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FORM U
TOWN OF NORTH ANDOVER
LOT RELEASE FOIUI
SUBDIVISION
ASSESSORS MAP
SUBDIVISION LOT(S) 1,e5�T -;I/ -?C?
PERMANENT ADDRESS (ASSIGNED BY D.P.W.)—,tf
STREET
APPLICANT
lz5W P PHONE .522f 71,r
DATE OF APPLICATION
PLANDgNG/tOARD
N
CONSERVATION COkDIISSION
TOWN USE BELOW THIS LINE
PATE APPROVED
DATE REJECTED
DEPARTMENT OF PUBLIC WORKS
DRIVEWAY PERk1IT t,'
SE*H-F;n/WATER CONNECTIOY
FIRE DEPT. /�,
RECEIVED BY BUILDING INSPECTION
DATE i
17 1 C- F'
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APPROVED il-M471
REJECTED i
APPROVED
REJECTED
F tr/K C -,-/ 17/
V-2 IZ��
This form shall be signed by tile agents of the Planning and Health Boards,
the Conservation Commission prior to the issuance of any building permits
for the subject lot. This form shall not releive tile applicant from tile
compliance of any applicable Town requirement or Bylaw.
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Location
No. 17o Date fh,3.li2
T TOWN OF NORTH ANDOVER
so Certificate of Occupancy $
4L Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
Sewer Connection Fee $
-2-.,,Water Connection Fee $
TOTAL $
I g In ctor
Div. Public Works
40 7 3,9
Location
No. Date
VORT" TOWN OP NORTH ANDOVER -
0
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
CHU
Other Permit Fee $
Sewer Connection Fee $0
Water Connection F $
TOTAL
5148
10
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CERTIFICATE OF USE & OCCUPANCY
Town of North Andover
Building Permit Number/ ZO Date
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 292 CAMLESTICK ROAD (Lot #39)
MAY BE OCCUPIED AS SINGLE FAMILY DWELLING W/3 CAR GAMGEIN ACCORDANCE
AITACHED
WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND
SUCH OTHER REGULATIONS AS MAY "PLY.
CERTIFICATE ISSUED TO Jerad Place IT Dpy. Co=.
212 Elm Street
ADDRESS Somerville, MA
ACHUS Building Inspector
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MASSACHUSETTS UNIFORM APPLICA
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Location
e,
of
New Renovation 0 Replacement El
FOR PERMIT TO DO PLUMBING
57
60 Permit #—&6!�,T
6 Aj Amount
Vans Submitted Yes No
(Print or type) Check one: Certificate
Installing Company Name -ri i4ALLo-fArJ Corp.
Address 0 7 Partrier.
vi rz tio C C M A
Business Telephone 19 -7 2f 492 9 5-- 9 5-0 1-/ El Firm/Co.
Name of Licensed Plumber: . 77k 110 S 1-14 116
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy Other 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
..Signature Owner Agent
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 Massachusetts State Plpmbing Code and Chapter 142 of the General Laws.
By: Signature 01 Licensea riumoer
Type of Plumbing License
Title AY03
City/Town i-icense Numoer Master Journeyman 12
APPROVED (OFFICE USE ONLY
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MASSACHUSETrS UNWORM APPLICATON FOR
T ype or print)
y�
NORTH ANQOVER, MASSACHUSETTS
Building Locations
7 /-
5 aeV-eA-- Owner's I
New F� Renovation F� Replacement F1
TO DO GAS F=(;
Date 49- 0 5 -
Plans Submitted F�
Penn it 9 J—/d
Amount S C& . OZ7—
(Print or type) Check one: Certificate Installing Company
Ni am e-7 11 Corp.
Address A50 doix- F-1
e-.--e-e- ovor y.2 F-1
Business Telephone a 2( -5-- :7,s—a I/ -
Niame of Licensed Plumber or Gas Fitter 44,//a 4 -f
Partner.
Firm/Co.
INS(itNANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivaipnt. Yes M
I
If you have checked ves oiease indicate the tvt)e coveraize bv checking the appropriate box.
Liability insurance policy Other ty Bond
. F1 peofindemnity M
Nio M
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:
Si2nature of Owner or Owner's Agent Owner Aizent
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 pertineric provisions of the Massachusetts State Gas Code and Cha 1421 of the General Laws.
By:
Title
City/Town
A
APPROVED (oi,i-u- OSE ONLY) J
Signature ofLicensed Plumber Or Gas Fitter
Plumber
r7 Gas Fitter License Numoe-
F—i Master
r,0 Jourrievi-rian
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