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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
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This certifies that ......... .. ...............
has permission to perform ............... ........................................ —
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wiring in the building of ......... ................
at ..... � .................................. . North Andover, Mass. 10
Fee...... .............. Lic. No . ............. ................
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
lice Vsw 0"l y
The Commonwealth o Massachusetts
)f
Pe mi NO.
Departmenf of Public Safct.V
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR IZ-Oo 13/90 CUPAnCY & Fee Checked
A, (leav blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All %,ork to be periormed in accordance writh the Ma"Achusens Electrical Code. 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL IHFORHATION) Date: 6 i(dqf-
City or Town of ' NbrA To the Inspecior'of Wires:
The undersigned applies for a permit to perform the electrical work described below.
Loc.ation (Street & Number) -�o
Owner or Tenant 11�c it +
,Owner's Address 94,.,R,
Is this permit in conjunction with a building permit: Yes 121� No (Check Appropriate Box)
Purpose of Buildin CAW C Ill."- - Utility Authorization NO.
Existing Service �40 Amps 2,Z volts Overhead F�Undgrd -------------
New Service -------- �mps L__J NO. of Meters 2-
---_yoits Overhead El Undgrd E] No. of Meters
Number of Feeders and Ampacit
Location and Nature of Proposed Electrical Work
No. of Lighting Outlets
No. of Lighting Fixtures
No. of Receptacle Outlets
No. of Switch dtitlets
No. of Ranges
No. of Disposals
No. of Dishwashers
No. of Dryers
No. of Hot Tubs
_57 JSwLmming pool Ab -
_2ve [D In-. E]
A grnd
NO. of Oil Burners
NO. Of Gas Burners
No. of Air Cond.
Re'atTotal
No. of "um s . Tons
Space/Area Heating
Heating Devices
L %4
Zo t
otal
tons
To ta
No. of Water �Heaters KW no, Or No. or
Siens R�11�.
No. �Hyd�romassage T�ubs No. Of Motors Total HP
OTHER:
�N�0.of Transformers Total
Generators KVA
No. or bmergency Lighting
Battery Units
FIRE ALARMS No. of Zones
No. of Detection and
Initiating Devices 7
No. of Sounding Devices
KW No. of Self Contained
Detection/Sounding Devices
Municipal
KW Local ElConnectionElOther
LOW Voltage
INSURANCE COVERAGE: Pursuant to the requirements of Massachu
I have a current Lis s etts General Laws
_4ility Insurance Policy including Completed Operations Coverage or its stbst nt al
equivalent. YESEJ-1' No 0 1 have submitted valid proof of same to this office. YES 0 No
If you have checked YES, please Indicate the type of coverage by chacking the appropriate box �? A4 -
INSURANCE [E]"BOND F] OTHER 0 (Please Specify)
Estimated Value f El rical Work S (Expirati,�n -Date)
Work to S tart 1�� - Inspection Date Requested: Rough,_Wt �� CAL- --Final
Signed under the penalties of perjury:
FIRM NAME
LTC. NO. E.206 �-7
Licensee Signature LTC. NO.
Address t4 0,- Bus . 0.
-Al t . Tel. No. 1 5-747. y, k -) q
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the Insurance cover -age or its sub-
pplication waives this requirement. r.
tantial equivalent as required by Massachusetts Gene il and that my signature on this permit
Owner Agent (Please check one)
Signature of Owner or Agenz,, - Telephone No. PERMIT FEE S 4�t�_
01
Office
Of als its permit No.
G, 4t UMMUMMn . w - - ��
--7
p., -y A Fee OwdU94'
.331t;=7=021 Of I;tLf3UX
CC=
0eave bwniq
BOARD OF FIRE PREMMON FEGULATIONS SZ7 CUR 12:00
PERFORM ELECTRICAL VORK
APPLICATION FOR PERMIT
- - jk to tji- p - rf&rfied in ac=fdance with trie Massaiatusetts Mectrical Cade, SZ7 CMR 1
All wo e : . I -L'2 7
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date
To tne inspector of Wires:
<M or Town of NORTH ANDOVER
The udersigned appfles for a permit to perform tt%e eiec:rical work described be(ow.
Location (Street & Number)
Owner or Tenant co
Cwner's Address No (C'neck Appropriate Box)
in C:=njunc-
Is zi-lis permit ion with a,-uilcing ;:ermit: Yes
P,;rccse ct Building Utility Autncrization No. 20 2 00 z-
Cuernead Uncignia No. of Meters
E.xistir.g Ser./ice _ Amps No. of Meters
New Service Z700 Amps Icits Cvernead E----Uncgmd
Numaer of Feeders and Ampacity
Location and Nature at Proposed Elec*ncai INcrK.
—.0tal
No. =r 7ranstormers
KVA
Nc. at 1,;gning Cut!e(S No. --r -Ct --'=S
No. �r L..;nZing =xtures S�wnrn:ng gnnc. Generators KVA
No. :t =:rergency Uignung
Nn ners Bacery Units
. - at Racantac!8 Cutlets No. =r Cil Sur
No. of Switc.'l Cutlets
No. or 3as =%;rr.ers;
'7otat
No. at Ranges
No. Czrc. =ns
No. of -1-iscosais
Nc.=r 7b n s
7aai
No. of Cisnwasners
Szace/,Area
No. at Orvers
'r4eannq ::a -ices
NO. or Nc-
KW S600
Sign- Ba!laszs
No. at Water Heaters
M- "—, XA—.— --hS
140. -zt Motors -ctai
i-iP
C -, 'r'. E F;:
FIRS AL -ARMS No. at ZOMOS
No. at _-election ana
Initialing cavicas
.140. cr qounaing I-evicas
No. :.,� ��ait Caniaine(3
::ev,cas
�-7 Ctner
=caj
Cannect:on
I.ow Vattage
Wirmc
tNSL�RANCZ CCVEPAGE. Pi.,rsuant -0 :,-.8 ac'.;:remer.-s zr Massac:'-'-ser-s ;enerai t-a%vs
, -=e-a=ms Coverage or ;*is su=santial --culvatent. YES = NO
I nave a current L-aciiity insurance Polic-1 ;nc:=:`nc zn- -�cu nave cnecxec YES. �,iease incicat8i Tie yr.6 c;-�--vWrage I-V
N
nave suarnirtea valid proof at same -0 T.8 C!tics. YES
cniecKing tn accragpdrts Max. = ,Please S=ec!�-,)
INSUSANC- 5-:�SCNO = OTHSR 4EXotratlan 0ale)
Ss.tmatea Value t Cl cal Work S —J� �00 4)/// ef-Cil Fnal
Inscec--Cn =ata ReC--;es--eC:
work to Stan O� i r1o) e--
S;gnea uncer -Me Pe perlu C. NO.
FiRM NAME
C UC. NO.
L�,cansee -- ca �Zl -
at:z. '7ai. No. --S
Alt. 761. No.
CWNE:;*S iNSURANCE WAIVER: I am aware tnat ='O L-clilnseill Sces not ma insurance coverage or it$ sucarantial ecwvaJOnt as -
cu&rec zy Mas"cnusetts General Laws. anci trial --Tv s:qnazure an *r= =efmit acCucatiOn waives tnts recuirement. Owner A ent
(Please cnocx.Onol) 70loonone No, PERMIT FF--- S
(S4nature at o%vner cr Aqeml
N2 Date.. ..........................
vkoRTFj
TOWN OF NORTH ANDOVER
0
PERMIT FOR WIRING
CU
..................
This certifies that� .................................................... ..................
has permission to perform
wiring in the building of ... . ..................
at ��-.J� ... ........
.................................. . North Andover, Maslp...
cm
Fee A -Z Lic. . ...................................
ELECTRICAL INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
Office Use 0
4r. Lfamminiurdth of Musar4itsitts Permit No.
1ItPMtMzrrt d Public E-.dztq
Occupancy A F" Chockod'-�
BOARD OF FIRE PREVENTION REGULATIONS 527 C,191R 12:00 3/90 Qeave blank)
--J
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massacnusetts Electrical Code, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date
(%X or Town of' --NORTH ANDOVER To the Inspector of Wires:
The udersigned applies for a permit to perform the electrical work described below.
Location (Street & Number) -3
'e
Owner or Tenant Ire- 1 7 71
Owner's Address
13 this permit in conjunction with a building permit: Yes No E ------(Check Appropriate Box)
Puroose of Buildino J�1�11i/c /X Utility Autnorization No.
Overr-dac '�Unogrnd
Sxisring Service Arnps/_��__Z12 %/cits
C] NO. of Moters
New Service Amps ti -volts No. of Motors
Cverr-eac Uncgrno
Numoee of Feecers and Ampacity 7
Lccaticn aric Nature of Prcoosec Elecu-caj '.1/cr.K
-fie "e e, -
No. or -;qnting Outlets I : -
No. z' Hat �--=s No. at 7ranstormigirs .0tai
KVA
Above— :n -
No. Ot Lighting Ft'intutis Swimming =,zoi
grna. gm.. Giiinerators KVA
No. at E.-norgency Lighting
No. 21 Recectac-o Outlets No. at --it Burners Battery Unit . s
No. of Switc.-I Outlets No. air 133as Burners FIRE ALARMS No. of Zones
No. of Ranges No. at Air -=--r.c. otai No. of Cotection ano
tons Initiating Covices
No. of clisoceals
No. of 011inwasmillirs
No. of
Heat -.otai --otai
pwrzs Tons K%V
iSoaCefArea Hearing KV1
Having Cevtces KVV
No. at 1140. of
No. of Water Heaters KW Signs Sailall*M
NO. Hvaro massage Tubs No. -at Molcrs --otai HP
OTHER:
No. at Sounaing Oevices
Na. at S*it Containeo
00mcnaniSounaing 0ovices
Lc . cat Municioat Other
C,3nnec-.:on --
Low I/ditage
Wir:ng
INSURANCE C-VERAGE; Pursuant -.0 the recuirements at ?.IassacnL;s8rs ;enttai Laws
I have a current Liaoiiity Insurance Policy inctucing -zr-1=:etec 01peraticns Czverage or ;is suo3-.antial ocuivatent. YES
nave ll.iomittoo valid ;root at same to the CHica. YES -iCu -a" C.-locKea YES. measo inaicato Me type of coverage Cy
Cneciting -no a0pro Oax.
INSURANCE e BONO = OTHER = tP!ease S=ec:lyl
e3timatea Value of E!oc-.ncai Work 5 lEmairation Oatei
Worit :a Start' 2 -a y -f Inscecnon Date Aacues.ac: R 0 u G 1 Mnai
S;gn*a unoor 'he Pe ltl*s a pe �Ury: �6f ;t
FIRM NAME ,e-- T.. . /,/ .4 LIC'
Licensee 1�1 jaw 4i5
4 7 -S;c;nat%;r. 49:z� e- UC. No.
IS u N 0. R7 F- zJa4/
Acores 21t- Alt- 7el. �Jo.
OWNEWS INSURANCE WAIVEq: I am aware Mat the LXonsee ao--os mot -nave in@ insurance coverage or its Suastanual stuivatent as to.
quir*o by Massachusetts Giiinerat Laws. ano '.nal -my signature on -.n;s =ermat a0piscation waives this reciaremorlt. Agent
(Posse shocit Ono) 0 .(;) C-)
FEE
7essonone No. PSAMIT
Isigmature at oviner of Agenil
N2 Date ........
TOWN OF NORTH ANDOVER
0
11'9
-vow PERMIT FOR WIRING
This certifies that ..... 'P.: ... ........
has permission to perform ....... ... ( ... ov.1,C4.p.a) ... 5. r� !;e-,
wiring in the building of ...S.L A ...... '-�- 'Y'P' 4A'6' BY -CHECK ............
at 7) o ...... --s.) ............................... . Noq And *over, Mass.
F... Lic. N'0'1,.77,,V . ...............................................................
J-0� NO I n MU"t4DEj'ft,",'0R
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
Locatio.i
14
No. Date 4z 4=
4, TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
CHU
Other Permit Fee $
Sewer Connection Fee $
Water Connection Fee $
TOTAL $
q —i I -d -i
L na:.Tlna�specto�
-14 03121197 031.27 C).W rn..
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OVA
LIMIT OF EXCAVATION
.WITHIN R.O.W.
— TAP 2- 1 " WATER SERVICES
INTO EXIST 12'* MAIN STA. 48+55,181 +/-..
INSTALL 2 CURB BOXES
- 50.44'
,--PROPOSED 1" COPPER WATER
SERVICES (TINO) L=139% 187'
N/F ZOLOT ET AL
42
PROPOSED 11.5' WIDE
UTILITY EASEMENT
-PROPOSED 20FT.
UTILITY EASEMENT
00\ N/F
DEMPSEY
LOT 3 4
AREA 6025 S F
PROP. 6"PVC
$EVER. L-29' OD INV=
S�-.01 5 b
INV=
98.02'
IW -
97.60'
#30
EXIST.
IG
1 STY
12.50" EXIST.
SEWER
DWELL
LIFT
22.25'
STATION
(SEE NOTE
5)
IL
I
GENERAL NOTI
1. LABOR. MATERIALS. AND WORKMAN%%P SHA
NORTH ANDOVER AND THE STATE OF MA
2. PRIOR TO CONSTRUC'nON THE C014TRACT
UTITLTY LOCATIONS AND roONTACT.-DIGSA
3. REFER TO TOWN 'OF NO. ANDOVER. ASSES.
.4. ZON14G DISTRICT - R3
5. At the time of construction th
on.Lot 34 shall be cleaned and
pump shall be . identified and 0
heavy duty) of equal or greate
The controls and Wiring shall bi
seCond'purnP to- r operate '01-terrV
An electric meter to record th,
lift station shall be installed.
An outdoor warning light to 01
malfunction shall be i.-lstalled.
The location of the rTettr qndl
be determined by the three iif
N/F AZIZ
70 WESLEY ST.
--- wow, .
r—I'l A IN, I
Registry of Deeds
Northern District of Essex County
Lawrence, MA 0184o
09/12/96
SCOTT & CHRISTINE DEMrSEY K.p
ocr Rec:time 1057 Ty e PLAN
. 1)
10.00
'—'FMies
1.00
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21.7
THANK YOU' Thomas Burke
Regist of Deeds
Town of North Andover
40YGE BRA,).' OFFICE OF
TO I I "
, Q J41JN
HDR9 �, . NITY DEVELOPMENT AND SERVICES
146 Main Stred
AuG ZZ 2 1. 6 F H % North Andover, mamuhusetts o 1 &45
WaUAMJ. SCOTT
Director
ATMM. EAL
T sAB &t 0 O%�f I( S
Tme Copy ihL%l ON
have
V.;thoul 'i"'go
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Town CiZrk
Prope-rty: _U ILILL_L.� OU
Scott & Christine Dempsey Dat 96
30 Innis Street Petiticn:029-96
Nlrl-t�- A-HOWQ- MA Q1 R4 U - ".
The Board of Appeals held a regular meeting on Tuesday evening, August
13, 1996 upon- the application of Scott and Christine Dempsey requesting
a VARIANCE from the requirement of Section 7 Paragraph 3 and Table 2 of
the Zoni.na Bvlaws so as to Dermit relief of the �1.ot dimension area
requirement setback of 25000' to . 6025 relief requested 18,975, Street
frontage required setback of 125' to 601 relief zequested 65'and front
setback requirement of 30' to 16' relief recruested 14' . and a SPECIAL
PERMIT under Section 9 Paragraph 9.1 of the Zoning Bylaws -in order to
alter and extent a second level to a non-conformiag legally existing
structure located at 30 Innis St. The following members were present and
voting: William Sullivan, Walter Soule, John Pallone, Scott Karpinski,
and Joseph Faris.
The hearing was advertised in the Lawrence Eagle Tribune on 7.27.96 and
8/1/96 and all abutter were notified by regular -.nail.
Uoon a motion by Walter Soule and seconded by John Pallone, the Board
voted unanimously to Grant the Variance and Soeclai Permit as requested
The petit4oner has satisfied the provisions of Section 10, Paragraph
10.4 of the Zoning Bylaw and that the granting of these variances will
not adversely affect the neighborhood or derogace from the
U 1 -
61�2
I%
intent and purpose or che Zoning Y CEP -1 2 �96 --H 10:5 1
1i L X_ " _L liti
The Board finds that the applicant has satisfied the provisions of
Section 9, paragraph. 9.1 of the Zoning Bylaw and chat such change,
extension or alteration shall not be substantially more detrimental than
the existing non -conforming structure to the neighborhood.
Note: The granting of the Variance and/or Special Permit as requested by
the applicant does not necessarily ensure the granting of a Building
permit as the iapplicant must ab-ide by all apprii--able local, state anxi
federal building codes and regulations, prior to the issuance of a
building permit as required by the Building Commissioner.
Board of Appeals,
/A -
William Suilivia'4,FZ_h�4aiZi
BOARD OF APPEALS 689-9541 BUaDING 688-9545 CONSERVATION 6M9530 HEALTH 689-9540 pLANMNG 688-9535
April 23, 1998
Kenneth Surette, Bldg Inspector
North Andover Bldg Dept.
Re: 30 Innis St.
Dear Mr. Surette:
Please be aqvised that I am no longer the contractor for permit numbers
133/435 for 30 Innis Street. I have not been on the project since late August
1997. Please consider this an official notice to your department.
I!
S. bKarthy
OA4"
bt,Carthy & Son Contniction
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* 40RTPI TOWN OF NORTH ANDOVER
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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 local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: Phone 6�?_70101
LOCATION: Assessor's Map Number Parcel
Subdivision Lot(s)
,2 130
Street e (S St. Number
************************official Use only************************
RE: )ATION�S OF TOWN AGENTS: < Ob
Date Approved
CDnsei�vation Administrator Date Rejected
Comments
)�, epm�o A Date Approved
T6w'n Planner U Date Rejected
Comments
Food Inspector -Health
—"J lld� - — - --:,
Septic In -spec -cut -Health
Comments
Date Approved
Date Rejected
Date Approved 21131z__j�
Date Rejected
Public Works - sewer/water connectionsi,/ai. )2�
- driveway perml, t
(%, - � A t
Fire Department
Received by Building Inspector Date
CERTI'FIED"PLOT PL
LOC.47ED IU NoRTVi ANDOViR �AA
E Zo DATE:
CHPISTIAKJSF-KJ F-KiGiKiEEPIKJG
114*KE-UCZ,A AVE. HAVERHILL
717
.T
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CLIF-f-JT : — 10L- 1 0&.
I CEPTI P7Y THAT THE
E3LJILDIKJG 5Ho\vKj C)Kj TH15
pLAKj CoKiPORMS TO T�-!E
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(DFFSE75 5HO\\/K-J APE POP
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oKiLy AKJ0 APE KJ()T To BE
USED TO ESTABI-115" PPO-
PFRTY LIKJF-S.
C)47rE. tAA-Y, 1984
THIS LOT
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CERTIFICATE OF USE & OCCUPANCY
Town of North Andover .
Building Permit Number
#403
THIS CERTIFIES THAT
Date July 20, 1994
THE BUILDING LOCATED ON 30 Innis Street- North Andoupr
MAY BE OCCUPIED AS A Single Family Residence IN ACCORDANCE
WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND
SUCH OTHER REGULATIONS AS MAY APPLY.
CERTIFICATE ISSUED TO
ADDRESS,
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Commonwealth of MassachiAsett
City/Town of N6W " ajt(
System Pumping Record
Facility Information:
System Location:
Address
k.11ty/ fown
SYStem Owner -
Name:
1:5 t&
Adress (if different from location of pump)
State
JAN 0 5 2008
TOWN
_L����, . o F..,ND
ALT cRTH NDOVER
MENT
,n)Ws'
Zip Code
city/Town State Zip Code
Telephone Number
Pumping Recor-d-
Date of Pumping uantity Pumped allons
Q bbb
Type of System
Septic Tank -Grease Trap Other
System Pumped by- IP --n
Company' ROOTER -MAN 12 East Dracut Rd-, Methuen, MA 0 1844
Location where contents were disposed: 7
Signature of Hauler Date
Date..
3718
TOWN OF NORTH ANDOVER
Ui
PERMIT FOR PLUMBING 11
This certifies that ...
4r— 00, ........................
has permission to perform ........
............. ,
plumbing in Ne buildings of
at. ................ North And ass.
Fee.. z Lic. No .......... ...............
PLUMBING INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
I&
a 7 � S"
MASSACHUSE77S UNIFORM APPLICATION FOR PERM11 0 0 PLUMBI G
(Pri9t. qr Type)
aC,4 /Lo CMass. Date Permit #
Building Location Owner's Name -S co
Type of Occupancy
.,,Ne,7��. Renovatio Replacement 13 PlansSubmitted: Yes 0 N01Y---
FIXTURES
Installing Company Name 0� , �� v r!Ei e-& 5
Business Te!ephone'--41
Name of Licensed Plumber
Check one:
• Corporation
• Partnership
,�,�irm/co.
Certificate
INSURANCE COVERAGE -
I have a curreDtAiability policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes 4 No 0
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy Other type of i ndemnity 0 Bond 0
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 0 Agent 0
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 the permit issued for this application will
be in compliance with all pertinent provisions of the MassactO-Sfiffs-Sta�e Plumbin -Q
_g lode and Chapter 142 of tr�e,.Ger*ral Laws.
Sig�at
, �e of Ucensed PjjAber
Type of Ucense: Masters--� Journeyman r-
Ucense Number I q
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1ST FLOOR
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Installing Company Name 0� , �� v r!Ei e-& 5
Business Te!ephone'--41
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Check one:
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,�,�irm/co.
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INSURANCE COVERAGE -
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Yes 4 No 0
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy Other type of i ndemnity 0 Bond 0
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 0 Agent 0
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 the permit issued for this application will
be in compliance with all pertinent provisions of the MassactO-Sfiffs-Sta�e Plumbin -Q
_g lode and Chapter 142 of tr�e,.Ger*ral Laws.
Sig�at
, �e of Ucensed PjjAber
Type of Ucense: Masters--� Journeyman r-
Ucense Number I q
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TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
A US
This certifies that 1.<.Yyef 0 ....... ....... V
has permission to perform .............................
plumbing in the buildings of ................... %D
................. I North Andover, Mass.
Fee. Lic. No—P ............
PLUMBING INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
75) Date ... 6..
I&ORTk TOWN OF NORTH ANDOVER
0 ,1
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6
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17 1. ))
i. "M % PERMIT FOR GAS INSTALLATION.,
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This certifies that .... ......................
co
has permission for gas inaIllati n ................ 9,-4' - -
in the buildings of ........... A�' �..
at ......... North And4er*,* M*'a*s*s'.
Fee ... 7--,:?:. Lic. No ........... ..........................
GAS INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS
(Print or T Xpe, , A� -q e-
8��tjeS� — Mass. Date 4 19 1/ Permit
Building Locatlon,-�o Owner's Name
TING
Type of Occupancy
Nevvjr// Renovation Replacement C3 Plans Submitted: Yeso NO—K/
Installing Company
�4 1-h 6? / go
f Tel S-Z:�'—
Business ephone
Name of I-Icensed Plumber or Gas Fitter
TITTIM
C3 Corporation
(3 Partnership
Firm/Co.
Certificate
INSURANCE COVERAGE:
I have a curKentjiability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes NZ No 0
If you have ch*cked yes, please Indicate the type coverage by checking the appropriate box
A liability insurance police� 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
Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement
Check one:
OwnerO Agent C3
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true,arfcr te to the best of my
knowledge and that all plumbing work and installations performed under the permit issued for this applicatioti-will in mpiiance with aJI
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gen4'3r
BY T! jaeof Ucense:
Smumber -sjlgj�jure of Ucens6d PrUmber or Gas Rittef
Title Gasfitter Ucense Number
City/Town its." ter
AP0PavE6To7I!ia USE ONLY) Journeyman
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Print or Type) j" -
W &-k-+ A Ig -A, Mass. C)ate 12-- Permitst 3
Z'/
Building Location 3kt� i-ln+
,t,v Y:L, Ownees Narne-C L A
Type of Occupancy I -QT Ld-L- ---1 h
New El Renovation 0 Replacennerd Q� Plans Submitted: Yes 0 No 0
FIXTURES
InstWllhg Company Name an du- i,- w
Ll C), #I V. e f - S -
Business Telephone 41 -7 V - -7-7- S� 0
Name of Ucensed Plumt>er
Check one:
0 Corporation
C] Partnership
104irm/Co.
Certificate
INSURANCE COVERAGE'
I have a current liability Insunance policy or its Substantial equivalent which meets the requirements of MGL Ch. 142.
Yes [4--- No 0
it you have checked y_q_s. please Micate the type coverage by checking the appropriate boy -
A liability Insurance policy Q— Other type of Indemnity 0 - Sond 0
OWNER'S INSURANCE WAIVER: I am aware that the licensee d2Ss not havp the Insurance coverage reqk,;ired by
Chapter 142 of the Mass. General! Laws. and that my signature on this permit application waives this requirernent.
Check one:
owner C3 Agent 0
I hereby certify that all of the details and information I have submitted (or entered) in above applicaUon are true and accurate to the oest 01 mY
knoyAedge and that all plumbing work and installations performed under the permit i&vjed lot this appkation will be in compliance vAth all
pertinent provisions of the masuchusetts State Plumbing Code and Chapter 142 of the General Laws,
Signature or Goenied Numoer
Title Type of License: Mastet Joutneytrkvi
License Number---Li—:?--1L--
=EMS
MEN
son
InstWllhg Company Name an du- i,- w
Ll C), #I V. e f - S -
Business Telephone 41 -7 V - -7-7- S� 0
Name of Ucensed Plumt>er
Check one:
0 Corporation
C] Partnership
104irm/Co.
Certificate
INSURANCE COVERAGE'
I have a current liability Insunance policy or its Substantial equivalent which meets the requirements of MGL Ch. 142.
Yes [4--- No 0
it you have checked y_q_s. please Micate the type coverage by checking the appropriate boy -
A liability Insurance policy Q— Other type of Indemnity 0 - Sond 0
OWNER'S INSURANCE WAIVER: I am aware that the licensee d2Ss not havp the Insurance coverage reqk,;ired by
Chapter 142 of the Mass. General! Laws. and that my signature on this permit application waives this requirernent.
Check one:
owner C3 Agent 0
I hereby certify that all of the details and information I have submitted (or entered) in above applicaUon are true and accurate to the oest 01 mY
knoyAedge and that all plumbing work and installations performed under the permit i&vjed lot this appkation will be in compliance vAth all
pertinent provisions of the masuchusetts State Plumbing Code and Chapter 142 of the General Laws,
Signature or Goenied Numoer
Title Type of License: Mastet Joutneytrkvi
License Number---Li—:?--1L--