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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
... ..............................
This certifies that ..........................................................
has permission to perform
............................................................................
wiring in the building of-,
..........................................................................
at ........ ,,2 . ...... .
............................................................. NorthhA"Lndover, Mass.
Fee.g�.el ........ Lic. No . ............. ... ........ . . ..
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Commonwealth Of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
FPermmuit NO. r -IV -
7
21r
0 occupancy and F
ccupancy and Fee Checked
ev. 1/07]
(leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PR17VTflVDX OR YTPE ALL �WFOAAIATJOA9 Date: ';7 10-15
n�::
City or Town oft NORTH ANDOVER To the In'spector of Wires:
By this application the undersigned gives otice of his or Km—r-intpnttim, t.
Location (Street &Number)_ n to perform the electrical work described below.
Owner or Tenant
Owner's Address C-1 9 1 or rvj Telephone No.
Is this permit in conjunction with a building permit?
Yes No
(Check Appropriate Box)
Purpose of Building_ t,16U Utility Authorization No.
Existing Service
2-6P- Amps 1Z&/04C`V0lts Overhead Undgrd No. of Meters
New Service Amps volts OverheadEj Und9rd No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work.
No. of Recessed Luminaires
No. of Lnminaire Outlets
No. of Luminaires
No. of Receptacle Outlets
FNo. of Switches
No. of Ranges
No -of Waste Disposers
No. of Dishwashers
No. of Dryers
No. of Water
Heaters KW
No. Hydromassage Bathtubs
No. of Ceil.-Susp. (Paddle) F
No. of Hot Tubs
Swimming pool Above
d.
0 No. of Oil Burners
No. of Gas Burners
No. of Air Cond. To
Space/Area Heating
KW
Heating Appliances
Generators KVA
No.. of
No. of
Signs
BaUas
No. of Motors
Total
table may be waived by the Inspector of Wires.
ans
0. 011 1 otal
Transformers KVA
Generators KVA
in-
d.
0.0 mergen y 9
e Units
FIRE. ALARM' - No. of Zones
0. oMe—tection and
Initiating Devices
tal
ns
-
No. of Alerting Devices
7—KW
No. of Self -C Tn—ta-in-e-d�
--j
Detection/Ale ng Devices
t
Local El IvIumcipa
Other
Connection
KW
Security Systems:* -
No. of Devices or ' quivale t
ts
Data Wiring:
No. of Devime or Equivalent
HP
Telec imm
No. of Device� or Equivalent 2
Estimated Value of Electrical Work: Attach additional detail if desired, or as required by the Inspector of Wires.
Work to Start . (When required by municipal policy.)
Inspections to be requested in accordance with IvMC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue ess
the licensee unI
.provides proof of Lability insurance including "completed operation" co erage or its substantial equivalent The
undersigned certifies that such coverage is in force, and has exhibited proof of same tvo the permit issuing office.
CHECK ONE: INSURANCE C� BOND OTHER 0 (Specify.)
I certift, under the
'JE �ndpenal -cs of th
_per at e information on this application is true and complete -
?W, th
FIRM NAA LIC. NO.: L2
Licensee:
(If applicable Signature LIC. NO.: 12 3 M
nter empi in the lic b I
6>,X tZ ( nse num r ine.
Address: C, >71 Bus. Tel No.: (ab c?26,- 3,, -3
AIL Tel. No.: 4=.& -Eqp
*Per M.G.L c. 147, s. 57-61, security wo requires Department of Public Safety 'IS" Lic—ense: 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-), Ell owne-r own I ent.
Owner/Agent owner s ag
Signature
Telephone No. FPE"IT FEE. S
Phe
earz
j
600 &Pe-
Orkersl C
t oftpens st,
r "0" Ins, AQ -'et
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Ivan2e. an 4rance,4 "'I'll &
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Address-� L/ �,�Zza.dojvjndl'lddlw)
1 11 5'' 0/ ................. ...................
C, n�'/ I tors/
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State
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ave 110 a
Working partner. have con J�
for m . employees
NO workft, C "I an listed hired the su&ftl�-r and I rype ,rP
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corytIl 6 Vact
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Ins1jrance. 9.
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Policy # 01- "'1
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nmel A Of A4GL ze (Showift
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-------------------- - - — ------------- — -- - — ---------- - - -------- -- ---- ----- ------ - ---- - ---------- - ---------------
I
Date..................................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
Ibis certifies that ...........................................................
..............................
has permission to perform ... I -le- __e_
.......................................................................
wiring in the building ............................................................
. ...........
at ..: . ...... . ....... . North Andover, Mass.
.. .... ... ................. ......... . .........
. . .... ..
�TR cTo
Fee ........... Lic. No . ............. ... ... i�i .... i;��i .... . . ..... .....
. . ... ;C�L
P AL
Check #
9204
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Commonwealth Of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit NO. Qfi;-0�
Occupancy and Fee Checked
[Rev. 1/07] Qeave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts El eLITical Code (MEC), 527 CMR 12.00
MLEASEPRflVTflVLVK OR YYPE ALL B`IIIIF0RAfAT10A9 Date: ';7
:27 --
City or Town of.- NORTH ANDOVER To the linspector of Wires:
By this application the undersigned gives otice of his or ]Te�r7--intpntim, t,,
Location (Street & Number) 0 y " Zj7n to perform the electrical work described below.
_,� Ct M
Owner or Tenant
Owner's Address r rvx g,�,3
Telephone No.
Is this permit in conjunction with a building permit?
1-> Yes No 0 (Check Appropriate Box)
Purpose of Building 1:�) >
ft.<,r r, �
e N / U,71\ Utility
Authorization No.
Existing Service Z61L Amps 1Z&12-qC-V01ts Overhead
— — — —
Undgrd No.
of Meters
New Service Amps
volts Overhead
Undgrd No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work.
No. of Recessed L Anaires
Completion o the ollowin table may be waived bY the Inspector of Wires.
No. of CeiL-Susp. (Paddle) Fans No. of Total
N No. of L
o. of Luminaire Outlets
No. of Hot Tubs
Transformers KVA
-VA
Generators K
N 0. of L
o. of Lurninakies
Swimming Pool ove E] in-
d.
0. 0 mergen cy 9
No. of Receptacle Outlets 10
d.
No. of Oil Burners
Battery Units
FIRE ALARM No. of- Zones
No. of Switches
No. of Gas Burners
No.of Detection and
No. of Ranges
No. of Air Cond. Total
. Initiating Devices
T�-----
No. of Alerting Devices
No. of Waste Disposers
H 7=1' I OHS 1 11� 1,11'
111 11 nfqP1f-
Pplf —+.;--A
of Dishwashers
0. of Dryers
Heaters KW
No. Hydromassage Bathtubs
Space/Area Heating KW
Heating Appliances KW
No. of �No. o f
Signs Ballasts
No. of Motors Total HP
El cm Other
=c,T,,".� El —
No. of Dei
Data Wiring:
No. of De,%
of Devices or Eauivalent2
Estimated Value of Electrical Work: Attach addition etail if desired, or as required by the Inspector of Wires.
Work to Start: (When required by municipal policy.)
,�- )0 Inspections to be requested in accordance with JvMC Rule 10, and upon completion.
INSURANCE COVERAG—E.--Unless waived by the owner, no permit for the performance of electrical
the licensee work may issue unless
.provides proof of Lability 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 1� BOND F-1 OTHER 0 (Specify:)
certift, under the3auts and enal
!f
(p 7, that the infonnation on this application is true and complete
AA r)2
so
FIRM N 1E LIC
Licensee: Signature NO.: LZ 23M 4-
(Ifapplicable nte, empt 11 in the ft LIC. NO.: 12 3 A
c nse numb r line.
Address: e>.X It 2 (0 /-) .-- - - / Bus. Tel. NO.: —724-- 30 -3
L—M4 Alt Tel. No.: 4=.6
*Per M.G.L c. 147, s. 57-61, security wo requires Department of Pub -1 - TI -f-349971
OWNER'S INSURANCE WArVER: I am aware that the Licensee d lic Safety "S" License: s Lic, No.
required by law. BY my signature below, I hereby waive t s requirern oes not have the liability in urance coverage normally
Owner/Agent hi ent I am the (check one) 0 owner owner�s a-ent.
Signature
Telephone No.
The
Commoftweaft of Massachusetts
Department of ZndustrialAccidenis
Office of Investigations
Ila
600 Tf-ashington Street
Boston, M4 02111
wwW.nwss.,&,ov1dia
Workers' COmPeftsRtion Wkrance Affidavit. BuildergContractorsT
APPlicant Information jectriciansMIumbers
L—PiEipt �Legib&
Nan�e (Business/DTgEmization/individual):
AddreSs: LID O(CL S�R6E
F6
city/state/zip-l"'', '9"
'721, 73- 1
-----------
A8re you an employer? Check -the appropriate box:
e Type of project (required):
am R employer with 4. D I am a general contractor and I
-part-time).*
F2.
lo
employees (HI and/or
Ul
f d/o�-
a
0-1 am a Eo�le proprietor or
U n
have hired the ob-contractors 6. E] New construcdon
listed
11
!�m �o partner-
ship and have no employees
7. [3 Remod
on the attached sheet eling
These sub -contractors have Demoj I ition
working for mein any capacity.
[NO work=' comp. insurance 5.
workers' comp. insurance. 9. n Building addition
We are a corporation and its
3. E3required-]
I am a homeowner doing
offic= , have exercised their 10.0 Electrical ruPairsor additions
all work
n;yself. [No -workers, comp.
right of exemption per MOL plumbing repairs or additions
C. L52, § 1(4),'and we have no
insurance required.] t
employees. [No workm-s' 12.F7 Roof repairs
comp. insurance require&] 1317.0ther
;AnY 8PPlica"t that checks )e #I -must also ful out the sectioR Wow shovAng their workeas' 6ompenution Poi icy information.
14—Lowners who submit this affidavit indimtting they doing
am all work an�d them hire outside contnctors mug submit a now afficlavit
�rconftwn; 1h st check this box must smahM an additional shca showing. the ngmc of the sub-cmy
indicaffig such.
Mr' -'P- Pt' iniD"n on.
icy gui
am &A employer tkx isproviifingworkers, compensadon insurmcefor W
informaio& . . ./ eMP10YeeL Below is the pogcy mdjgk site
Insurance Company Name:
POlicY 4 or Self -ins. Lie.
Expiration Date:
Job Site Address:
Attach a copy of the workers, compe city/state/zip:
asation policy ---------------
Failure declaration Page (showing the policy number and expiration dzte�
to se=re coverage as required under Section 25A of McjL c. 152 Can lead to the imposition of cnminal pmaltics of a
fine up to $4500-00 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 apinst.the violator.
Investigations of th' Be advised that a copy Of this statement may be forwarded to the offic f
e DIA for insurance coverage ve7ification. e a
I do hereby
InEjoauu
pen
'a
>im OfPerjwy that the inforniWon Pro vi&d ObO ve is ftue and coprea
Date.. /5— /C,D
Qff,tciat use Only. Do not wrize in this ".ea, to be c0jffPjgmr�.d h
y cil
Y or lon off
jdaL
City or Toww. Permit/License #
Issuing Authority (circle one):
L Board of Health 2- Building Department 3. CitY/T0WV Clerk 4. Electrical Inspector S- Plumbing I . nspector
6. Other
Contact Person: Phone 9.
Date. 7
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that .... ('0
has pennissian for gas installation .... Fi. Ce C -.4e . ..........
in the buildings of . .
.....................
Check,#- 21 -7 q
-774
.8
ai
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY rif MA DATE f I ;� 7
-7 -0 PERMIT #
JOBSITE ADDRESS OWN ER'S NAMEL-
GOWNER
-6-
ADDRESS
TYPE OR
OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
PRINT
CLEARILY
NEW: RENOVATION: 01 REPLACEMENT: PLANS SUBMITTED: YES NO 0-1
I
APPLIANCES -1 FLOORS— 13SM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER =======1 ====E:: 1==
BOOSTER ----- . . . . . . . JL�J
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR I
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT I
OVEN
POOL HEATER
ROOM / SPACE HEATER I
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER I
7b'fHER
........... .......... .. . ......... .
...... . . . . . . . . ...... ------
LL—j
INSURANCE COVERAGE
erl
I have a current liabili!y insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 E S -"11
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAG BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY M7 OTHER TYPE INDEMNITY BOND Ej
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER F---] AGENT
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complip lip the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ��f
PLUM BER-GASFITTER NAME —641" LICENSE SIGNATURE
MP [:1 MGF [:-]I JP -, JGF LPGI Mj CORPORATIONF-
J]# [= PARTNERSHIP 0# LLC #
COMPANY NAME: ADDRESS
CITY STATE �ZIP ]TEL
FAX CELL MAIL
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The Commonwealth ofMassachusetts
Department of Industrial Accidints
Office of Investigations
600 Washington Street
Boston, MA 02111
U9 www.mass-gov1dia
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information— Please Print Legibl,
Name (Business/Organization/Individual): /,A
Address: )4 Tft- M C
Phone
(CA Za
City/State/Zip I Phone#: �40 3� 62
Are you an employer? Check the appropriate box:
employer with
4. 0 1 am a general contractor and I
_
ea
ployees (fall and/or part-time).*
have hired the sub -contractors
listed on the attached sheet.
2. [Vam. a sole proprietor or partner-
ship and'have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
5. 0 We are a corporation and its
[No workers' comp. insurance
required.]
officers have exercised their
3. El I am a homeowner doing all, work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
employees. [No workers'
insurance required.] t
comp. insurance required-]
Type of project (required):
6. El New cOn ' structiOn
7. Remodeling
8. Demolition
9. El Building addition
10.El Electrical repairs or additions
11. Plumbing repairs or additions
12. Roof repairs
13.[] Other
*Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. idavit indicating such.
t
I Homeowners who submit this affidavit indicating they ale doing all work and then hire outside contractors must submit a new aff
TContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
Iam an employer that isproviding workers' compensation insurancefor my employees. Below is thepolicy andjob site
information. P "I �_i�
Insurance Company
JV V�
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Address- Pity/State/Zip:
Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requireclunder 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 firie
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ido hereby certp under the ams andpenalties ofperjury that the information provided above is true and correct.
Official use only. Do not write in this area, to be completed by city or town ofricial.
City or Town:
Permit/License 9.
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 9:
Information and Instruction --s
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "....every person in the service of another under any contract of hire,
express or implied, oral or written."
An employeiis defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
Of the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to consiruct buildings in the commonwealth for any
applicant who has not produced -acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152', §25C(7) states "Neither the commonwealth nor any of its political subdivi sions shall
enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your tu
si ation. and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLQ or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is. required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and'date the affidavit. The affidavit should
be returned to the city or town that the' application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate ae.
City or Town Officials
Please be sure that the affidavit is complete and printedlegibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Pleas ' e be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permittlicense applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" . the applicant should write "all locations in -(City or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is* on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or' -permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Cornmonwealt1l of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
TQL # 617-727-4900 ext 406 or 1-877rMASSAFE
Revised 5-26-05 Fax # 617-727-7749
__Www-mass,gov/dia
-7-,77
Date .... C . ......
,AORTH
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING J
A
A
This certifies that ........ ..............................
AAKI
has permission to perform ........ ........
wiring in the building of ................. 5,-/' ca 0.09� ............................................... I.
at .......... ............... . North Andover, Mass.
Fee.FS-:;�'—�... Lic. No. *4 ....................
ELECTRICAC IN R
Check# s-2-92-
7035,
-2
Commonwealth of Massachusetts Official Use Only
Department of Fire Services PermitNo. _ �� a�— - I
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev.9/051 (leaveblank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEQ, 527 CMR 12.00
(PLEASE PRINT JIN -flVK OR TYPE ALL INFORMA TIOA9 Date:___J11,o,21a6'
CityorTownofi 46r-6� Akyjacl-6r To the In�pefctor bf Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) ;t C/ fiorlwiq�t) RAO
OwnerorTenant Cce-n, sv\eq Telephone No.
Owner's Address SQ�h 4F,
Is this permit in conjunction with a building permit? Yes
Purpose of Building [�40 - ECM; W4? -
No F� (Check Appropriate Box)
Utility Authorization No.
Existing Service _ Amps Volts OverheadD Undgrd No. of Meters
New Service Amps volts Overhead F� Undgrd No. of Meters
Number of Feeders and Ampacity
Location and Nature of Propo d Electrical Work: _J1j,1C -C�/)
C-- I -- /�� 10 a I- � � )i2(-->ocJe-
Cnmnlpfinn nfth,, fhllnwinq tnhlo mm, ho Wgilwd A,, tho [.—t— -fw;—
No. of Recessed Luminaires
No. of Ceff.-Susp. (Paddle) Fans
No. of 0
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Above Ej In-
Swimming Pool grnd. 11rnd.
No. of Emergency Lighting
Battery Units
No. of Receptacle Outlets D -
No. of Oil Burners
FIRE ALARMS
JNo. of Zones
No. of Switches i S -
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
(0
No. of Waste Disposers
Heat Pump
Totals:
lj�, r
�mber__,
I Tons
.... . ... . .............
JIM
'15V f Self -Contained
o.o
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
I [:] Municipal
Lou Connection n Other
No. of Dryers
Heating Appliances KW
Security Systenis:*
No, of Devices or Equivalent
No. of Water
Heaters KW
No. of No. of
Sig s Ballasts
Data Win'ng:
No. of Devices or Equivalent
No. Hydromassage Bathtub.-
of tors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Estimated Value of Electrical Work:
Attach additional detail ij desireg or as required by the Inspector of Wires.
(When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such jo�erage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE JX BOND R OTHER F_] (Specify:)
I certi
fy, under the pains andpenaldes ofpedury, that the information on this application is true and complete
FIRM NAM : A LIC. NO.:
Licensee: -cc rrJ Signature AIIZZZ64 LIC. NO.:
(If applicable, enter "exempt in the license number line) Bus. Tel. No.;!72d�'A .3;LVI-537S
Address: , 1.1 brC?T,1yt--0- 120 — J Alt-Tel.No.:/Al kVcf- 6
*Security System Contractor License required for this work; if applicable, enter the lic��n"er 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) F] owner El owner's a ent.
Owner/Agent F,7
Signature Telephone No.— PERMIT FEE. $
aoa� 52 AC
!7� �—'-
Date
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that .............
has permission to perform
plumbing in the buildings of ........ k.-.1 ............
at . . 3 A. emrl.� .. �. ........... . North Andover, Mass.
Fee.-14//"-�- '� . Lic. No.,;)(
��L* U* �M*8;/IN INSPECTOR
P
Check #
7165
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETIS
Building
'f M411 Al) Owners Name
Date /�// 3
Permit #
Amount
Type of Occup
New 0 Renovation U-1 Replacement 0 PlansSubmitted Yes No
FIXTURES
(Print or type) ame L Check one:
Installing Company N _' Corp.
Address Isc."r Partner.
�"WAf--4
Business Telephone 0--F-i;;�Co
Name of Licensed Plumber 1jfAV-*A1z*-K 616111111 e I,,
Insurance Coverage: Indicatd'the type of insurance coverage by checki
Liability insurance policy rTy- Other type of indemnity
box:
Bond
Certificate
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 Owner 11 Agent El
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 M choetts Sfife 142 of the General Laws.
,7-
�AAAXO' I&
By: ;i , Qggna on It—cens UR ftt 6 er
Type of Plumbing License
Title 4�9
City/Town cLense Master Journeyman
APPROVED (OFFICE USE ONLY
T -
0
---.-2304
Date ........ .. ...
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ....... t. �A . ....... U�.O.�L's . .............................
has permission to perform ..... P).CAAk.q.q.Q0q .......... .........
..... . .... .. ..
wiring in the building of ..... 6.o.r.r'j—� .. ...............................................
at ........... .... k/r') a..*I. q ...................... h And M
ao
Lic. .............. .... .. ..... .
s
;�' 4�*'�- yc�o
EC-rlticA�L
Check #
WHITE: Applicant CANARY:-El6ildling Dept. PINK: Treasurer
ThE60AM0NffE4L7H0FAL4FS4C7RSEM Office Use
94 DEPARTAMWOFPUBLICSAFM Permit No.
BOAM OFFREPREVEAWONRWM770AS527CM 120 Occupancy & Fees Checked
APPUCATION FOR PERAff TO PEMORM ELECMCAL WORK
ALL WORK TO BE PERFORMED IN ACCORDANCE wITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) DatS_4,
Town of North Andover To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number)
Owner or Tenant
Owner's Address
Is this permit in conjunction with a building permit: Yes rM No (Check Appropriate Box)
Purpose of Building -5-1-17e�lle 4,1111 Utility Authorization No.
M No. of Meters
Existing Service 0- Amps-'�4/--1T-JVolts Overhead Underground
New Service Amps Vo)ts Overhead Underground No. ofMeters
Number of Feeders and Ampacity
on and Nature of Proposed Electrical Work 44;: - dol 114� I<AAzl— 11-41-1,
1119
0 Outlets
No. of Hot Tubs
No. ofTransformers
Total
TfLighting
KVA
go. of Lighting Fixtures
Swimming Pool Above
E]
Below
Generators
KVA
ground
ground
No. of'Receptacle Outlets
No. ofOil Burners
No. of Emergency Lighting Battery Units
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS
No. ofZones
No. of Ranges
No. of Air Cond. Total
Tons
No. of Detection and
No. of Disposals
No. of Heat Total Total
Pumps
Tons ---KW
Initiating Devices
No. ofSounding Devices
No. of Dishwashers
Space Area Heating KW
No. ofSelfContained
Detectiort/Sounding Devices
Local Municipal
M
Other
No. of Dryers
Heating Devices KW
Connections
No. ofWater Heaters KW
No. of No. of
Signs
Bailasis
No. Hydro Massage Tubs
No. of Motors
Total HP
OTHER-
Insumxecovaar. %qmtiDthereqzm=tsdNbsmdw9wsG=W Laws
Iha%eaamatiablitykmr&=PbbcymdudmgCaT#ftOpwA*mCojmaWcrdssi)ganbalegzAft YES 1�3 NO
ItmeahniftedNalidpreofafswrlelotleOffim YES rM NO W)mtmedxdWYESPkmmdc*tctAxOfWArdWbydedmgthe
zVpW bcx
INSURANCE BOND ftweSpM&Y) 1A 41,11
M r E;ViratimDat
Wclklostst 4,c,7-a,415P InsptxfiwD*RapmWd
FIRMNAME
CA Z
z91
Li== 'I Z v7K Sip.
Esftln&dVahledE1eCftX3lWdk $
Rao FmW
�-i /4,(/ / 1,,� /,�4-
ZF,2-0 Z--s--X-
X I-Mmlb A;—?o -0-fr
Btsir=TdNid �ay Vr
J- J C8-6
ddim— AIL TeL No.
OwNsrsNsuRAN�mWAIVER,i.ammmffittbel=mdmnot &mwa=ammF"mbwrideWwalatasmqLuWbyMazxhEmCzvdLam
(Please check one) Owner Agent M Telephone No. PERMIT FEE
Location,
No. Date /0
,40PTN
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
CHUS
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL
Check #
Building Inspe6ar'
1.1 Property Address:
va r mia
1.2 Assessors Map and Parcel
Map Nu6iber
Number:
Parcel Number
1.3 Zoning Information:
4 --
Zoning 56�ct Proposed Use
1.4 Property Dimensions:
—
Lot Area (sf)
Frontage (ft)
1.6 BUELDING SETBACKS (ft)
Front Yard
Side Yard
Rear Yard
Required Provide
ReqWred Provi&d
Required
Provided
1
1.7 Water Supply M.G.L.C.40. 54)
Public 0 Private 0 Zone
1.5. Flood Zone Irtformation:
— Outside Flood Zone 0
1.8
municipal
Sewerage Disposal System:
0 On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHW/AUTHORIZED AGENT
2.1 Owner of Record
Ms. &V1i,7e
Name (Print) Address for Service':
Signature
2.2 Owner of Record:
Name Print Address for Service:
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
RA, /I d &//�4,K-47
Licensed Construction Supervi
Address
h"& /, a? . eq 1?-- 0
Signature - -- / — 61, Telephone
3.2 Registered Home Improvement
0MCA
Company Name
FAI
00c-, - / 9 a ?,
Not Applicable 0
— C I �s 0
License Number
Expiration Dahe—w.--
Not Applicable 0
104 (? A -A M—Jrd\!�4��
Registrafion' Number'2:::�-
- �Iv T10d
Expiration Date
I SECTION 4 - WORKERS COMPENSATION (NLG.L C 152 § 25c(6) I
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit %ill result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes ...... 4 No ....... 0
SECTION 5 Description o Propoosed Work (check applicable)
New Construction 0
Existing Building 0
Repair(s) 0-
Alterations(s)
Addition 0
Accessory Bldg. 0
Demolition 0
Other El Specify
Brief Description of Proposed Work:
&44-1A7 &Mid 6741�- a-Xa1J14 S11164 Lle*
ecIrIc, �c )r;pl�x &-2
I
"Pes-
L/
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
LAL
OFFIC'" "USEONLY
I . Building
/01
(a) Building Permit Fee
Multiplier
3
2 Electrical
(b) Estimated Total Cost of
Construction
Plumbing
Building Permit fee (a) x (b)
-3
4 Mechanical (HVAC)
5 Fire Protection
Total (1+2+3+4+5)
Check Number
.6
SECTION 7a OWNER AUTHORIZATION TO BE COMIPLETED WBEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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 of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
1, 411 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
664"'1
Print Name
Signature of Owned ent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TEVMERS I ST 2 ND 3 RD
SPAf;
DIMENSIONS OF SILLS
DR�ENSIONS OF POSTS
DINMNSIONS OF GIRDERS
HEIGHT OF FOUNDATION TfUCKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
1S BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
�1
BUILDING DEPARTIV=
DEBRIS DISPOSAL FORM
In accordance with the provisions of MGL c 40 S 54, a condition of Building Permit Number
Is that the debris resulting form tins work shall be disposed of in a properly licensed solid waste disposal facility as
defined by MGL c 11, S 150A
ne debris will be disposed of in:
4127 Ar/
Location of Facifity
Tignature of Permit Applicant
Date
NOTE: Demolitionpermi . t from the Town of North Andover must be obtained for this project through the Office of
the Building Inspector
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Date. Z/ - / -I - 6 &
. .. .......
TOWN OF NORTH ANDOVI��/
PERMIT FOR PLUMBING
This certifies that .................
has permission to perform .... �4 1/1
....................
plumbing in the buildings of ..................
....... -North Andover, Mass.
at. . - .......
Fee. . Lie. No.. .. .... (2)1."izj ...........
�'/ PLUMBING INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS ate
P t
/7 AV/- � mr -
Building Locq]�,on OwnersName Permit #
Amount
Type of Occupancy
P1 ubm
New F1 Renovation ED Replacement [D-- itted Yes E] No
VTyTTTRFS
(Print or type)
Installing Company
16,
Address A/ X, -5
Check one: ertificate
El -corp. 157? -5;1 V -
ElPartner.
11 Firm/Co-
Name ofLicensed Plumber- 7 ��Ty ' c--" L / - -L-�
Insurance Coverage; Indicate the type of insurance coverage by checking the appropriate bo)c
Liability insurance policy Other type of indemnity Bond
insurance Waiver L the undersigned, have been made aware that the licensee of this application does noi have any one of the above
three insurance
Signature Owner Agent rl
I hereby certify that all of the details and infimation I have submitted (or entered) in above application am true and accurate to the
best ofmy knowledge and that all plumbing work and installations perlb_rmed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Phim4izig-Itode and Chapter �42 of the General Laws.
By- bLgnatUre ofiziciscu riumorz
Type ofPlumbing License
Title eyman
City/Town ricense Numoer Master Journ El
APPROVED (OFFICE USE ONLY
0 Date ..................................
ORT"
TOWN OF NORTH ANDOVER
0
PERMIT FOR WIRING
4F
SA
This certifies that ................................
has permission to perform ...............................................................................
wiringin the building of ...................................................................................
at ............................................................................... . North Andover, Mass.
Fee..................... Lic. No . ............. ...............................................................
ELECTRICAL INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File
offtcc usc'Only.
The Commonwealth of Massachusetts rcr-ic 2e6o-Z
paqm c , Pf of Public Sofcfy occupancy & r�. ch�r,,,,
.J
BOARD OF FIRE PREVENTION REGULATIONS S27 CMR 12= 3/90 (1-ca�c blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All "rk to t�e periorrncd In accordance with.thc Ma".achuscru Electrical Ccd*c. 527 CMR 12:00
(PLEASE -2RINT IN INK OR =E ALL 1ITFORHATION, Date
City or Towa Of—& To the Inspector of Wires:
The undersigned ipplics for a permit to perform the electrical work described below.
Location (street& Number) C� I
Owner or�'Tcaant 0 fpn
Owner's Address
ElIs -this permit in conjunction with a building permit: Yes N?:J� (Check Appropriate.B�
Utility Authorization N
64Z) A -P, ��Volts Ov,rhcadA�T�ndgrd Meters I -
Existing Service
Rev Service J�Amps Volts Ovcrhc:a1�__R_Undgrd No. of Meters
Bumb,cr of Feeders and Ampacity
Locationcand Nature of.'Proposed Electrical Work A4;4J7,-
No. of Lighting Outlets
HNII.�,of Hot -Tubs
Total
of Transformers ICVA
No. of Lighting Fixtures
Pool Above E3 11n1_
Swimmm grnd. grn
Gcne�tors YVA
No. f Rece tacle Outlets
0, P,
NO. Of Oil _ners
No. of ,jrgency Lighti��&�
BatterytnMs
No. of Swit ch Outlets
No. of Gas Burn s
FIRE ALAPIKS of nes
0 of ne'
'�o. of De�ection d
c io
Dinen d
Initiating D.ev e
t v
�A e
No. of Sound Devic
No. of Sel nt-ained
Detectio Sounding Devic
ti, i� Devi
L
tun ipal 0
tunicipal thr
Local Co ctio Other
Connection[E-1
No. of Ranges
Tota 1
No. of Air Cond. Z>`�tons
No. of Disposals
Beat tal. Total
No'. of Pumps Tons KW
No. of Dishwashers
Space/ArtAeating;-,-
No. of Dryers ------
,Hc:atin g Devices M
No. of Water Hcatcr3-_----M-
No. 90. Of
Si Ballasts
'Low V ltage
WiF el,
No. H ydro Massage Tubs
of Motors ''Total HP
OTHER: IAN 1 8
pot',-, I_ cc, 64 /ZIL lqr- 15 0 0 12.2 V
'MSURANCEXOVERAGE: Pursuanti'tolthe'requirements�of �assachuset�s General Laws
I bavel/a. current Liability Insuranc�p Policy including i�mpleted Operations Coverage or its substantial
equivalent. YE,'#,fz_r--NO�0 I have. s�.bmitted valid proof of same to this office. YFi4�j�NO C3
If yo��ha�� checked'YES, plea'se indicate the type of coverage by checking the appropriate box.
INSURANCE`.[] BOND[] .,OTHEREI,,(Please Specify)
Estijuated Value of e rical
Work to Start ---
Signed under the.penalties of
Work S.
Inspectiori Date Requested:'-
perjury:
F1 Rm - N AmE Vrc 5 c ej &71C 1C. NO. 310 -3
Licensee 3ev"-r5 K47--ltree 1, Si ::::�Ticr
gnatur LIC. NO ---
Address lelo—clya-r- Bus. Tel. No. g!�/7_ 7�Y37_�5'
"I Alt. Tel. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub-
stantiaA equivalent as required by Massachusetts General Laws, and that my slgna�,ure on this permit
..application waives this requirement. Owner Agent (Please -check one)
C?�
Telephone No. PERMIT FEEI_1*�'!5�
(Signature of Owner or Agent) .
kExpiration Date
Roug . Final 4-,,,#'// //
kl-ocatlon 1
No. Z Date
TOWN OF NORTH ANDOVER
s
Certificate of Occupancy
$
Building/Frame Permit Fee
$
Hu
Foundation Permit Fee
$
Other Permit Fee
$
Sewer Connection Fee
$
Water Connection Fee
$
TOTAL
$
Building Inspector
Div. Public Works
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Location Oe—1
No. 7-ig/ — Date
- �2- -1Z �,. TOWN OF NORTH ANDOVER
� Check#
16,26 5
Building Inspector
Certificate of Occupancy
$
C"Ust.
Building/Frame Permit Fee
$
Foundation Permit Fee
$
Other Permit Fee
$
TOTAL
$
� Check#
16,26 5
Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAI$ RENOVATE. OR DEMOLISH A ONE OR TWO FAMILY DWELLING
1�1 PmpcdyAddrcss�
3ci NQKMA-W
BUILDING PERMIT NUNMER: '131
DATE ISSUED:
SIGNATURE: //tw ?,2t=
Building Commissioner/Inspector of Buildings Date
SECTION I- SITE INFORMATION
1�1 PmpcdyAddrcss�
3ci NQKMA-W
1.2 AsszorsMapad Parcel Number
Map Number Paroal Number
1
1.3 Zoning Information:
ZcninD Di;-YTc—L Proposed Use
1.4 PropedyDimensions:
Lot Area (st) Frontage (11)
1. 6 BUILDING SETBACKS (ft)
Front Yard Side Yard Rear Yard
Required Provide Required
Provided ReqWred
Provided
1. 7Aaw StqTly AGILCA0. 34) I.S. Flow z0ft Infonnnion: 1.8 Sc%=WD4ou1S)s1=
Flublic 0 Niwa 13 7a" Outsi& Rood Zo" 0 muicipal 0 On Site Dispml Symm 0
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
Coce.a,o2!!j 7.
Name (Print)
Address for Service:
Sigatfire V Telephone
2.2 Owner of Record:
Name Print
Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction S . Wr,
N 7'A -
Licensed Construction Sup6Nisor:
Address
Signature Telephone
Not Appficablo
License Number
rxpiration Date
3.2 Registered Home Improvement Contractor
[A
Not Applicable 0
Company Name
Registrafion Number
Address
Expiration Date
Signature Telephone
0,
0
z
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90
0
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SECTION 4 - WORKERS COMPENSATION (nG.L. C 152 .4 25C(6)
Workers Compensation Insurance affidavit must be completed and submitted with thi pplication. Failure to provide this affidavit wUl resul
in the denial of the issuance of the building Pennit. 11 isf A
affidavit Attached Yes—. —a No ....... 0 l\J I n
.Signed
SECTIONS Description Proposed Work (check
100plicable)
New Construction 0
Existing Building 0
Repair(s) 0
Alterations(s) 0
Addition 0
Accessory Bldg, 0
Demolition 0
Other )�- Specify_ S
Brief Description of Proposed Work;
AJ
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollar) to be
Completed by permit applicant
OY'ViCIAVUSLONLY-i,
f-
1. Building
o D
(a) Building Permit Fee
M111tipli
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Peradt cc (z) x- (b)
Mechanical (HVAC)
.4
5 Fire Protection
6 Total (1+2+3+4+5)
Check Number
SECTION 7a OWNER AUTHORIZATI TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERAUT
1, as OwnerlAuthori7ed Agent of subject property
Hereby authorize to act on
My behajf. in all matters rclati t k uthorized bv this building permit application.
Signiture of Owrifer
OWNER/AUTHORIZED AGENT DECLARATION T
.SECTION7b
I, as Owner/Authorized Agent of subject
Property
Hereby declare that the statements andinformation on the foregoing application are true mid accurate, to the best of my knowledge
andbelief
Print Name
Signature of Owner/Agent Date
NO. OF STORIES SEE
BASEMENT OR SLAB
SIZE OF FLOOR TIT�MERS Y"u 3RD
SPAN
DIMENSIONS OF� SILLS
DIIAENSIONS OF POSTS
D2VIENSIONS OF GIRDERS
HEIGHT OF FOUNDATION TIRCKNESS
SIZE OF FOO11NG X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
MAYlAY * 25.,�OR�, V ) 3: 5�M,Z A'J"fy, WM. MALUNhY
PJNCY. MOPAN 4 TIVNAN. INC.
92015TERCO LS"D -9UILVPVK5 NAMMI
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wORCOTER- wA o i a I a Loc&Tiom
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MAY.25.2005 3:57PM NO.668 P.112
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FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
*&********"***APPLICANT FILLS OUT THIS SECTION
APPLICANT I-
-7Y
PHONE 91
LOCATION: Assessoes Map Number PARCEL -00 i -ZI
SUBDIVISION LOT (a) )
STREET P�-N C,_J, ST. NUMBER
***************""OFF1lC1AL USE ONL
DATE
'ED
DATE REJECTED
TOWN PLANNER DATE APPROVED
DATE REJECTED
FOOD INSPECTOR -HEALTH DATE APPROVED
DATE REJECTED
SEPTIC INSPECTOR -HEALTH DATEAPPROVED
DATE REJECTED
COMMENTS
PUBLIC WORKS - SEWERIWATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE
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