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HomeMy WebLinkAboutMiscellaneous - 30 WINDKIST FARM ROAD 4/30/2018N O O m N O O O O O Commonwealth of Massachusetts _ W City/Town of No.Andover R CEIVED } System Pumping Record ` Form 4 NOV 1 U 1011 TOWN OF NORTH ANDO Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. �efion DEP has provided this form for use by local Boards of Health. Ot er ftmrnswWpbp-p,s�ec6r bu the information must be substantially the same as that provided here. a ore using Is or , 1 with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information 1 on: Address No.Andover City/Town 2. System Owner: Name Address (if different from location) City/Town Ma State State Telephone Number 01845 Zip Code Zip Code B. Pumping Record /0— 1. Date of Pumping 2. Quantity Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s) EAeptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: 6. em Pumped Name Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-tre Plant, 20 So. Mill Bradfor Signature of Ha Signature of Recei'virfg Facility If yes, was it cleaned? ❑ Yes ❑ No Vehicle License Number Ma 01835 Date 16 -Z�-// Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 Z Date....:. ll... . ..... 3: ;•'�`'° ;' "�oTOWN OF NORTH ANDOVER = PERMIT FOR WIRING This certifies that �.- has permission to perform ...... ..................................... wiring in the building of I : atm �' ....... .'.r .................... North Andover, Mass. a�+e� ( I Fee r............ Lic. No Z �?a� . ` . ...................... ELECTRICAL I1 SCTOR r j Check # GIk 7465' Official Use only Commonwealth of Massachusetts Department of Fire Services Permit No. Occupancy and Fee Checked. BOARD OF FIRE PREVENTION REGULATIONS V. 9/05] (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 PRINT IN INK OR TYPE ALL INFQRMATION) No: City or Town of: A/, l9n 0 Ve-✓ To the Inspector of Wires: By this application the undersigned gives notice of his or her rrintent ion to perfo the electrical work described below. Location (Street & Number) 0 W i % (_, S 4- t ares Owner or Tenant JAI& 9 - Owner's Address 3a W e./n Telephone No. 176 - & �/- 1�_7 yj- Is this permit in conjunction wit a uilding permit? Yes IT No EJ (check Appropriate Bog) Purpose.of Building �tfw-odd AS- ^^�;+ 4- Utility Authorization No. . Existing Service D Amps 2 Volts 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: 1? ,4, &Aq L`- N7 &"4454 ye %a6 c� Jf Completion of the following table may be waived by the Incnertnr of wirnc No. of Recessed Luminaires / 0 No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above In- Swimming Pool nd. ❑grnd. ❑ o. of Emergency L—iglifing Batteg Units No. of Receptacle Outlets I,2 No. of OilBurners FIRE ALARMS No. of Zones No. of SwitchesNo. 3 of Gas Burners o.. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Tot l No. of Alerting Devices No. of Waste Disposers eat ump Totals: ._um., er Tons w" ' W µ' o. o el - ontained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW 1 Local ❑ Municipal . El Other, Connection No. of Dryers Heating Appliances KW Security ystems:* No. of Devices or Equivalent No. of WaterKW . Heaters No: of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiringg: No. of Devices or Eq uivSent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work �,Sa (When required bymunicipal policy.) Work to Start: & h(o /(0 Inspections to be requested in accordance with NEC 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 coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [BOND ❑ OTHER .❑ (Specify:) I certify, under the pains and enaldes o,1 perjury, thai the information on this application is true and completes FIRM NAME: 6,,5CdC— G�, se -e , t t -s LIC. NO.: AZU d 52, Licensee: )Ke earl ,,,Sc. r Signature /%�-4-- /� LIC. NO.: �Syc�28 (Ifapplicable, enter `exempt" in the license n er line.) ' Bus. Tel. No. Q 7$ S6 ` ��i Address: D C®)ifol e- ►-, C `r 5lwp-p 414 �t�7% Alt, Tel.No.• *Security System Contractor L' nse required for thisw6rk, if applicable, enter the license number here: OWNER'S INSURANCE WAIVER I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑owner ❑owner's a ent. Owner/Agent C rc Signature Telephone No. PERMIT FEE: $-�Z) m m M O m -i O m z N n -1 O m O m m m Cl) itl N N C a T (D (D 90 z O D M M r on o D z 1 O -n z r- m0 O m c m �m = n U5 I 0 7° r 0 v � O m X N Y r r U�E Clummunwealth of BadRt B Pofmit o.G_ igcpmttutrt of public J%&q Occupwy A les Checi ed BOARD OF FIRE PREVENTION REGULATIONS 527 C&IR 12:00 0 om a'f'10 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed In accordance with the Massacnusetts Electrical Code, 527 CMA 1 .00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date T& or Town of To the Inspector 6f Wlrea: The udersigned applies for a permit to Location (Street b Number) Owner or Tenant Owner's Address 16 4(1 'Ta,, ,v IS this permit in conjunction with a building permit: Yes No Q (Check Appropriate Box). Purpose of Building V L i t2JZ/-Y u//-Lr.tiG Utility Authorization No. 70 0 - 11V3 Existing Service Amps —J Volts Overhead Undgrnd rF7 No. of Meters New Service Amps lr,,�O 1JI& Volts Overnead Unagrno No. of Maters Number of Feeders ana Ampacity Location and Nature of Proposed Electrical 'Nom �NJi/fZ� (,ti/ p r„6 �o� SeIV&el �,,g�j `41 r �1W'�- LLr /VG No. of Lignttng Outlets I No. of `lot ':cs I No. of Transformers Total KVA No. of Lighting Fixtures i Acve— in - swimming t— grno. _ grno. I Generators KVA �. No. of ReceoaNo. of Emergency Lightingcle Outlets I Na. of Oil ourners Battery Units No. of Swacn OutletsNo. or Gas 2urr.ers I FIRE ALARMS No. of Zone* No. of Ostection and Intliating Oevtcu No. of Sounding Oevlces No. of Self Contained Oetectlon/Sounoing Oevtce* Local '— Muntcibal f'—OtherConnection No. of Ranges I No. cl Air Ccr..c. Total 'cns No. of Oisoo*als I No.of Heat To:al Total Put-..zs :ans I(W NO. Of OiahWi*ner3 SOaCetArea Heater a I(VI No. of Oryers I Healing Cewces KW No. 01 Water Heaters KW I No. of vo �)I Signs °ailas:s Low voltage Wiring No. Hydro Massage Tubs . t I No. of Motors Total HP OTHER: INSURANCE COVERAGE. Pursuant :o the reauwrements at ''.lassacr.Lsers ;eneral Laws 1 have a current Liability Insurance Policy inctuotng Ccmc:etec Ocerattons Coverage or its substantial equivalent. YES K NO = 1 have suom,tted valid proof of same to the Office. YES ,,C— VO = If you nave checxea YES. phase indicate the type of coverage oy Checking the aoproortate box. INSURANCE �Z SONO = OTHER = (Please S: ec:"/) Estimated Value Of E!ectnC*I work S (Exwauon Oatet Work to Start Insoecuon Date Aacues:ec: Rougn Final Signed under :he Penalties of p*qury! FIRM NAME r � L j/_� uC. NO. Licansee/'ll S.g:7w;:re UC. NO. �D Bus. Tel. No. Address���✓�/sU Alt. Til. No. --Ze J Iot r, OWNER'S INSURANCE WAIVER: I am aware tnat the t.:censee toes not nave the insurance coverage or Its 40stantial equivalent *s re- gtureo by Massacnusens General Laws. ana that my signature an r% -s -.rmn application waives this requirement. Owner Agent (Pies" ch*cn ones' �f Taeonone No. PERMIT FEE 3 ` N2 L TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that .............. 4 .................................................... .. ....................... hasp ermission to perform .................. wiring in the building of ........... ........ ................................................... at -.:%).......'!.1 ..............I...................... North Andover, Mass. Fee1-0 ................. Lic. No��/(:! ... ...... ;; ................. t...... ...................... 'ELECTRICAL INSPECTOR rt WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Office Use Only . �I�e C�ommunurettlt� of �fttt�$�cf�usetts Permit No. t:tg Occupanry 6 Fee Checked Bepartintnt of Vubilc $af_ 9190 (leave blank) BOARD OF FiRE PREVENTION REGULATIONS 527 CMR 12:00 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12.00 PLEASE PRINT IN INK OR PE ALL I FORMATION) Date City or Town of �Y" GyJar)Y[�lL� To the inspector of Wires: be udersigned applies for a permit to perform the electrical work described below. Location (Street & Number) Owner or Tenant Owner's Address (p thls permit in conjunction with o. building permit: Ourpose of Building 1xisting Service Amps I -*Its Vew Service Amps _._! Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work Yes ❑ No �0 (Check Appropriate Boz) Utifity Authorization No. Overhead ❑ * Undgrnd ❑ No. of Meters Overhead ❑ Undgrnd ❑ No. of Meters No. of Lighting Outlets No. No. of Lighting Fixtures No. of Receptacle Outlets No. of Hot lube Swimming Pool Above Abo ❑ No. of Oil Bumers In - grnd. ❑ No. of ltanslormers Total KVA No. of toe No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones Tptal No. of Detection and No. of Ranges No. of Air Cond. tons initiating Devices No. of Disposals No.of HeaatW Total Tons PumNo. Total KW No. of Sounding Devices of Solt Contained No. of Dishwashers Sp&WArea Heating K1N DetectioNSounding Devices Heating Devices KW Municipal Local ion ❑Other No. of Dryers No. of No. of Low vbitag Wking No. of Water Heaters KW Slgni Ballasts No. Hydro Massage Nibs No. of Motors 'Ibtal HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws 1 have a current Liability tnsuranw Policy Including Completed Operations Coverage or its substantial equivalent. YES G NO O i have submitted valid proof of same to the Office. YES O NO O It you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE O BOND. O OTHER O (P ease Specify) - (Expiration Date) Estimated Value of Elecal Work t �� o �J Work to Start Inspection Date Requested: Rough Final Signed under the Penalties of penury: LIC. NO. 1 ? 31G__ FIRM NAMETneLIC, NO.. 1231G Licenses nnnAl d A flrnnks _-Signature — Bus. Tel. No. (ftl) '741-4008 Address 111 Morse Street, Norwood MA Alt. Tet. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does -not have aw Insurunce coverage or hs substantial equivalent as re- qulred by Massachusetts General Laws, and thni my signature on ppik this permit aatan wolves this requirement. Owner Agent (Please Chock one) _ _•. Telephone No. PERMIT FEE S . YSS fSMn.i—a at nwnnr at Montl , fi4A i 2� Location C50 ���S 1,74 `Y 1 No. 4 6 Date `af TOWN OF NORTH ANDOVER Certificate of Occupancy $ •�SscHUSEt� Building/Frame Permit Fee $ ' Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 3 /� r Check # 1 / Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING a $.:.. BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Lose Building Commissioner/InEepororf 1ags Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Ww A ).s Falrw\. Rda _fid 10q 3 A-r ��w' m/I / /' o � l Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided RecMired Provided 1 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Recordw �AV >N A 1 � `�W SV ' ' `\ �0 Name (Print) Address for Service : /V(10\' YVI of 4 dl `! L,-� Ck , Signature I Telephone 2.2 Owner of Record: Name Print Address for Service: Si na:dre Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 LiFensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: License Number Address Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work(check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: O c� SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Com feted bv permit applicant OFF CIALVSE ONLY .� ; 1. Building �� j7 (/ (a) Building Permit Fee Multiplier / (� 2 Electrical i LP ZIP (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) �.� v ' 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, 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 Owne Date SECTION 7rLOWNE UTHORIZED AGENT DECLARATION Lk ( 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 -�:)C\\J° a o L Print Name rn -3130 Si ature of Own JA en t Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 j 2 ND 3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING ZrX MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 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 APPLICANT o V' & L PHONE LOCATION: Assessoes Map Number l ol FARCE_ SUEDIVISION LOT (S) STRE=T 30 w `q W ��R04 ST. NUMEER 3� 2Y` Sr - OFFICIAL USE ONLY ReOOMMENDAT IONS OF TOWN AGENTS: N rig I d �-)�3 (' 0? DJ D CONSERVATION ADMINISTRATOR COMMENTS N0 - TOWN PLANNER COMMENTS P-4(,�AJS) �' DATE APPROVED �J l tJ UO DATE REJECTED l^ 1d0,-, DATE APPROVED DATE REJECTED_ FOOD INSPECTOR -HEALTH DATE. APPROVED — r)AT= R5= 1;=rTF±i SEPTIC INSPECTOR -HEALTH COMMENTS uH i t HrrMU v cv DATE REJECTED PUELIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED EY BUILDING ii ISPECTO Revized 9 97 im DATE Ste. w f / lho Jr, (,fit Sj-d, -OV / ✓ � til - 4LT" -(pQ 33-140 N � 4 I o / A O i N A CSA aG o w cn a V) O z z � �C w o o w x U co w O U W to o w G w O 1-4 W v ,Wj W 00 o c2 � V) c w" 0 F z � o 0: G LL W d w co cn o cn 6 am z : k"*3 o `m c C N Coo U CD C C :.0co N coo CF N ` C ` O m Wcm Q CL a= € L ca mIL 3 eo p 0 E m R y O ; = O Of mak; =cp a (� 'act � �lo:mor m VtH O O Z c° o •� Co CL. O C N m C •C 2 o m :5 C) N 0 y m o� m t ID � .vyi d=OC Z �ui 5`r O•N O_ U .Q p 0 C C a� V) m O Q 4 t 0a m > a ON LJ CD O CD y CD .E CLL co C O CD ci m i7 CO2 O C.) CO2 O V R C d CIO rte, co 3� o co O L- CL 0. O a �a r=te+ C !� O O O zCD CL y C LU 0 U) LU U) LLIIr LLJw U) �?Ca %% N° 2 Date ................................. t pOFTM 1 ° t�``° ;•• "° TOWN OF NORTH ANDOVER a� PERMIT FOR WIRING �cMusE�h This certifies that ..`...... `.... r. �`..:.:.:'. /...`....�........ ................J.. has permission to perform ..: ...'..: wiring in the building of ............ ................................. ..... .......................... at . �......... r •:... �'.....r° , North Andover, Mass. Fee ..................... Lic. No........ ...:......."^,.'..........`.....�...�� ELECTRICAL INSPECTOR �v 01/27/99 1224 35,00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer A t Office Use OnI ., u >� LQ1nYIIIIri11IEttjt Uf fflaaga#gttt Permit No. igevartmtnt of Public i—ElAfetq Occupancy ,& Fee Checked ,4 BOARD OF FIRE PREVENTION REGULATIONS 521 CMR 12:00 1 3/90 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date / —2S-917 City or Town of IV d %Z 9y !9AJ'd U Vr To the Inspector of Wires: The udersigned applies for a permit to perform the electrical work described below. Location (Street & Number) 3 d > kl J PiDl k1. S% /-.4,e ? D Owner or Tenant �O /G ni r//yl�' ,'0a� Owner's Address �-�/ Is this permit in conjunction with a building permit: Yes 2 No ❑ (Check Appropriate Box) Purpose of Building %Z -e S / Cfo^ //A % Utility Authorization No Existing Service Amps _/ Volts Overhead ❑ Undgrnd ❑ • New Service Amps _J Volts Overhead ❑ Undgrnd (Dumber of Feeders and Ampacity Location and Nature of Proposed Electrical Work CU ri �y 41a No. of Meters No. of Meters No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above In- grnd. ❑ grnd. ❑ Generators KVA No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Initiating Devices No. of Sounding Devices No. of Self Contained Detection/Sounding Devices Local Municipal ❑ Other ❑ Connection No. of Ranges No. of Air Cond. Total tons No. of Disposals No.of Heat Total Total Pumps Tons KW No. of Dishwashers Space/Area Heating KW No. of Dryers rY Heating Devices KW No. of Water Heaters KW No. of No. of Signs Ballasts Low Voltage Wiring No. Hydro Massage Tubs No. of Motors Total HP OTHER: S -PC V / / V-7 AIn r M INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws I have a current Liability Insurance Policy including CompI ted Operations Coverage or its substantial equivalent. YES C� NO FJI have submitted valid proof of same to the Office. YES ? NO ❑ If you have checked YES, please indicate the type of coverage by checking the app ,!ppriate box. INSURANCE ff BOND ❑ OTHER 0y-` (Please Specify) Estimated Value of Electrical rk $ 90© • Work to Start `- Z s Inspection Date Requested: Signed under the Penal}ties of perjury FIRM NAME s� %/I �4^j ,l ,44 Licensee 4 T7 L), Signature ! (Expiration Date) Rough Final �1� .G rt i 1 Bus. Tel. No. 7 Address 2 % / "' /Q �� / Alt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as re- quired by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) Telephone No. PERMIT FEE $ (Signature of Owner or Agent) x-6565 N2 2--;u1 Date.... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....... PIZ L c tz, c ........................................ ........................................... has permission to perform ... ........... N.uj .... ...... wiring in the building of ...... Caloo,nk( ......U.�AkcvR .... ....... North Andover. Masi� at ..k ....... F�! P&W. 04)0 ... Lic. No.11?7.04? ................ , L R 'LN'*S'i;ll!C�4� C412& I i4'. o1 WHITE: Applicant CANARY: Building 3Dept. P%K: Treasurer THECOADIONWE4THoffice Use only DEPARTMEVTOFPUBIX FM Perrnit No. t71 BOARD OF MEPREVEWONREGUL4T10 5r(W 12'QD U9A4 Occupancy &Fees Checked PPUCATIONFOR PERMITTO PERF RMELECTRICAL 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) DatL. Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street � Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: /nYes © No (Check Appropriate Box) Purpose of Building �� c /1/6 ti. F M /Ly oiyUf�L`r 414 Utility Authorization No. �a Existing Service Amps Volts Overhead M Underground M No. of Meters New Service 070D Amps /40 lo?Yb Volts Overhead [=1 Underground r----1 No. of Meters Number of Feeders and Ampacity Locaticfiand Nature ofProposed Electrical Work (M.� �(1i/r oil�(/�Ib/ IAlbGZ ArY//[_y DW£c-z.r.v& No. of Lighting Outlets No. of Rot Tubs No. of Transformers Total KVA No. of ighting Fixtures Swimming Pool Above Below Generators KVA groundg1:1round El No. of Receptacle Outlets No. of 0il Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones 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. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipala Other No. of Dryers Heating Devices KW a Connections No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro}vtassage Tubs No. of Motors Total HP OTHER' \ 1 hwanceCo&aw- %suarttlothe I ha�eaatQattLiabtldyb�toePotic 1 ha�esubm�dvandptoofofs8rtetot zWLVTa4ebox NR ANLE BOND FIRM NAME Add= P'"/b OWNER'S ]NSURANCE W. M. e (Please check one) Owner ® Agent a Fsttrr &d Valued'E Mxal Wade $ Rough Final :,,_ •_ — Licmrs o n Btsiness Tel.Na .� Alt. TdNa 7$I , 77 5 i tt3atmadbvxse!!;s Galeal laws Telephone No. PERMIT FEE $ ' I Location 3© � � � � �r� � l � /7 A 440. Date 3 � TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $— Foundation Permit Fee $ Other Permit FeelF'I'eP`4Cv- $ a f Sewer Connection Fee $ `—"'- -i S Water Connection Fee $ /e, 00 ;1 TOTAL q $ I A 0 ` Bjldin 4ns7� 9I P. 6 _ _ __ Ai.• D� li U/n.Lo I u 1 u I u I t 1- 1- 1— 1� 16 J JLU LU V � � J W m z z z v r 4 O W O �r N F M N - � O — — Z 0 U)7/ 2 Z W m O O u u m N b F F Q 0 O O yfj F a IL u_ O m -N W W u W < < W J III d d W J JLU LU V � � J W z z z v I1 r �r I1 O ADOND r D D -Homml- W CD T NNOA ` ^D m A IO aO mN p•p N Om cy;{lN(zV O 0 D �x nN> MNOv m O w o aa A D 0 O000 OOO`" - O -2 y OOG O y T m Zay O pn 3 ZN ON w Cm C- () p N G N pm oDznNJ p;v 3T mn7C zN <i a ND Zmz3:0ornO •`. DC 10 Z CD -<O N ~ 0 D LLL Z A 0 IIII LLL I I I I I I I I I I I I I I IV III'_ 11J1� (A Z�^OriiCpa2NrnO O m- D Z D p O m O v .� -�-+;yZA mrnOr p D p- �I D D O D DN O c m D y D(12 N p D D �oAz (1 0 !C ;T p TT m Z Z CO Z A 2 D V M C p N TO (��'N-�O mti Jo D r) r �. OTn mra2 (1D�r= mm -, A-� Q Q)0 C f1 ?; S 0 Sm f1MM Om AvDw T{NpZ Z `m<< m > n SZOON rn -/ Z -/ N D O Z i C3. Z A A W D O A -+ Z 0 y ^' z D -1 ; D C Z m2Op pc O p T p mN <rO X m N m 7�n (1 T o O A S X C m Z Z N .-. 7 r Q. w -1 N D a A Z N �z< 0 D Z T. 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M A I I I I���I 111 I1 l�ll!IrN �LLI�I� I!I!III- III r_N Zn m N-1 D0 ZZ v3 c D U) �N -i x 0 O� 3m m ZD N_0 0-1 Z2 0x Om mZ N_ m0 C N F r NO �D -Z -I p =o o-1 Oz M> mm mm � m 00 3 FORM U - VERIFICATION 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: 1=Li 74 , ,� ZZ Phone LOCATION: Assessor's Map Number /0 > Parcel 27 Subdivision /5 �.�?��/ Lot(s) /% Street1W, St. Number �D ************************Official RECO DAT ON OF WN AGENTS: , Conservation Administrator Comments Town Planner Comments Food Ins ector-Health i nspector-Health Comments Use Only************************ Date Approved Data Rejected Date Approved Date. Rejected Date Approved Date Rejected Date Approved Date Rejected Public Works - sewer/water connections :2L,12 % - driveway permit Fire Department /Lf% T Received by Building Inspector ate ,,-/ 13::7 FAX 508 6889556 NORTH ANDOVER uu1 Growth Management Bylaw Exemption Statement Town of North'Andover Building Department This form shall be used to assist the building Departmentin their determination of exemptions under section 8.7.6 of the Town of North Andover Growth Management Bylaw. The building applicant shall provide all of the necessary intam+ation as requested below. Name of Applicant on Building Permit ((below) Address of Prope for Permit (below) Ladkr S N't X S Map and Parcel: /01r pyPurpose of Application (check below) Phone Number of Applicant: - V Single Family Two Family I the undersigned applicant for the above property attest that the attached building permit for which this form is completed does comply with the EXEMPTION section 8.7.6 of the North Andover Growth Management Bylaw. I also understand providing this form does not absolve me or any patty to this permit front the requirements of obtaining other permits required prior to the issuance of the Building Permit. Further l understand that my interpretation of the EXEMPTION status is subject to review by the Building 0epaaMvnt and i3 only officially accepted when the Building Permit I% issued. Based on section 8.7.6 of the North Andover Growth Bylaw the above lot and the work as applied for on th9 above lot, in the building permit application and associated attachments, c9mplie3 with one or more of the following sections as indicated by a check mark. This is an application for a building permit for the enlargement reotoradon, or reconmcben of a dwelling in existence as of the effective date of this by-law. provided that no additional residential unit is created. The (alts) werelwaa created prior to May 5.1996 we exempt from the pmwsions of this Section 8.7 of the Zoning ytaw- This applleadon is for dwelling units tar low andlor moderate income farnUies or individuals, where all of the condition of 5,7.6.c•>iro mot and/or represents Owelling units for senior residents, where occupancy of the units is rustriaed to senior persons through a properly exrated and recorded deed restriction running with lite land. For putp99e3 al this Secnon'Senior" stroll mein person over the age of 55. 7'hia appticatlon in a part of a development protect wnten voluntarily agreed to a minimum 60% perrmanent rcaucdon in density. (buildable lotsl, below the density. (buildable lots), permitted under toning and teasible given Me. environmental conditions of the tract, with the surplus land equal to at least ten buildable aCnK and permanendy deslgnatod as open sake and/or farmland. The land to be preserved shall be protected from development by an Agricultural Pneservatlon Restriction, Conservation Restriction. dedication to the Town, of other similar mechanism approved by the Planning Board that will ensure it= protection. _ This appik=lon repreeents a tract of land existing and not held by a Developer in common ownership with an aoracent parcel on the eltecnve date of IMS Se=n 8.7 shall receive a one-time exemption from the Planned Growth Rate and Development Scheduling provision= for the purpose of constructing one single family dwelling unit on the parcel. This apollotton represents a lot which is ready for building permits.(i.e. all other perms from an other boards and commissions missions have been received and the protect is to compliance with those permits), and the Oevelopment Schedule does not accommodate issuing a building permit in that Year. one building permit will be issued per Year per 0evploament urtdl sucn t(me as the Development Schedule accommodates issuing building permits. Applicant must supply approved form U with this EXEMPTION. Please provide any and all information that would assist the Building Oepartment in making 3 7etermination' that your application is allowed one or more of the above EXEMPTIONS. 13yy signing below I attest lathe accuracy of the infamtation provided and that the attached building permit is allowed an EXEMPTION as cited abovf+. Further I understand that the submittal of misleading and or inaccurate information, or the checking off of an above item which does not comply, whether done to my knowledge or nor, is grounds for refusal by the Building 0epartment to issue a Building Permit. sur o w Cr ur u oozed Agent woo s'. ed the Amstrad Bwldrn9 Permit at is tart( mwt be attachfad to the 9uilding permit upon applicauon for sucn oermiL r MAScheck COMPLIANCE REPORT Massachusetts Energy Code MAScheck Software Version 2.0 CITY: Lawrence STATE: Massachusetts HDD: 6235 CONSTRUCTION TYPE: 1 HEATING SYSTEM TYPE: DATE: 10-14-1998 DATE OF PLANS: or 2 family, detached Other (Non -Electric Resistance) TITLE: 30 Windkist Farm Rd. COMPANY INFORMATION: William Barrett Homes 1049 Turnpike St. No. Andover, Ma. 01845 978-682-2320 COMPLIANCE: PASSES Required UA = 771 Your Home = 747 Permit # Checked by/Date Area or Insul Sheath Glazing/Door Perimeter R -Value R -Value U -Value UA W. --------------------------- CEILINGS ---------- -------- 1746 -------- 38.0 -------------------------- 3.0 48 WALLS: Wood Frame, 16" O.C. 3200 15.0 3.0 214 WALLS: Wood Frame, 16" O.C. 198 19.0 3.0 11 GLAZING: Windows or Doors 702 0.500 351 FLOORS: Over Unconditioned Space 1927 19.0 92 BSMT: 4.0' ht/0.0' bg/4.0' insul. 80 19.0 4 BSMT: 8.0' ht/7.0' bg/0.0' insul. 120 0.0 27 HVAC EFFICIENCY: Furnace, ------------------------------------------------------------------------------- 90.0 AFUE COMPLIANCE STATEMENT: The proposed building design represented in these documents is consistent with the building plans, specifications, and other calculations submitted with the permit application. The proposed building has been designed to meet the requirements of the Massachusetts Energy Code. The heating load for this building, and the cooling load if appropriate has been determined using the applicable Standard Design Conditions found in the Code. The HVAC equipment selected to heat or cool the building shall be no greater than 1250 of the design load as specified in sections 780CMR 1310 and J4.4. Builder/Designer Date •� l b A x h IN 21 0 1 -V of F� l 'AR ell Nl P � 0 f 160-96' 60 9 ,i k , a / '. r;,"•Y i/ � / SII w 0 O FM4 O a y � o a CD a orN 0 V � w R :Z W m CA �• ��'Q gra �•6 :� � c w w w rx s «f��� w" w w cn O cn x cn Y u m CL � J u Q' � • V z 0 U R O Z co CL O y � C Ww\ cm CD I O �. 'E m m = O� O � i C a CMQ y � o CD 0O. orN 0 V R :Z m CA �• ��'Q gra �•6 :� � c Y u m CL � J u Q' � • V z 0 U R O Z co CL O y � C Ww\ cm CD I O �. 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Iz :t y �^y I 6,V diAJOO l :A9WYM 5NO)15 MOW ,mall,6,15 MOH ANI -Ao �..� �� '� ~11 -TAA T9M;l-5NQNIM ;I z H lllil�� 0�1d ,ni N>N n �•� �Q�cC �\ XV0 it �lww.l O r 1101 III - t u O 1 N � 3 `yam z H N�hl n0- 6 Ov N \ Ofl X O O ,ni N>N n �•� �Q�cC �\ XV0 it �lww.l O r 1101 III - t I O u N � 3 `yam � N�hl n0- 6 N \ Ofl X O O m O N � ZZ v z -------------- o O N \ NDN NxN 1L N � 3- I O u N � 3 `yam � N�hl N \ Ofl X O O C' N u N � � N�hl N \ Ofl X O I � � lI 05/U6/99 1HU U9:52 kAA 9l5 tJ64 957:5 INUKIR AINI)Uvrt( Ur1Yq f �P rUU4 9-16— i 9�►S 1: 32AM FRO14 • �� ��� RECEIVED , TOWN OF NORTH T ANDOVER MAY 2 8 1999 WRIT-! ANP.CVP771 CONS t:FilAT;JIN CJivi;4iisslols APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION ADDRESSILOCATION OF PROPERTY: DATE REQUESTED FILEDrREADY FOR INSPECTION ,5 q g_ CLOSING DATE ON PROPERTY_ 141 qq Fn (5) DAYS NOTICE PRIOR TO CLOSING DATE ISREQUIRED J_ ALL WORK AND PERMIT SIGN -OFFS MUST SE COMPLETED" WITHIN THIS TIME FRAME. A RE -INSPECTION FEE OF TWENTY DOLLARD $20.00) WILL BE CHARGED IF THE STRUCTURE DOES NOT MEET ALL APPLICABLE CODES. SIGNED ROUTING CONSERVATION PLANNING 1 DPW - WATER METER NOTE: DPW MUST INDICATE THAT WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF THE OCCUPANCYANSPECTION REQUEST DPW1�"� Signatr CERTIFICATE OF USE &OCCUPANCY Town of North Andover Building Permit Numb, 9PA 98 Date i 39'9' THIS CERTIFIES THAT THE BUILDING LOCATED ON 30 FA#sJ" R44 MAY BE OCCUPIED AS v51094 ' �• dry IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. CERTIFICATE ISSUED TO A440PAOIs f FA#'01 kkcb ADDRESS 0 y vim+ A r00 S ;00a Building Inspector l 9 0 A 0 z • O o � ..i v U ,t O �.+ :"Nib O CDN rm0 m N om V O: t; -40, N R m m N C m 3 o � • m N Oc V: N o N m m O a c deft' acz o� .N La Z r.+ Cy a r O F- ¢ `I/ ■ O C m .c 3 _ +� o aoH miW -AD N CLC - cc •E �a f cc -in V m pn m:CC_ CLH n 2 /N0O = 0 aw m a �7 A Cf� o� E B cl)ca� N C oO rr1 W U C m Vr ) C: r ) CD wv m O cp C_ �C N CD z O Z :� y O Me E O L O O V CO) O V .CL CO) /0 V R ■C V !D _ •� i-- y J > I L O V O 0. CA C CO CM C coO D 'fl H =_ 3� co i O Q' d cmQ C •� cc J 'L3 O O Z CD CL CA C 0 ¢� ren m Y ! or - �' o a Cd Cd v °�° co � w 7 �, z Q p w2 U) w° U w � ;\) J- cn CQ cin u) A 0 z • O o � ..i v U ,t O �.+ :"Nib O CDN rm0 m N om V O: t; -40, N R m m N C m 3 o � • m N Oc V: N o N m m O a c deft' acz o� .N La Z r.+ Cy a r O F- ¢ `I/ ■ O C m .c 3 _ +� o aoH miW -AD N CLC - cc •E �a f cc -in V m pn m:CC_ CLH n 2 /N0O = 0 aw m a �7 A Cf� o� E B cl)ca� N C oO rr1 W U C m Vr ) C: r ) CD wv m O cp C_ �C N CD z O Z :� y O Me E O L O O V CO) O V .CL CO) /0 V R ■C V !D _ •� i-- y J > I L O V O 0. CA C CO CM C coO D 'fl H =_ 3� co i O Q' d cmQ C •� cc J 'L3 O O Z CD CL CA C Date..":%7-.� 1.- 3929 TOWN OF NORTH ANDOVER , .. -'• roc p PERMIT FOR PLUMBING 61 This certifies that �,/!!'" ................... has permission to perform ... .................... . plumbing in the buildings of.'"�?�",'�..r-r"`". ........ at.,-:','. C! --. ---' . 1 ` .. ..... North Andover, Mass. �� Few � ..... Lic. No...7 ...... • =,,ti."_ ..�. � . . PLUMBING INSPECTOR 01/21/99 14:32 300.00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer dW- MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUM IN (Prin t /or Type) /l/ u/ji�-cam Mass. Date ! 19 Permit # �9 Building Locatiork.?© ��4�-+�.I�' y Owner's Name 4 n f New Renovation ❑ Replacement ❑ FIXTURES Type of Occupancy Plans Submitted: Yes ❑ No ❑ Installing Company Name Check one: Address ������ �e/ Corporation v3 ❑ Partnership i Business Telephone t!, G3 �3 d�3a .� — ❑ Firm/Co. Name of Licensed Plumber Certificate INSURANCE COVERAGE: I have a curre t liability Insurance pollcy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes plyNo ❑ If you have checked y.0, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy 4 Other type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee dots Dol 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: Owner Cl Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted for 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 lot this application will be in compliance with all pertinent provisions of Uu Massachusstts State Plumbing Code Chaptrt 112 of Griner By —,�JJ Signature WUcensod Plumber Title Typo of license: kAaster Journeyman ❑ City/Town -V �iV:r L Ucense Number z 2 N < NZ N O Y z Z W y� W W Y J b r < U < ►- N O a G w ¢ z O z o O - W h W N G r U < C l7 < - < O ,� U = 5 O m O fL N N ¢ 7 h• < VI J = y! < G 0 J S O z x C O W W2 ~ ~ W O O Y ¢ N < Y Z Z 4 W LL Y W & U> 1- O 0.2 0 a yr F- Z 0 0 H O U Z Y J m N O O J O SUB—BSMT. BASEMENT IST FLOOR aN0 FLOOR `. I 3RO FLOOR 4Th FLOOR STN FLOOR eTNFLOOR ?TN FLOOR eTN FLOOR I-1 L ---+H+ Installing Company Name Check one: Address ������ �e/ Corporation v3 ❑ Partnership i Business Telephone t!, G3 �3 d�3a .� — ❑ Firm/Co. Name of Licensed Plumber Certificate INSURANCE COVERAGE: I have a curre t liability Insurance pollcy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes plyNo ❑ If you have checked y.0, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy 4 Other type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee dots Dol 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: Owner Cl Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted for 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 lot this application will be in compliance with all pertinent provisions of Uu Massachusstts State Plumbing Code Chaptrt 112 of Griner By —,�JJ Signature WUcensod Plumber Title Typo of license: kAaster Journeyman ❑ City/Town -V �iV:r L Ucense Number im m fn r ~ y O O O 9 O c w m i r= r m S O C y = S = O -1 o, O v , r c i A m fn r O O n m c w m i 1 r 31 U Date .... . 7 ....... 14,° TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION, i • IjJ, SSACHUSEt to This certifies that ....... '..`....... • ... �^".... • • • • • • • "' c has permission for gas installation ..':.':~'::.... am r n � •9�=o in the buildings of ... : ' fu... ` . r+• . • • . .. • • • •N at ..... : , ,' ra �� • •' '` ` / North Andover, Mass. Feer....... Lic. No.X;!............. '••c GAS INSPECTOR Z • . WHITE: A°°Ilcant CANARY: Building Dept. PINK: Treasurer t MASSACHUSETTS U.NIFURM AFYL1cA I IVr (Print or Type) r F Mass. City, Town Building AT: Location G a U. HMI I I U UV%a/1Jr"s a s a%%& �7 1 Yrm — 19 ` -C19 0 it # 151/ Namer, Type of Occupancy:„' ist,'{�s2_ New Renovation[7 Replacement"M Plans Submitted Yes Q No Q FEU0-5 N' ME MEESE �i■nniiuiiiimi�ISM iiMEN �� (Print or Type) Installing Company Name �CC5 r1 i OC�Ln-Q- Address � n ye, ci a 3 Check One: Certificate (Corp. Q Partnership Q Firm/Company Business Telephone Name of Licensed Plumber or Gasfitter 7LY-1) zes�4�-� 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 Al plumbing work and installations performed under Permit issued for this appiicatian will be in =rnP m- With ill pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. By Title City/Town: APPROVED (OFFICE USE ONLY) TYPE LICENSE: a Plumber Gasfitter Signature of Licensed � � or Gasfitter Master . P""f "7 Journeyman —r License Number X m —4 z. 2 - m fir co m. X m —4 2 - m co m. tv $Of O J Date .......... Q H NORTN TOWN OF NORTH ANDOVER py a° ,e,tiOL PERMIT FOR GAS INSTALLATION FzP o `SA NU d' This certifies that ......................................... g; . has permission for gas installation ............. ..........o . in the buildings of ...:.:..... ......'.......:............. at ........ ...............'� .......... North Andover, Mass. Fee.;.' .... . Lic. No......�: �.. ........ + .. GASINSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT (Print or Type) Mass. Date G Building Locatlony© grz Owner' I I DO GASFI"NG Permit # &O 95 &to • C-, Occupancy New A, -- Renovation ❑ Replacement ❑ Plans Submitted: Yes(] No ❑ Installing Company Name �� A 4'7*'. Check one: Certificate Address -Z7, o'i//y Corporation G3U 3 CP ❑ Partnership Business Telephone 4G3 �33 oZ ❑ Firm/Co. Name of Licensed Plumber or Gas FitterA�za. INSURANCE COVERAGE: I have a curreXt liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy k Other type of indemnity ❑ Bond ❑ 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: Owner[] Agent ❑ 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 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 Massachusetts State Gas Code and Chapter 142 of the By T f License. Plumber gnature of Licensed umber or Gas Fitter Title slitter ster License Number City/Town Journeyman N ¢ N w q Y Z ¢ N N U ¢ H z N cc h ¢ O O v+ x r W O W J N¢ ¢ w O U z o W 4 < ¢¢ N = o O o 1' w < ¢ m of w F Q W = W Z O- F- a O c '�► > 4 W a¢ W W N fn w t7 = u < W x ¢ h ¢ w Q¢ ¢ W r W r x 1A ¢ z !- < W J w F' <¢ z F h y N m Z O 2 W O 1~A x ¢' x ¢ O t7 Y ti Z < 3 ¢< o c7 Q J O U O ¢ W > O %a O SUB—BSMT. BASEMENT I 1ST FLOOR 2ND FLOOR I 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing Company Name �� A 4'7*'. Check one: Certificate Address -Z7, o'i//y Corporation G3U 3 CP ❑ Partnership Business Telephone 4G3 �33 oZ ❑ Firm/Co. Name of Licensed Plumber or Gas FitterA�za. INSURANCE COVERAGE: I have a curreXt liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy k Other type of indemnity ❑ Bond ❑ 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: Owner[] Agent ❑ 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 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 Massachusetts State Gas Code and Chapter 142 of the By T f License. Plumber gnature of Licensed umber or Gas Fitter Title slitter ster License Number City/Town Journeyman i A D N 2 0 T m m