____S�A
Homebwnexs Vho submifiIi affi&vit indicfiug &CY d -i-9 aU rk --d ffi- hi- - =sid. a onn-act.. 4IL-t gdbm i t a aw iffid.,it in di Ic
"Colit—tars, th-at rhech thl-- b0z =._= a--hed an additionZI sheet showiag ffi, —�ng ,, h.
ranz an earnployer that isproviding workersl coin "C)f the sub-cCmtmctc,, and their workers' co -p- P 0Hcy informatimL
pensai�onitz.�zirancaformyemployeev Beloifl is thepolicyZndjob site
hisurancc Compiny Name . :
-POlicY # or Solf-ias. Lic.
E-xpiration..Date:
Job Site Address:
city/state/zip:
Attach a copy -of the workers' compensation Policy declarationpage (showing the policy
number -and expiration date).
Failure to seoura coverage as required u n*d--r Section 25A ofMC-xL c. 1521 ran lead to the imposition of criminal penalties of a
fillb UP to $1,500.00 and/or one-year iropiisQnracn� as well as civil penalties &6.for of
in M a STOP WORK ORDER and a fine
Of UP to S250-.00 a day aiainft the. violator. Be advised that a copy of this statement may bt, forwarded to the Office of
lavcstigatiom of the DIA for insurance, coverage verification.
—7 do he! w, by der epain�4dpqiuda`es of th-* inYorina2ion providedaho,,6-i, jj,,
Phone 4t:
Qf�ycicd zese only. Do not wri&irz this arej; to he completed hj, citj, or town of
ficial,
CH3, or Town:
1'ermitucense #
Autbority (circle one).
I- -Board Of Health 2. -Building Department 3- GWTqwia Clerk -
6. Other
Contact Person:
4- Electrical Inspector S. Plumbingr InspeEtor
.Phone'ff.
.,1? o,
,7 It j
Location , q Alvllc- xb
No. Date �Y/b? T/405
RT#q TOWN OF NORTH ANDOVER
,a �..
- 0
0 16.
Certificate of Occupancy $
Building/Frame Permit Fee $
CHU
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check# el,34
ILI
A/M
18 6 Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT UZA—B RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
fiW Offi"
Ila sedi"Aw
BLUDING pERMrr NUNMER: DATE ISSUED:
4e
I
Al J,/
SIGNATURE:
Building Commidioner/Ing.Wor of Buildings Datc
SECTION I- SITE INFORMATION
1.1 Property A&iress:
1.2 Assessors?�ap and Parcel Number -
3 ? 67
RIC
A
Map Number Parcel Number
C2 -1\1
1.3 Zoning Information:
1.4 Propedy Dimensions:
Zoning Dii�d— Proposed Use
Lot Area (sf) Frontage (tt)
1.6 BURDINC
Froi Rear Yard
Requira ovided Required Provided
1.8 Sewerap Disposal System:
1.7 Water Supply M me 0 Municipal 0 OnSiteDisposal System 0
Public 0 -Pri,
SECTION 2 -
2.1 Owner of R
Name (Print) ress for Service
Signatu;6��'
2.2 Owner of R
Name Print dress for Service:
Siiznature Telep, on
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable
Licensed Construction Supervisor:
License Number
Address
Expiration Date
Signature Telephone
3.2 Registered Home Improvement Contractor
Not Applicable o
ompany Name
Registration Number
Address
Expiration Date
Signature Telephone
im
SECTION 4 - WORICERS COMEPENSATION (KG.L C 152 § 25,(6)
Workers Compensation Insurance affidavit must be completed and submitted with this
in the denial nf the i--mitanitp. nf tho h,,;m;.. --.,*
1.
to provide this affidavit will result
Signed affidavit Attached Yes ....... 0 No ....... 0
Estimated Cost (Dollar) to be OMCL4L USE ONLY
SECTION 5 IDIescrilption Proposed WOrk (check
applilcable)
I .
New Construction 0
Existing Building 11
Repair(s)
0
0 _[A�on
0
Accessory Bldg. 0'
Demolition 0
Other 0
ify
Brief Description of Proposed Work:
.)q x �, . a�, (D I CA
Construction
3
Plumbing
Building Permit fee (a) x (b)
QVrTTnN A - IWQTTM A TlP-n *-CWWV-I-nTT��
4
Itern
Estimated Cost (Dollar) to be OMCL4L USE ONLY
Completed by permit applicant
I .
Building
OfK) Build ingPermitFee
Multi lier
2
Electrical
(b) Estimated Total Coij-0—f
Construction
3
Plumbing
Building Permit fee (a) x (b)
4
Mechanical (HVAC)
5
Fire Protection
L
6
Total (1+2+3+4+5)
1 C ber
RVIrTION
7a OWN -V10 ATTIMno 17 A qrTAZqro"% imw
OWNERS AGENT OR CONUZACTOR APPLIES FOR BU"ING PERAUT
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 ofOwner Date
FSECTION7b 9"ER/AUTHORIZED AGENT DECLARATUIN I
#�Vner/Au)*horized Agent of subject
Yoperty
Hereby declare that thetatements and information on the foregoing application are Lrue and accurate, to the best of my knowledge
and belief
Print Name
Signature ot -
01��
NO, OF STORIES SIZE
BASEMENT OR SLAB
–SIZE OF FLOOR TRvIBERS 2 Ni)
SPAN
DD,4ENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOT]NG x
MATERIAL OF CHRVMY
IS BUILDING ON SOLID OR FELLED LAND
IS BUILDJNG CONNECTED TO NATUIZAT. GAS T MR
V1 -
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
%RENOVATE
APPLICATION TO CONSTRUCT M!A , _ OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUMDING PERMIT NLTWER: DATE ISSUED:
SIGN
Buildi7z -Commidloner/laWtor of Buildings Date
SECTION I- SITE INFORMATION
I Property Address:
1.2 Assessors Map and Parcel Number:
3 ?
Map Number Parcel Number
C2
1.3 Zoning Information:
Zoning District Proposed Use-
1.4 Property Dimensions:
Lot Area (sf) Frontage (R)
1.6 BURDING SETBACKS (ft)
Front Yard Side Yard Rear Yard
Required Provide Regaired, Provided Required Provided
1
1.7 Waw Supply M.G.L.C.40.. 34) 1.5. Flood Zone Infonnation: 1.8 Sewcrage Disposal System:
Public 0 Privaft 0 zone Outside Flood Zone 0 Municipal 0 On Site DispxW System 0
SECTION 2 - PROPERTY OWNERSEE[PJAUTHORIZED AGENT r Uicti'!Cf:
2.1 owner of Record
J- Ai A/Xt4 A?z 6at-
Name (P,7*nt),,��) Address for Service
Sipatu&,,-" Telephone
2.2 Owner of Record:
iNatne Print Address for Service:
Signatur Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor:
Address
Signature Telephone
Not Applicable
License Number
Expiration Date
3.2 Registered Home Improvement Contractor
Not Applicable o
.'�-ompany Name
U
Registration Number
-
Address
Expiration Date
Signature Telephone
2!R
SECTION 4 - WORKERS COMPENSATION (MLG.L C 152 § 25
worKers; �_ompcnsauon insurance amciavit 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 o Proposed Work (check
app&able) F
New Construction 0
Existing Building 0
Repair(s) 0
Alterations(s) 0
Addition 0
Accessory Bldg. 0'
Demolition 0
Other 0 Specify
Brief Description of Proposed Work:
) q �c I (' L- 9�& Li"
lzle �91_f \ 'Q–s–D C -e— ? ( 'A r' -J, -7
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Itern Estimated Cost (Dollar) to be
Completed by permit applicant
OMCIAL USE ONLY
I . Building .1 '2 0�
I ra) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) x (b)
'3
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 APPLILES FOR BUIELDING PERAHT
1, 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 ot'Owner Date
SECTION 7b Q"ER/AUTHORIZED AGENT DECLARATION
� 1,
4p�eirty q,(�b�wner/Au ofized Agent of subject
Hereby declare that thetatements 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 TDvIBERS 2ND
SPAN
DINENSIONS OF S.9_LS
DINEENSIONS OF POSTS
DAENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERLAL OF CBEVMY
-IS BITIMLD119G ON SOLID OR FlLLED LAND
-IS BUILDJNG CONNECTED TO NATMZAL GAS LJNE
"IV
F'J
FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from
Boards and Departments having jurisdiction havebeen obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
"""'APPLICANT FILLS OUT THIS SECTION***
APPLICANT & Al / PHONE �7r-,IFF
LOCATION: Assessoes Map Number PARCEL
SUBDIVISION LOT (8)
STREET ST. NUMBER
CO
------- *OFFICIAL USE ONLY*******
AGENTS:
NSERVATION ADMINISTRATOR DATE APPROVED `r-
TOWN PLANNER DATE APPROVED
DATE REJECTED
COMMENTS
FOOD IN OR7 DATE APPROVED
DATE REJECTED
A&T4C`1hSPECT6R44fEALT.I;K DATE APPROVED
DATE REJECTED %7t;
COMMENTS A
or 4
2
PUBLIC WORKS SEWERMATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR
---DATE
RGVWW MY Jm
D. Robert Nicetta,
Building Commissioner
Please print
DATE:
JOB LOCATION:
HOMEOWNER
TOWN OF NORTH ANDOVER
OFFICE OF
BUILDING DEPARTMENT
400 Osgood Street
North Andover, Massachusetts 0 1845
Telephone (978) 688-95454
Fax (978) 688-9542
HOMEOWNER LICENSE EXEMPTION
Number Street Address Map/Lot
2 A jf-
, 04'ev f—
Name Home Aone Work Phone
I'll X_ a
PRESENT MAILING ADDRESS q-7 -1 C
/%42� 11,
X�_ e If 144"r
City Town State Zip Code
The current exemption for "homeowners" was extended to include owner -occupied dwellings to 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 HOMEOWNER
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 structures. A person who constructs more that one home in a two-year period shall not
be considered a homeowner.
The undersigned "bomeownee' assumes responsibility for compliances with the State Building Code and other
Applicable codes, by-laws, rules and regulations.
The undersigned "homeowner"
minimum inspection procedure
requirements.
HOMEOWNERS SIGNA
APPROVAL OF BUILDING OFFICIAL
- understands the Town of North Andover Building Department
and that he/she will comply with said procedures and
I I0. kR D OF,\ PPFALS (M-9541 CONSITVATION (M-9530 IlFAJ. I'll 6."-,)540 ITANNIVi ("XR-9535
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Date..................................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ... . ...............................................................
has permission to perform ..... rl�Fw
............................ ?/
wiring in the building of ........... .................................... ..............
at ..... 4?. ...... k0b ...................................... - North Andover, Mass.
.................
Fee ..... ...... Lic. No!A.�:��4 ............. .. ....... :��w )a—..
/Leizcmc;A�ZiN�s�;P�Ecm
Check # 5-�-33
85Laj
'A
Commonwealth of Massachusetts Official Use Only
Permit No. Ss -y D
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev.1107] (leavebtank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (ME�), 527,CMR 12.00
(PLEASE PRINT IN INK ORTYPEALL INFORMA TION) Date: / ZV1 -7 / 0 9
City or Town of. NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gigs notJqe of his or her iAtet�ion to perform the electrical work described below.
Location (Street & N
Owner or Tenant
Owner's Address
Is this permit in conjunction with a building permit? Yes Lk
Purpose of Building 4zk �"-
Existing Service;-, ao Amps Volts Overhead [:1 Undgrd No. of Meters
New Service Amps Volts OverheadEl Undgrd No. of Meters
Number of Feeders and Ampacity
Logation anqNaturg)of Proposed Electrical Work: -776� an r 12 r A
Telephone No.
No El (Check Appropriate Box)
Utility Authorization No.
COMDletion of the followinp, tahle mav he waivpd hv thp In rtnr nf Wirpv
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 o In
Swimming Pool
0. of Emergency Lighting
grnd. grnd.
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
I No. of Zones
No. of Switches
No. of Gas Burners
No. 57 —Detectoon and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
I.NyMPer—Tons
....
I ....... .....
TICW—
..........
No. of Self -Contained
Totals:
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local E] Municipal El other
Connection
No. of Dryers
Heating Appliances KW
Security Svstems:*
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
I
Telecommunications Wirin
I No. of Devices or Eq Tent
uiva
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of retr* al Work: (When required by municipal policy.)
w
Work to Start/ Inspections to be requested in accordance with NffiC Rule 10, and upon completion.
INSURANCE C V GE: 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.
CBECK ONE: INSURANCE [I BOND F1 OTBER F1 (Specify:)
I certify, under thepains atidpenalties o rperjury, that the ipformation on this application is true and complete.
FIRM NAME: -0 4 e7Z��IPL L I C. N 0.: 3 zo
Licensee: to
Signatu
P LTC. NO.:
(Ifapplicable, �pt 11 11 1 the li se n r linel�— No. -0
-..Wr exe t ( Bus. Tel. S�el'77 �-/ �
Address: - Z5 r,-4� 4M / 4 � lknzf Alt. Tel. No.:. ZO - 47,V1 - yt-�1'9
*Per M.G.L c. 147, s. 57-6 1, security work riquires Departnkent 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) [:1 owner 0 owner's a�ent,
Owner/Agent 7
Signature Telephone No. PERMIT FEE: $ 5-J— -
( 0
-.. �' ca..
Date
TOWN OF NOWTH ANDOVER
PERM!YWOR PLUMBING
A9,
This certifies that . /�'. ........................
has permission to perform ... C .... .............
plumbing in the buildings of I .........................
at. P.� ............. , North Andover, Mass.
Fee.-��. Lic. No../ .. ...... .............
-PLU M*B*ING INSPECTOR
Check #
1" 9 1
45
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING 5-6
n�� (Print or Type)
V
A Mass. Date 0 LL!!2e- A) 20 <9 (o . Permit
QC� Or`)y7e -LywnerS Narne
J\1 44J4 Type ofOccupanCy P061 k71rjy__x,0,
New Renovation 0 Replacement 0 Plans Submitted: Ye.SA No 0
FIXTURES
Installing Company Name 4E D C A _SC- Check one: Certificate
Addre 13 g,- d x- P,,D 0 Corporation
MA V,3 A- 0 Partnership
Business Telephone 'eo;7;7 0 hrm/co.
Name of Ucensed Plumber ZE�atwczn-,O� Cosee,
INS ' URANCE COVERAGE:
I have a current [Lability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes 0 NoA
If you have checked Yes. please indicate the type coverage by checking the appropriate box.
A liability Insurance policy 0 Other type of Indemnity 0 Bond 0
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
2' of the Mass. G ws and that my signature
C7 e r.1 4, eneral L2 permit application waives this requirement.
Check one -
owner 0 Age*nt
Cannnti irp I rx"nor ~ rl'. A---# - P__�
i nereby 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
knowiedge and that all plumbing woric, and installations performed under the permit issued for this appl bon will be in mpliance t all
pertinent provisions of the Massachusetts State Plumbi C;ode and ChapteVY42 of the General Laws. ica co vA h
Title &gnature of Licensed P11imbe,
Qty/'Town Type of License: Master [] Journe
AP� �(OFFICE �USE 05NLYJ License Number r9j /a,
L
MENOMONEE]
NEI
MENNEN
NONE
Installing Company Name 4E D C A _SC- Check one: Certificate
Addre 13 g,- d x- P,,D 0 Corporation
MA V,3 A- 0 Partnership
Business Telephone 'eo;7;7 0 hrm/co.
Name of Ucensed Plumber ZE�atwczn-,O� Cosee,
INS ' URANCE COVERAGE:
I have a current [Lability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes 0 NoA
If you have checked Yes. please indicate the type coverage by checking the appropriate box.
A liability Insurance policy 0 Other type of Indemnity 0 Bond 0
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
2' of the Mass. G ws and that my signature
C7 e r.1 4, eneral L2 permit application waives this requirement.
Check one -
owner 0 Age*nt
Cannnti irp I rx"nor ~ rl'. A---# - P__�
i nereby 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
knowiedge and that all plumbing woric, and installations performed under the permit issued for this appl bon will be in mpliance t all
pertinent provisions of the Massachusetts State Plumbi C;ode and ChapteVY42 of the General Laws. ica co vA h
Title &gnature of Licensed P11imbe,
Qty/'Town Type of License: Master [] Journe
AP� �(OFFICE �USE 05NLYJ License Number r9j /a,
L
V
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0
PERMZ OR GAS INSTALLATION
This certifies that ... f.). . r. n -:� ......................
has permission for gas installation ......
in the buildings of ... 4.�
at .............. North Andover, Mass.
Fee. . Lic. No..) ... .......
)6SINSPECTOR
Check #
5 6-2 4
AnUOVee. Mass. Date -Jt,(.,i e- l-- 20- 'Permit#
Building Location 19-41 Y?e
Owner's Name2c)b Li�lai LC
Z
TV= cf
"It
New, Renovation 0 Replacement [3 Plans Submitted: Yes�X . No
ImstaflingCompany.Name 6 -of -CA�C $ Check one:' . Cerrdicate
Address K_ d 06--M, -4 ie - d�gt- IQ A 0 'Corporation
ve (Z Im J1 0/1? 0. Partnership.
Business Telephone 93 ;;* e 0 ;;"71 0 Ftrm/Co*.
Name -of Ucensed Plumber or. Gas Filter -,!FdW1zf?a( /q C`45�
INSURANCE COVERAGE:
I have a current liability insurance policy or its imbstantizil equivalent which meets the requirements of MGL Ch. . 142 -
Yes, 0 No
if you have. checked Yes. pifiase Indicate the type coverage- by checking the appropriate box
A liability insurance policy 0 Other type of indemnity 0 Bond 0
OWNER'S INSURANCE WAIVER: I am aware that the licersee does not have the Insurance coverage required by
Chapter 142 of the Mass. General Laws. a�d that my signature on this permit application waives this requirement
Check one:
Owner[] Agent
Sic)�naturiot-C-m—erorOWnCrsAcent L/
I hereby cedify that all of the details and information I have submitted (or entered) in above application are true and a=urate to the best'of my
knowledge and that all plumbing work and installations performed under the permit issued for this appli be in-ccimpliance with all
pertinent provisions of the Massachusetts State.Gas Code and Chapter 142 of the rit
TvDe of Ucanse:
BY
�Nftumber
TrUe Gasfitter q
Master Ucense Number
City/Town �Joumeyman
APPROVEDY _(671—CEUS �ONL i-
mm- M
ImstaflingCompany.Name 6 -of -CA�C $ Check one:' . Cerrdicate
Address K_ d 06--M, -4 ie - d�gt- IQ A 0 'Corporation
ve (Z Im J1 0/1? 0. Partnership.
Business Telephone 93 ;;* e 0 ;;"71 0 Ftrm/Co*.
Name -of Ucensed Plumber or. Gas Filter -,!FdW1zf?a( /q C`45�
INSURANCE COVERAGE:
I have a current liability insurance policy or its imbstantizil equivalent which meets the requirements of MGL Ch. . 142 -
Yes, 0 No
if you have. checked Yes. pifiase Indicate the type coverage- by checking the appropriate box
A liability insurance policy 0 Other type of indemnity 0 Bond 0
OWNER'S INSURANCE WAIVER: I am aware that the licersee does not have the Insurance coverage required by
Chapter 142 of the Mass. General Laws. a�d that my signature on this permit application waives this requirement
Check one:
Owner[] Agent
Sic)�naturiot-C-m—erorOWnCrsAcent L/
I hereby cedify that all of the details and information I have submitted (or entered) in above application are true and a=urate to the best'of my
knowledge and that all plumbing work and installations performed under the permit issued for this appli be in-ccimpliance with all
pertinent provisions of the Massachusetts State.Gas Code and Chapter 142 of the rit
TvDe of Ucanse:
BY
�Nftumber
TrUe Gasfitter q
Master Ucense Number
City/Town �Joumeyman
APPROVEDY _(671—CEUS �ONL i-
. to
ca
Aa
Date 2Z13
No
TOWN OF NORTH ANDOVER
0
I.. BUILDING DEPARTMENT
0 0 0
Building/Frame Permit Fee
CHUS
Foundation Permit Fee
s
Other 'Permit Fee
i7u
4, Lot -
CO �&Id�g lnspector�
co
C
"Location
No. Date r�
VkORT
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ P
'tSA MU `-Foubdation Permit Fee $
Other Permit Fee $
Sew'e'r Connection Fee $
Water Connection Fee
TOTAL
Z4
Building Inspector
6325
Div. Public Works
Location 2
No. Date
0.
i kORTH
TOWN OF NORTH ANDOVER
zL�mfim�d*
Certificate of Occupancy $ '(2
Building/Frame Permit Fee $
Acmus
Foundation Permit Fee -,j C -J
Other Permit Fee
Sewer Connection Fee
Wa3er nnection Fee
4
TQTAL
A-alciong, Inspector
3 2 5 5
Div. Public Works
T jejLocation Ahj),X�
4. Date
4
TOWN OF NORTH ANDOVER
M
gA I 10. 0
It.. Me- A M 5 a
ipllmrqx�
Div. Public Works
Certificate of Occupancy $
Buildirig/Frame Permit Fee $
1 CRUS Foundation Permit Fee $
Other Permit Fee $
PAY �"5Connection Fee $
--4j
qVVatec Connection Fee $
M4 ?
TOTAL $
M
gA I 10. 0
It.. Me- A M 5 a
ipllmrqx�
Div. Public Works
PEWAfff
,.A
APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. J� I�IV �y/ ;lilt PAGE I
MAP iiO.
LOT NO.
2 RECORD OF OWNERSHIP IDATE
BOOK 'PAGE
ZONE
SUB DIV. LOT N6.
-3
1
a3 �?,r
LOCATION a 9 Ah) g k -b
PURPOSE OF BUILDING R5� 1412) 61,o
—
OWNER'S NA14E LA ,S� j -
NO. OF STORIES SIZE
OWNER'S ADDRESS ro r- c!
BASEMENT OR SLAB
ARCHITECT'S NAME 4ppL5g
SIZE OF FLOOR TIMBERS IST ZXJO 2ND 3RD
BUILDER'S NAME P, f, R e -N
SPAN
DISTANCE TO NEAREST BUILDING
DIMENSIONS OF SILLS
DISTANCE FROM STREET
go
POSTS
Y� m
4.1
DISTANCE FROM LOT LINES - SIDES REAR
a/ Ar
GIRDERS -5-
lo x a -
AREA OF LOT FRONTAGE
HEIGHT OF FOUNDATION THICKNESS fl
IS BUILDING NEW YES
SIZE OF FOOTING x
19 BUILDING ADDITION
MATER:AL OF CHIMNEY R I'. --
IS BUILDING ALTERATION
IS BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE
IS BUILDING CONNECTED TO TOWN WATER
y ),
BOARD OF APPEALS ACTION. IF ANY
IS BUILDING CONNECTED TO TOWN SEWER No
IS BUILDING CONNECTED TO NATURAL GAS LINE y9 -s
INSTRUCTIONS
SEE BOTH SIDES WARM FM $L "ril �2.
IftlkA
PAGE I FILL OUT SECTIONS 1 3 CZ
PAGE 2 FILL OUT SECTIONS 1 12 am low
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
DATE FILED
SIGNATURE TF OWNER OR A�THORI�;)TENT,
d
IA4 " 91 0-
F E E
-
PERWT GRAPWTO
A 19
ol -LR TEL. # 664 -
co TELL #!!%J7-5-
3 PROPERTY INFORMATION
LAND COST
EST. BLDG. COST
EST. BLDG. COST PER GQ Ff. 0: W., v,, 6 o
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
BOARD OF HEALTH
PLANNING BOARD
DOARD OF SELECrMIEN
'NsPaCTOR
BUILDING RECORD
OCCUPANCY 12
�INGLE FAMILY
I STORIES
MULTI. FAMILY
[aFFICES
APARTMENTS
I
CONSTRUCTION
2 FOUNDATION
8 INTERIOR
FINISH
CONCRETE
PINE
a
2 13
CONCRETE BL K.
BRICK OR STONE
HARDW D
PIERS
TASTER
DRY WALL
UNFIN.
3 BASEMENT
AREA FULL
1/1 1/2 1/4
FIN. B M T AREA
F11 , ATTIC AREA
tLO 8 M T
FIRE PLACES
T
HEAD ROOM
MODERN KITCHEN
4 WALLS
9 FLOORS
CLAPBOARDS
B
1
2
3
DROP SIDING
CONCRETE
EARTH
_-FiARDV-/ D
COMMCN
-ASPH TILE
WOOD SHINGLES
ASPHALT SIDING
ASBESTOS SIDING
VERT. SIDING
STUCCO ON MASONRY
STUCCO ON FRAME
BRICK ON MASONRY
ATTIC STRS. & FLOOR
BRICK ON FRAME
CONC. OR CINDER BLK.
WIRING
STONE ON MASONRY
STONE ON FRAME
SUPERIOR POOR
_�DEQUATE NONE
10 PLUMBING
5 ROOF
GAB L'�
BATH (3 FIX.)
GAMB EL
I
-tip
MANSARD
TOILET RM. (2 FIX.1
F LAT
SHED
WATER CLOSET
ASPHALT SHINGLES
LAVATORY
WOOD SHINGES
KITCHEN SINK
SLATE
NO PLUMBING
TAR & GRAVEL
STALL SHOWER
ROLL ROOFING
MODERN FIXTURES
FLOOR
_LILE
TILE DADO
6 FRAMING
11 HEATING
WOOD JOIST
PIPELESS FURNACE
FORCED HOT AIR FURN.
TIMBER SMS. & COLS.
STEAM
STEEL BMS. & COLS.
HOT W'T'R OR VAPOR
WOOD RAFTERS
AIR CONDITIONING
RADIANT H'T*G
UNIT HEATERS
7 NO. OF ROOMS
S
B'M'T 2nd
1-5-
- 1 �14
1
THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM
LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA-
RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN.
I., f
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 local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: Phone 49P _2�2j_
LOCATION:
Subdivision
Assessor's Map Number
Parcel
Lot (-ej
Street 4wr- Rl�-o I St. Number 42-Z
************************Official Use Only************************
RECOMMENDATIONS OF TOWN AGENTS:
Date Approved
conservati n Administrator Date Rejected
Comments
Date Approved
Ifow'n'Planner- IJ Date Rejected
Comments
Food Inspector -Health
.4..L_
Septic Inspector -Health
Date Approved
Date Rejected
Date Approved _ 7171'9&
Date Rejected
Comments IIV57_;�461VI_,1,1�ltl
(Se�g IV67-e 7
Public Works - _skawsrz/water connecti
- driveway p
Fire Department
ly-��/-?� Y19--
CReceived by Bui
lding Inspector
Date
CERTIFIED FOUNDA TION PLAN
LOCATED IN, H0.ANj)0VJHR-, HA.
SCALE: /".= -4e DATE: 12-113
Scott L. G//es R L. 5
50 Dear Meadow Road
North Andover, mass.
/ CERTIFY THAT
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SHOWN COMPLY
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)I :F R A.:
I It 111.1 )INU
(�:UNSF , RVATIM
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)CATION-4� A
UNERIS NAME:—�E
1ILVER'S NAME:
SON'S NAME:
%SON'S ADORE
Yown of
NORT11,ANDOVER
"U 111VINI(IN111-
1'1,,,\-NNlNG'. (AAMIAWNYYY DI-I'V11-1,011AIL-N-1-
KAH-EN' 11.1'. NI: LSON. 1)11 W(A (M
CHIMNEY APPLICAI'1014 ANO VERAll f
m
PERNil'. # f-� ?-
�SOWS TELEPHONE:
JERIAL OF CHIMNEY: j 'Ut
ITERIOR CHIMNEY: EXIL-RIOR C11104EV:
ll%i BER AND SIZE OF FLUES:_!
(ICKNESS OF HEARTH:_' t(
,�U chbiney oa ()iAepCace con(loAm to 4he Acqubmileill-.6 oo the cude culd flave "clito and
,gu.Zatiow been /Lecv-Zved:
,TE:
m
.GNATURE OF hMON:
JWIT GRANTED:
'BERT NICETTA
fILDING INSPECTOR
SPECTEO:
-MARKS:
FLE 0
SOLiD BLOCK H EQU I It EA)
THIS PERMIT MUSF GE UISPLAVLO 014 ME
9
CERTIFICATE OF USE & OCCUPANCY
Town of North Andover
Building Permit Number 289
THIS CERTIFIES THAT
Date DECEMBER 14, 1993
THE BUILDING LOCATED ON 29 ANNE ROAD (Lot #3)
MAYBE OCCUPIED AS SINGLE FAMILY DWELLING W/3 CAR IN ACCORDANCE
GARAGE
WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND
SUCH OTHER REGULATIONS AS MAY "PLY.
CR 714
CERTIFICATE ISSUED TO Stephen & Paula Sideri
15 Cochrane Circle
ADDRESS Methupn, MA
Building Inspector
4
14
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Location
No. Date 4
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
)w�
, Building Insp r
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Z' I
0�jy
BUILDING PERNfIT NUMBER /-70
DATE ISSUED:
SIGNATURE:
Building Comau-s'sioner/Inspector of Buildings Date
Address: 1.2 Assessors Map and Parcel Number:
3 70 - —
Map Number Parcel Number
1.3 Zoning Ln-lormation: 1.4 Property Dimensions:
4 37 Ac,-�
Zon ing District -- Proposed Use Lot Area (sf) fron-ge —00
1.6 BUTU)ING SETBACKS (ft)
Front Yard — I Side Yard Rear Yard
Required I Provide I Required I Provided Reqwred Proy—ided
1.7 Water Supply.M.G.L.C.40. 9 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System:
Public 0 Private 0 Zone . Outside Flood Zone 0 Municipal 0 On Site Disposal System
SECTION 2 - PROPERTY OWN-ERSIDP/AUTHORIZED AGENT
2.1 Ownerof Record
A�20�e-�-7L
N. Address for Service
7e
Signature Telephone
2.2 Uwner of Record:
=21
T
- CONSTIR
3,1 Licensed Construction Supervisor:
Licensed Construction Supervi'sor:
Addrs zC,
j3ign-.1ure Telephone
a
ti
p r �,,nn t C. ri�t
�.2 Registered-Iforne I p ment Contractor
,ompany Name
Adress
one
z ? .44, ,
Address for Service:
c?-7re-- 43F--�-
Not Applicable 0
0 102-1c,
License Number
?/.?- -9h 00 5 -
Expiration Date '
Not Applicable 0
13210.2 -
Registration Number
cz/�-3 /-:z
Expiration' Date '
M
X
z
0
N
M
M
9�
0
.z
M
0
71
M
r"'
r -
E
0
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 ....... 0
SIECTION5 DescriDtion of ProlDosed Work (check all affllliCahle)
New Construction >(
Existing Building 0
Repair(s) 0
1 Alterations(s) 0
Addition 0
Accessory Bldg. 0
Demolition 0
Other Specify
Brief Description of Proposed
Work:
�J-� -4r
X 3
1<,dA,'?1-1
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by permit ap licannt
Int
1. Building
(a) Building Perniit Fee
Multiplier
I2 Elect *cal
(b) Estimated Total Cost of
Constructi
c2 8'( 6) 0
3 Plumbing
Building Permit fee (a) x (b)
b? ?0
4 Mechanical (HVAC)
5 Fire Protection
6 Total (1+2+3+4+5)
0 C�-o
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONWCTOR ArPLIES FOR BUrLDING PERMIT
as Owner/Authorized Agent of subject property
reby aA�,�nz, 57 e�r
to act on
M=lI matters relative to Work authonisedby this building permit application,
4 �.
S ig�ire ofo%ier Date
I SECTION 7-VOWNER/AUTHORIZED AGENT PECLAVATION I
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
of Owner/
Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR T9v1BERS I ST 3 RD
SPAN
DIMENSIONS OF SILLS
DD,ENSIONS OF POSTS
D11vMNSIONS 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
91te ol���� 0/
Board of Building Regulati
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement Contractor Registration
AQUA -CRAFT GUNITE POOLS, INC.
STPHEN ZAGORSKI JR.
29 NEWBURY STREET
PEABODY, MA 01960
Registration: 139102
Type: Private Corporation
Expiration: 6/13/2005
Update Address and return card. Mark reason for change.
D Address D Renewal [] Employment [] Lost Card
0—
/X1 lellwl../a 11_�&Malklde&
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 010216
Birthdate: 09/29/1934
Expires: 09/29/2005 Tr. no: 1890
Restricted: 00
STEPHEN S ZAGORSKI JR
29 NEWBURY ST zz_�
PEABODY, MA 01960 Administrator
P910?12004 08:49 SULLIVAN INSLJRRNCE 4 19?B5356003
%P &m it o st t%#P% rg wr Lamm
BSrPAPd N.Sullivas Im Agency
U ftrkst St.
p - 0 " am $68
XPm1 Ch, KA 01938
Neu= Aquayraw Gunits Pool$ INC-"
22 Newbury st
Pesbi*o PA u9so
2mem9l I
TM POLVES OF INSLIRANCE LISTED BELOW HAVri
ANY REQUREMENT, TERM OR 0=ITION OF AW C4
MAY PERTAK THE INSURANCE AFFORDE BYTHQJA
POUVES. AWREGAT9 UMITS SHOWN MAY HAVE 151
MED I" (Any cme powoo
TM W 1AMURAW1
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THIa CERTIFICATE IS MSUED AS A MATTER OF OR ION
0 AND CONFERS NO R1014TO UPON M GERTI ICATE
m 011L T1418 CERTIFMATE D= NOT AMEND, I ENDOR
ALTEI_t THE 2Q9!MHAfFOROEDVV THE POLCIES BELOW.
INSURERS AFFORDING COVWGE NAX 0
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INSURR & PartfQFd Ui �r*rffiers Im.-Al __Wfj_X
INWRFA
ISSUED TO THE NBURF.D NAmEo AWVE FOR 7HE POLICY PENOO "MATED. NCTIAM'IrSTANDING
ACT OR OTHER Q=MENT WITH RESPEcT To W�Wm Tws cERTI;;CATE MAy 9E ISSUED OR
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FAILLIRI TO SAA11, WAR NOTIC9 WALL NPOU 90 OBLIGATION CUt PARILrry
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FORM - U - LOT RELEASE FORM
INSTRUCTIONS:. This form is used to venify that all -necessary approval /permits from
Boards and Departments having junisdiction have been obtamied. This does not relieve the
applicant and or landowner from compliance with any applicable requirements.
APPLICANT t�-10 ie
PHONE 4 3 3
ASSESSORS MAP NUMBER 376 -LOTNUMBER 47
SUBDIVISION LOTNUMBER
STREET STREET NUMBER
OFFICIAL USE ONLY
RECOAYN4ENDATIONS OF TOWN AGENTS
DATE APPROVED
COAERVATION ADMINISTr DATE REJECTED f
TOWN PLANNER
COMMENTS
FOOD INWCCTT BEALTH
P
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S 40CEAETH
COUNIENTS 63 -4,X -,,L
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PUBLIC WORKS - SEWER / WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTNIENT
COMNIENTS
RECEIVED BY BUILDING INSPECTOR
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED Z
DATE REJECTED
I 57 -IN I I I ".. a a MAN a -11
DATE REJECTED
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pt'� 4 ,F,ORM - U - LOT RELEASE FORM
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INSTRUCTIONS:. This form is used to venify 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.
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ASSESSORS MAP NUMBER
LOTNUMBER
SUBDIVISION LOT NUMBER
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OFFICIAL USE ONLY
RECOMMENDATIONS OF TOWN AGENTS
Ono MENEM
41
DATE APPROVED
FrRVATION ADMINISTRATOR
DATE REJECTED
CONOJENTS A, Vol
=I WAWA=
TOWN PLANNER
COM[M[ENTS
FOOD INSPECTOR - BEALTH
SEPTIC INSPECTOR - HEALTH
-k- ;2 44 , I.;?.
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
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DATE APPROVED
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DATE REJECTED
CONVAENTS
RECEIVED BY BUILDING INSPECTOR DATE
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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
40
This certifies that ...... ...... �� � 'I C I () "k-.;
............. . .......... . ................
has permission to perform ...... �Z7: . ....... . ........ .........
. . ................
Z
wi4ring in the building of ........ DAL ...... &4-F.E./ . ...................................
at i .. .... ................. ..... . No�rlh
.�do;ver, ass
Fee ..... ..... Lic. No..�� . . . . . . . . . . . . . . . . . . . . . . . . .
LECrRICAA ;�E R
Check#
5192
Official Use OnIv
Permit No -s--.7
P -P& Occupancy & Fee Checked--,/
BOARD OF FIRE PREVENTION REGULATIONS.527 CMR 12:00
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00
(Please Print in ink or type all information) Date /0
i To the Inspector of Wires:
Townof North Andover
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number AAWE fg-Q
Owner or Tenant )n v
Owner's Address 51Q
is this permit in conjunction with a building permit Yesk No 0 (Check Appropriate Box)
Purpose of Building _______�Utility Authorization No.
'Existing Service Z Amps lZO–Z40 Voits Overhead 0 Undgmd Qr, No. of Meters
'4New Service Amps____----Yoits
Number of Feeders and Ampacity—
Location and Nature of Proposed Electrical
Overhead 0 Undgmd 0 No. cyf Meters
OTHER:
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO
,4w&-snbm4ked 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
,,-' IMURANCE-'f BOND = OTHER = (Please Specify) (Expiration Date)
Estimated Value of
Work to Start—Av
Signed under ttjA.E
FIRM NAME--�,-1
Work$
Inspection Date Resquested ______Rough Final --
Of
L I C. NO. -35L9
LIC. NO.
s. Tel I MAD- 99V I
w Uuft Tel. 140 -
Address 474nlgluelu 47L No.�- � -4 7 J; -3
OVMER'S INSURANCE WAIVER: I am aware tfiat the Licenses does not have th,e ans-branci 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) C) U
Telephone No. PERMITIPEE $
(Signature of Owner or Agent)
Total
No. of Lighting Outlets
No. of Hot fuse
No. of Transformers KVA
Abo 0 In X
No. of Lighting Fixtures
Swhnming Pool
gmd 0 gmd 0
Generators KVA
No. of Emergency Lighting
No. of Receptacles Outlets
No. of Oil Burners
Battery Units
No. of Switch Outlets
No of Gas Burners
FIRE ALARMS No. of Zone
No. of Detection and
Total
N4. of Ranges
No of Air Cond
Tons
Initiating Devices
Heat Total Total
No. of Diposal
No.
Pumps Tons
KW
No. of Sounding Devices
No./ of Self Contained
Detection'Sounding Devices
0 Municipal 0 Other
No. of Dishwashers
Space/Area Heating KW
No. of Dryers
Heating Devices
KW
Local Connection
No. of
No. of
Low Voltage
No. of Water Heaters KW
Signs
Bailases
Wiring
No.. Hydro Massage Tuds X
No. of Motors
Total HIP
OTHER:
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO
,4w&-snbm4ked 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
,,-' IMURANCE-'f BOND = OTHER = (Please Specify) (Expiration Date)
Estimated Value of
Work to Start—Av
Signed under ttjA.E
FIRM NAME--�,-1
Work$
Inspection Date Resquested ______Rough Final --
Of
L I C. NO. -35L9
LIC. NO.
s. Tel I MAD- 99V I
w Uuft Tel. 140 -
Address 474nlgluelu 47L No.�- � -4 7 J; -3
OVMER'S INSURANCE WAIVER: I am aware tfiat the Licenses does not have th,e ans-branci 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) C) U
Telephone No. PERMITIPEE $
(Signature of Owner or Agent)
3 6 , - 1z". ,
..........
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that
.............. :� ...............
has permission for gas installation ........ �/ ..........
in the buildings of Z :'. . - � ... Z /, �
. ...........................
at ...... I ........... < ......... .......... North Andover, Mass.
Fee ......... Lic. No..'. .........
GASINSPECTOR
I/
WHITE: Applicant CANARY: Building Dept. PINK: Tre83urer
t"�- P5--
MAS!§ACHUSETTS UNIFORM APPLICATION FOFt PERMIT TO DO GASFITTIN'G
(Print or Type)
NORTH ANDOVER Mass. Date
A5 �uilding Location Permit # -3 c/
Owners Name Anf
New Renovation Replacement Plans Submitted 0
FIXTURCIZ
L
(Print or Type) Check one: Certificate
Name ANDOVER PL13G. & HTG. CO., INCM Corp. 2122
Installing Compa y
Address 5731 SO. UNION STREET' Partner.
LAWRENCE, MA. 01843 - = Firm/Co.
Business Telephone: 978 685-8383
Name,, of Llconsed"- �,u
or Gas Fitter - 6FOgGE jAgnsF
I�su nce N'ge�" Indicate the type of insurance coverage by''chetking the
appropriate box:
Liability insurance policy E2f0ther type of indemnity = 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 coverages.
Signature of owner/agent of property Owner Agent
I heicby certiCy that aU of the dc(AUs and infacmation I have submitted (or entered) In above applicationsce trucand accusate to the best of my
knowledge and that all plumbing week and Instx1lations performed under'retmit issued fox this application will-behico Hance I!itk ad V=tlncnt
provisions of the Massachusetts StateCas Code and Chaptes 142 of the General LAwL
By TYPE LICENSE:
Plumber
Title Gasfitter- Sign'A'ure of Licensed
City/Town: Master Plumber or Gasfitter
Journeyman - QQ81
APPRbVED (OFFICE USE ONLY) License Number
W-191:=14PUb
SENSE
MMEEMENNESIS
MISINSIMINEMSEE
mm�
R1,16114NUOT61;
(Print or Type) Check one: Certificate
Name ANDOVER PL13G. & HTG. CO., INCM Corp. 2122
Installing Compa y
Address 5731 SO. UNION STREET' Partner.
LAWRENCE, MA. 01843 - = Firm/Co.
Business Telephone: 978 685-8383
Name,, of Llconsed"- �,u
or Gas Fitter - 6FOgGE jAgnsF
I�su nce N'ge�" Indicate the type of insurance coverage by''chetking the
appropriate box:
Liability insurance policy E2f0ther type of indemnity = 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 coverages.
Signature of owner/agent of property Owner Agent
I heicby certiCy that aU of the dc(AUs and infacmation I have submitted (or entered) In above applicationsce trucand accusate to the best of my
knowledge and that all plumbing week and Instx1lations performed under'retmit issued fox this application will-behico Hance I!itk ad V=tlncnt
provisions of the Massachusetts StateCas Code and Chaptes 142 of the General LAwL
By TYPE LICENSE:
Plumber
Title Gasfitter- Sign'A'ure of Licensed
City/Town: Master Plumber or Gasfitter
Journeyman - QQ81
APPRbVED (OFFICE USE ONLY) License Number
e 6— /' C) 5�'
Dat.....................
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that O's . . ? 4 P-
..... ...............
1 n ........... .............
has permission for gas installatio
in the buildings of .... Y ...........................
at ... C. J ............ North Andover, Mass.
Fee. .3 CLic. No:. q 9-35 --T, %P 10 -'? z 1. 1 # g.( G'—
......... ............ '. / .......
GASINSPECTOR
Check#
MASSACHusFmuNiMRMAPPHCA
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Locations 69-
7 klIAI,�F S 1-�
N, 1+4"04-,VC-7� OVer's Name
New Renovation Replacement
TODOGMFITTNG
Date
Permit #
Amount $ 302, f-0
Plans Submitted
(Print or type) Chec one: Certificate Installing Company
Name STCI-6i ftol-7121,y4 ff Corp.
Address 0 J) y -5-J 4. 0 Partner.
V- OF' Jq //-I I- 1- /9 /� S, f Co.
Tu-Mn'e—ss Telephone �i 1 -,9 1/- -0,�
Nameof Licensed Plumber or Gas Fitter Sr-,t�"Owclv C a, f
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 0- Noo
I ; A; # th. t P covera e by checking the ann priate box.
11 you nave checked yes, p ease - 1. � JF t�
Liability insurance policy Er Other type of indemnity Bond 13
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner Agent
I hereby certify that all ol the cletails anct imormation 1 nave SUUIIUtLrU kUl cilLc;1c;u� m auvv� afflj21
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 Massachuse)ts Stat
,p, Gas Code and Chapter 142 of the General Laws.
-1-1
1APPROVED (OFFICE USE ONLY)
,.-Sigfiature of Licensed Plumber Or Gas Fitter "00,
Plumber rp-2, ?ax
Gas Fitter nse NumL)er
[D'Master
[:] Journeyman
—2N D F —LO 0 R
Flow., �AFKU
7TH. FLOOR
(Print or type) Chec one: Certificate Installing Company
Name STCI-6i ftol-7121,y4 ff Corp.
Address 0 J) y -5-J 4. 0 Partner.
V- OF' Jq //-I I- 1- /9 /� S, f Co.
Tu-Mn'e—ss Telephone �i 1 -,9 1/- -0,�
Nameof Licensed Plumber or Gas Fitter Sr-,t�"Owclv C a, f
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 0- Noo
I ; A; # th. t P covera e by checking the ann priate box.
11 you nave checked yes, p ease - 1. � JF t�
Liability insurance policy Er Other type of indemnity Bond 13
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner Agent
I hereby certify that all ol the cletails anct imormation 1 nave SUUIIUtLrU kUl cilLc;1c;u� m auvv� afflj21
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 Massachuse)ts Stat
,p, Gas Code and Chapter 142 of the General Laws.
-1-1
1APPROVED (OFFICE USE ONLY)
,.-Sigfiature of Licensed Plumber Or Gas Fitter "00,
Plumber rp-2, ?ax
Gas Fitter nse NumL)er
[D'Master
[:] Journeyman