HomeMy WebLinkAboutMiscellaneous - 3 Village Green0
Date ... ..........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that
....... ... ....
has permission to perform
wiring in the building of ... .. �i�e . .........................................
at v ...... A ... ... ftqu—. !;T� v. C .................. . North Andover, Mass.
Fee
.... Lic. No.
w3t '� *L' F-*C"'T* R** I'C* * A- L- E** C** T**O'*
Check # '13 -to �
1278 2-/
� . A
-%Z:� ���Cp
Commonwealth of Massachusetts Official Use Only
Permit No.
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. I/o7] (leaveblank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code rQ), 527 CMR 12.00
(PLEASE PAINTHNK OR TYPEALL JNFORMATION) Date: / o I q I I �;-
City or Town of. NORTH ANDOVER To the Inspector Jf Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number)_ -S V,, I \ aqe- G ry- P- n 'D r � 4 f -
Owner or Tenant
Owner's Address
Is this permit in conjunction with a building permit? Yes
Purpose of Building U v %' Y\
%J
Telephone No.
No [I (Check Appropriate Box)
Utility Authorization No.
- Existing Service Amps Volts Overhead LJ Undgrd LJ No. of Meters
New Service Amps Volts OverheadF] Undgrd n No. of Meters --
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: C-V� (-V
k - Completion ofthe followinq table may be waived by the Inspector of Wires.
No. of Recessed Luminaires
No. of Ceili-Susp. (Paddle) Fans
No. o Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above Ej In-
Lynd. grnd. El
iNo. of Emergency lt-gTting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
IN'o. of Zones
No. of Switches Z-
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges V
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
1APIAber
............
I Tons
I .........................
I KW
I ...............
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local El Mun'c'pPl El Other
Connection
No. of Dryers
Heating Appliances Kwl
Security Systems:*
No. of Devices or Equivalent
No. of Water KW 0
Heaters
No. of No. of
Signs Ballasts
Data Wiring:
. No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total IP � L
Telecommunications Wiring:
No.of Devices orEciulvalent
OTHER:
/&V 0 Attach additional detail i(desired, or as reqtdred by the Inspector of Ires.
Estimated Value o Elec 'ca ork: i (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with NIEC Rule 10, and upon completion.
INSURANCIE�C-C-COMAGE: 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 operation7' coverage or its substantial equivalent. The
undersigned certifies that such co>yage is in force, and has exhibited proof of same to the permit issuing office.
CBECK ONE: INSURANCI�>U BOND [I OTBER [:1 (Specify:)
I cerqy, under th pains andpienalti qfperju that the inforinatio, is app 1i I true and com
FIRM t plete.
NAMF,- JlrxroA V. Wrn*t1c (-e-c4r, -7/ LIC.NO.:
r Licensee: P Ckf-C) V-\ \-/., ��i 2V+d1V,1 LIC. NO.: /-3 -zz 5 - 13,
(If applicable, gnter "ex t" in the li m ntim er line Bus. Tel. No.:
Address: -,�T q i�f-.-A &Z �� 0, ..it 0 10 -z- e- Alt. Tel. No.: 7 18 - I (o4- 79'34�
*Per M.G.L c. 147, s. 57-61, security work requires . :At 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) [I owner E] owner's agent.
Owner/Agent FEE. -
Signature Telephone No. $
4
e-
2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3L.
Permits shall be limited as to the time of ongoing construction activity, and may be -deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012.
• Rule 8 — Permit/Date Closed: Note: Reapply for new permit 0
• Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass M
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass [a
Failed
Re- Inspection Required 0
Inspectors Comments: .
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass M
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass M
Failed
Re- Inspection Required ($.) 0
Inspectors Comments:
Inspectors Signature:
Date:
FE'4AL INSPECTION:
Pass M
Failed
Re- Inspection Required ($.) 0
Inspectors Comments:
Inspectors Signature:
Date:
DEBWEINHOLD ... TOWN OF MERRIMAC, MA . ....... dweinhold@townofmerrimac.com
The Coinmonwealth of Massachusetts
Department ofindustrialAccidents
I Congress Street, Suite 100
_goston, AIA o2114-2017
'Workers2 Compensation.
I TOBB
Name, (Business/6igani7-ationadividual):_
Address: q�
city/statdzip:_
. - -;.1 .. priate box:
Are you an employer? q4eck the appro
www.mass-gov1dia
nce Affidavit: Buflder5/(
WrrE[ THE PERIMrM
V,
4 01 'khon #
i.Qym a employer with oyees (fLill and/or part-time).*
___�10PI
1;t_ffI am a sole proprietor or partnership I'd have no employees working for me In
1, any capacity. (No workers' comP. insurance required] insurance required.] t
3.[] 1 am a homeowner doing all work myself LNO workers' cOMP,
<1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no' 16i�ploye8s.
5.Fj I am a general contracl:P� ja.0 d- I.,have hired the sub - contractors listed on the attached sheet.
These sub-contractorsbav6 e�qploYees and have workers' comp. insurance.
6.Fj We are a corporatip and its, officers have exercised their right of exemption per MGL C.
comp. insurance required.]
152 91(4) and We have �3.a o'yd�s. [No workers'
,7
Type ofproject ()Vequired);
7. [j NeW'd6nstr66t1on
emodelijig
8. ;9�kl
9. 0 Demolition
10 E] Building addition
11.F] Electrical p5p.airs or additiq)is
Qpj=bing repairs or additions
11E] Rb6f re�air�
14.n Other____�
I I . , - . li inf
- I � �l I fin out the section below showing their workers' compensation PO cY Ormat'on.'
*Any applicant that chdok§ b6k 01 . . so hire outside contractors must submit a now. affidavit indicating such-
"nii-thisAdavit indicating they are doing all work pd then or not those pntiqes� have
I 110meowners who subi d hil additional sheet showing the name of the sub -contractors and statq whether
tContractors that check ihis box must attache
employees. If the sub-co'niractois have employees, they must provide their workers' comp. policy number.
16yees. Pelow is t1lepoftey andYoh slt�
I am an employer that isproviding -workers' compensation insurancefOr MY e P
information.
insurance ConiPanY Name:
Policy # or Self -ins. Lic-
Expiration 1)4te;
fob Site Address, City/State/Zip -. atiou date),
Attach a copy of the workers' compensation policy declaration page (showing the policynninber and expir
ed under MGL 0. 152, §25A is a criminal violation Punishable by a fulb up to $1,500.00
Failure to secure coverage as requix ell as civil penalties—bAff9rin of a STOP WORK 6RDER a -ad a fine of up to $250.00 a
and/or one-year imprisomne office of Investigations of the DIA for insurance
day against the violapp7c-101,�IP7011fWtbis statem af if –b 0 �fl�D�04�2ffi e
coyej-dgu Vull.Liv ---- e an correct
o hereb ti pen es ur le� rmat" nprovidedabove
Date:
Si
P
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): 'I
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Phone#:
Contact Person:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their enlp�6y�es.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contra'ct of Mik
express or implied, oral or written."
An employer is'deffied as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enf6rprise, and including the legal representatives of a deceased employer, or the
receiv6t'or trmtdd 6 fan 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 b6 deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced -acceptable evidence of compliance with the insurance coverage ieq'irited."
Additionally, MGL chapter 152, §25C(l) states "Neither the commonwealth nor any of its political subdivisions shall
enter intp any contract for the performance of public -work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Pleasb fill out the workers, compensation affidavit completely, by checking the boxes that apply to your situation and, if
nece�sary, supply sub'contractor(s) name(s), address(es) and phone number(s) along with their certificatets) Of
insurance. Limited -Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. 1�e advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirruation 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 requ�steq, not the Department of
Industrial -Accident's. §hould you have any' questions regarding the law or if you are requ�red to obtain a workers'
compensatiori policy, please call the Department at the number listed below. Self-insured companies shoWd enter their
self-insuraric'e license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office ofInvestigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
thai must submit multiple pormit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "fob 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 now affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-NIASSATE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
112 ; 00
Date .........
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
it I "��
This certifies that ......
..... ......... ... ................... . ......
has permission to perform ........... ..........
plumbing in t�e building (of ...... IAA�.C-C' !.e . .......................
at..,-:!::) ..... V .......... 42-45� ............................. , North Andover, Mass.
"'N-Z� . .... ... .......
Fee.�q.150 .... Lic. No. 12. 4 ........................ ........................................................
Check # S a- 5 1 PLUMBING INSPECTOR
V -k
112
�j
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY f -W Ift UV MA DATE IPERMIT#
JOBSITE ADDRESS OWNER'S NAME
POWNER
ADDRESS L TEL JIFAX L
TYPE OR
OCCUPANCYTYPE COMMERCIAL EDUCATIONAL RESIDENTIALJ�j
PRINT
CLEARLY
NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES N
FIXTURES -1 FLOOR- BSM 1 2 3
4 5 6 7 8 9 10
1 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOILISAND SYSTEM
DEDICATED GREASE SYSTEM 1-7D
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
. . . . . . . . . . . . . .
DISHWASHER
L -.J --j
DRINKING FOUNTAIN ....... . . . . . . . . . . . . . . . . . .
FOOD DISPOSER ...... --j
FLOOR / AREA DRAIN "---j
INTERCEPTOR (INTERIOR) . .... ..
KITCHEN SINK
LAVATORY ------- I
ROOF DRAIN E -7 -
SHOWER STALL
SERVICE / MOP SINK
TOILET -.-.I L --j _3
0=3
URINAL
WASHING MACHINE CONNECTION I - j
WATER HEATER ALL TYPES I I— -----J
WATER PIPING I j �j
OTHER
J=—= - -- ---- �
F—
E-7
------- - ----INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO Ell
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY DI BOND
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 E-1 AGENT IEJ
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 arA 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 complia&e- ith all Pertinent provi of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. t
LICENSE#
PLUMBER'S NAME LIJ SIGNATURE
MP ip CORPORATION f4# PARTNERSHIP D # � LLC
COMPANY NAME ADDRESS % : —4c A
7m:& 7� As�&—
CITY �j iOATE zip [ O� TEL
FAX CELL EMAIL
112
�j
FMMI
w
rL
Iii
LU
LL.
-10 1
Commonwealth ofHassachusetts
Department of Indust""ialAecidents
I congress Street, SWte 100
Boston, MA o2114_2017
www.mass-gov1dia ctors/Electricians/P14Mbers.
I -
. . . . . Workers, Compensation Insurance Affidavit, Builders/Contra OFJTY.
TO BE FILED WITH TM PF-RMTTMG AUTH
F.J.
Name (Business/Oigal�'zat'ongnd'v"la):�
Address:
City/State/Zip:_'
Are you an erup�oyer?
Pli
the appropriate box:
Phone #:
loyees (full and/or part-time)-*
1f4l am aemploYer with d_c"Mp
t— tnership and have no emPlOYees,"OTking for me in
In I am a sole proprietor" Pal
any capacity. [No workers- comp. insurance required]
3.0 1 am ahomeovmer doing all workroyself. [No workers, comp. insurance required.] t
4.FJI am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers, compensation insurance or are sole
. w �� , ,
proprietors with no 6mPlo-Yees. attached sheet.
5.FJ I am a general con ",,ctpr
�iI4 � have hired the sub -contractors listed on the
These sub -contractors hav6 ei�ployees and have workers' comp. insurance.t
have exercised their right ofexemption per MGL c.
6. [_1 We are a corporation and its. officers
We . hav&��eir dy��. [No workers' comp. insurance required.]
Type of project (Tequiroll).
7.
8. El Remodeling
9. C1 Demolition
10 E] Building addition
ll.E1Elec#ica1 Tqpags ora.dditigAs
-�M.g repai,rs or additionS
Ro6f
re&ir6
14.Q Other—
IDA, V Lk�J. -t
compensation policy infoirnatiom,
out the section below showing their workers' indicating such
Any applic ant that chi 6 r,4k[q§ b 6k 4 1 so must submit a now affidavit
- Qi,,this aMaavit indicating they are, doing all work and then hire outside contractors
'I Holneowners who sub ,I ._ , � of the sub -contractors and statqwhe�ther or pot those..entities, have
tContractors that check Ws bok must attached �m additional sheet showing the name
have emoloyees, they must provide their workers' comp. policy number-
.Taman,mployert7zatisprovidingwOrkers'
Below is thepolley and)0b site
compensation insurancefor MY efnPlbYees-
information.
insurance Company Name:
policy# or Self -ins. Lie. M.— COOT301 Expiration Date:
—City/State/Zip-_1 yv(�
owing the polif
fob Site Address, compensation policy declaration page (sh y number and expiration datep
Attach a copy of the workers unishable by a ab up to $1,500-00
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation P
and/or one-year imprisonment, as we'll as civil penalties in the form of a STOP WORKORDER and a fine, of up to $250.00 a
day against the violator. A copy Of this statement may be forwarded to the office of Investigations of the DIA for insurance
coverage verification. erjury th at th e information pro vided above is true and correct
I do hereby certify er thepainS andpenalties ofp -�, I - —\ I I "c—
Official use only. Do not -write in this area, to be completed by citY or town official.
permit/License #
City or Town:
I
issuing Authority (circle One): 3. CitylTown Clerk 4. Flectrical Inspector 5. plumbing Inspector
1. Board of Health 2 -Building Department
6. Other
Phone
Contact Person:
Information and Instrnctions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their eniOdyees.
Pursuant to this statute, an employee is defmed as "...every person in the service of another under any contract of Wk
express or implied, oral or written.,,
An employer is'deffi6d as "an individual, partnership, association, corporation or other legal entity� or any two or more
Of the foregoing engaged in ajoint enfirprise, and including the legal representatives of a deceased employer, or the
receiv6for trustdd 6f an individual, partnership, association or other legal entity, employing eMpl6ypp§. - However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occup"ant' ofthe
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 b6 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 op6rate a business or to construct buildings in the commonwealth for any
applicant who has not prod -aced -acceptable evidence of compliance with the insurance coverage ieq'W`red."
Additionally, MGL chapter 152, §25C(l) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance ofpublir, work until accep* table evidence of compliance with the insurance
requirements of thi s chapter have been presented to the contracting authority."
Applicants
Pleasb fill out the Workers, compensation affidavit completely, by checking the boxes that apply to your situation and, if
nec6sary� supply sub'contractor(s) name(s), address(es) and phone number(s) along with their certiflcateO 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 do'6s have
employees, a policy is required. 1�e 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 requesteq, not the D '. artment of
ep
Industrial Accidents. Should you have any' questions regarding the law or if you are reqa�'red to obtain aw'6rkers'
compensatioii policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurano'c license numb on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
thai must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "fob Site Address" the applicant should write 5'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 Department's address, telephone and fax number:
The Conunonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
AND GAS F:l TTERS;:i';;"
PLUMBER
I�SSUES I 'NG:' ':L' I C E N S
,;:..THE FOLLOW
MASTER P'L,UM-BE
L J B E L L
30 S u S A:N'. 'D'R
RPAD I NG
IV
A 01867-M9
Location
No. e,71
Date
4119A
TPI
TOWN OF NORTH ANDOVER
19D
Certificate of Occupancy $
529 2a-
Building/Frame Permit Fee $
4 C 0.
Foundation Permit Fee $
Other Permit Fee $
Sewer Connection Fee $
Water Connection Fee $
TOTAL $
Tzo L L
58. 00 PAID BuildiN�nspector
9885 Div. Public Works
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OFFICE OF:
AFFF—ALS
BUILDING
CONSERVATION
HF--kLTH
P "N.*% ING
7_
-7 7�
i2d main street
Nonh Andover.
NORTH ANDOVER
massdchtisetts o I 84s
DMISION OF
PLANNING & COMMUNITY DEVELOPNIENT
KNRE-N HP_ LNELSON. DIRECTOR
In acc--rdancz wich the :;rcv�1;c7te, . cl Z -�'. 53 5-4. a condiii;cn of Building Permft
INUMber LS �Ict';s I
-=ulting Cm Ehis work shall be
disnosed of 'r, a orcpe-�,,; 1-,'cz-_SZZ -,C,7d r� . "
zs u==cd by
4z . M G L c 111, S
1-
7he debris will be disposed cf in:
0
L'U PC- rl 13d D7
cf ":1_C.11L,;1
Signa,ure Of Pc.-,Tnit Applicam
�q a/
2aL�_ /9- 1
0 Date � I
NOT'.�-: Demolit-Lon permit fro= the To ---a of North Andover must be obtained for
this project chrough the Office of the Building Inspector.